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Thinking about medicine 

Thinking about medicine
Chapter:
Thinking about medicine
Author(s):

Murray Longmore

, Ian B. Wilkinson

, Andrew Baldwin

, and Elizabeth Wallin

DOI:
10.1093/med/9780199609628.003.0001
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Subscriber: null; date: 12 December 2017

Thinking about medicine: Contents

Where should we keep this oath? Not in the dusty confines of a book, but in our limbic system ([link]), where it has every chance of influencing unconscious action, before our subverting cerebral cortex comes up with brilliant and convenient excuses as to why, in this case, the oath does not apply.

See also the bmas Revised Hippocratic Oath and the gmcs Duties of a Doctor

We thank our Junior Reader Mathuranayagham Niroshan for his contribution.

A new Hippocratic oath ∼2013ad

I will make my patient my first concern. I will treat all my patients as individuals, and respect their dignity and right to confidentiality.

I will do my best to help anyone in medical need and ensure the health of patients and the public is protected and promoted.

I will use my medical knowledge to benefit people's health. I will be honest, respectful, and compassionate to all.

I will provide a good standard of care, uninfluenced by political or religious pressure, or the age, race, sexual orientation, social class or wealth of my patient.

I will listen to patients and respond to their concerns. I will give patients information they want or need in a way they can understand.

I will help patients reach decisions about their treatment and care and will respect decisions of informed and competent patients, even if treatment is refused.

I will recognize the limits of my knowledge and competence, and seek advice when needed. I will keep my knowledge and skills up to date, and ensure poor standards or bad practices are exposed without delay to those who can improve them.

I will show respect for all those with whom I work, and will work with colleagues in a way that best serves the interest of my patients. I will be ready to share my knowledge by teaching others.

I recognize the special value of human life, but I also know that prolonging life is not the only aim of health care.

I will promote fair use of health resources and try to influence positively those whose policies harm public health.

I recognize that I have responsibilities to humankind that transcend diktats and orders of States, and which no legislature can countermand. I will oppose health policies that breach internationally accepted standards of human rights.

I will learn from my mistakes and seek help from colleagues to promote patient safety. While keeping within this framework, I will not be discouraged by failure, and will try to continue in a spirit of practical and rational optimism.

The old Hippocratic oath ∼425bc

I swear by Apollo the physician, and Aesculapius and Health and All-heal, and all the gods and goddesses, that, according to my ability and judgement, I will keep this oath and stipulation—to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation, and that by percept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none other.

I will follow that system of regimen, which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practise my Art.

I will not cut persons labouring under the stone, but will leave this work to be done by men who are practitioners of this work.

Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females, or males, of freemen or slaves.

Whatever, in connection with my professional practice, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

While I continue to keep this oath unviolated, may it be granted to me to enjoy life and practise this Art, respected by all men, in all times. Should I violate this Oath, may the reverse be my lot.

Fig 2. Ever since Hippocrates banned surgery for bladder stones and inaugurated the turf war between barber-surgeons and physicians, doctors of all sorts have been keen to have a go: after all, what is forbidden holds a special fascination. Albucasis (930–1013ad) developed this charming and delicate implement to insert through his patient's perineum and into the bladder. As we listen to him saying “just a small prick coming…you won't feel a thing…” we hear an echo of our own bedside manner, and feel the admonishing hand of Hippocrates on our shoulder.

Fig 2.
Ever since Hippocrates banned surgery for bladder stones and inaugurated the turf war between barber-surgeons and physicians, doctors of all sorts have been keen to have a go: after all, what is forbidden holds a special fascination. Albucasis (930–1013ad) developed this charming and delicate implement to insert through his patient's perineum and into the bladder. As we listen to him saying “just a small prick coming…you won't feel a thing…” we hear an echo of our own bedside manner, and feel the admonishing hand of Hippocrates on our shoulder.

Image courtesy of Rabie E Abdel-Halim

Thinking about medicineWhen your back is to the wall

Addressed to gods we do not recognize, and entreating us to abhor operations for stones we never felt any compulsion to remove, we spent the first years of our training thinking that Hippocrates was merely quaint, until one day we took up work in a new hospital on the outskirts of a small but quite well-known city in the middle of the country. There were carpets on the floor and all signs to the Labour Ward had been removed and replaced with ones to the ‘Delivery Suite’. Everything was perfect and painless. There was even time for an introductory tour by the proud Administrator. As he droned on, our eyes roamed over the carpets, to the pictures on the walls, and settled on the ceiling, where there were undeniable squiggles of arterial blood. How had it got up there? And so soon after opening? Pain and calamity were seeping into that hospital even before the paint was dry. As our work unfolded, backs frequently to the wall, floored by vicious circumstances, and with ceilings caving in, Hippocrates seemed even further away, on his dark blue island of Cos,1 under his famous tree (fig 1). No floors, no walls, and no ceilings. Then all became clear. What Hippocrates had at his back was no man-made wall but the bark of our living family tree, that most rooted of all our collective medical memories. Now, when our back is to the wall, we can sometimes hypnotize ourselves into feeling the rough contour of that supporting trunk; and now, when we look up, through the blood, we see sky.

Fig 1. Hippocrates sits under his famous tree, dispensing, in equal measure, the fruits of reductionist medicine (on his right) and those of integrative medicine (on his left).

Fig 1.
Hippocrates sits under his famous tree, dispensing, in equal measure, the fruits of reductionist medicine (on his right) and those of integrative medicine (on his left).

Ideals

Decision and intervention are the essence of action: reflection and conjecture are the essence of thought: the essence of medicine is combining these in the service of others. We offer our ideals to stimulate thought and action: like the stars, ideals are hard to reach, but they serve for navigation during the night. We choose Orion (fig 1) as our emblem for this navigation as he had miraculous sight (a gift from his immortal lover, Eos, to help him in his task of hunting down all dangerous things)—and, as his constellation is visible in the northern and the southern hemispheres (being at the celestial equator), he links our readers everywhere.

  • Thinking about medicine Do not blame the sick for being sick.

  • Thinking about medicine If the patient's wishes are known, comply with them.

  • Thinking about medicine Work for your patients, not your consultant.

  • Thinking about medicine Ward staff are usually right; respect their opinions.

  • Thinking about medicine Treat the whole patient, not the disease, or the nurses.

  • Thinking about medicine Admit people—not ‘strokes’, ‘infarcts’, or ‘crumble’.

  • Thinking about medicine Spend time with the bereaved; help them to shed tears.

  • Thinking about medicine Give the patient (and yourself) time: time for questions, to reflect, to allow healing, and time to gain autonomy.

  • Thinking about medicine Give patients the benefit of the doubt. Be optimistic. Optimistic patients who feel in charge live longer.2

  • Thinking about medicine Use ward rounds to boost patients’ morale, not your own.

  • Thinking about medicine Be kind to yourself: you are not an inexhaustible resource.

  • Thinking about medicine Question your conscience—however strongly it tells you to act.

Fig 1. The constellation of Orion has 3 superb stars: Bellatrix (the stethoscope's bell), Betelgeuse (b) and Rigel (r). The 3 stars at the crossover (Orion's Belt) are Alnitak, Alnilam, and Mintaka.

Fig 1.
The constellation of Orion has 3 superb stars: Bellatrix (the stethoscope's bell), Betelgeuse (b) and Rigel (r). The 3 stars at the crossover (Orion's Belt) are Alnitak, Alnilam, and Mintaka.

©jml & David Malin

Ideal and less than ideal methods of care

Sleepwalking with our head in the clouds, we see neither the dozen stars above our head nor the tripwires at our feet, so we are frequently surprised to find ourselves falling head-over-heels in love with the idea that we are doing quite well. The great beauty of clinical medicine is that we are all levelled by our patients and their carers, whether we are students or professors, as this story shows: A man cut his hand and went round to his neighbour for help. This neighbour happened to be a doctor, but it was not the doctor but his 3-year-old daughter who opened the door. Seeing that he was hurt and bleeding, she took him in, pressed her handkerchief over his wound, and reclined him, feet up, in the best chair. She stroked his head and patted his hand, and told him about her flowers, and then about her frogs, and, after some time, was starting to tell him about her father—when he eventually appeared. He quickly turned the neighbour into a patient, and then into a bleeding biohazard, and then dispatched him to a&e ‘for suturing’. (The neighbour had no idea what this was.) He waited 3 hours in a&e, had 2 desultory stitches, and an interview, with a medical student who suggested a tetanus vaccination (to which he was allergic). He returned to the doctor next door a few days later, praising his young carer, but not the doctor (who had turned him into a patient), nor the hospital (who had turned him into an item on a conveyor belt), nor the student who turned him into a question mark (does a 50-year-old with a full series of tetanus vaccinations need a booster at the time of injury?).

It was the 3-year-old who was his true physician, who took him in, cared for him, and gave him time and dignity. Question her instinct for care as you will: point out that it could have led to harm; that it was not evidence-based; and that the hospital was just a victim of its own success. But remember that the story shows there is, as ts Eliot said, at best, only a limited value in the knowledge derived from experience, eg the knowledge encompassed in this book. The child had the innate understanding and the natural compassion that we all too easily lose amid the science, the knowledge, and our stainless-steel universe of organized health care.

The bedside manner and communication skills

On opening a window to ventilate a stuffy consulting room, one of the authors overheard some candid feedback from the previous patient whose husband had asked how the consultation had gone: “I suppose he got it right…pity about the bedside manner.” The window was quickly closed again! The point of this page is to slowly re-open the window on the understanding that few doctors have special gifts in this area, and most have a rich catalogue of errors to draw on.

Our bedside manner matters as it shows patients if they can trust us. Where there is no trust there is little healing. A good bedside manner is not static. It develops in the light of patients’ needs. And it is grounded in the timeless virtues of honesty, humour, and humility in the presence of human weakness and suffering.

Doctors tend to write pompously about the bedside manner as if they were paragons, and patients may write with anger about it, without grasping the constraints (excuses?) which lead to our poor bedside manner. So let us start with doctors who are patients. You cannot get better than this doctor's report on her physician: “I felt he understood me: he asked all about how my illness interfered with my work and what I felt about it. He even seemed to remember parts of our previous consultation.”

It is simple to understand that words we use at the bedside are often misinterpreted: for example, 10% of patients say that jaundice means yellow vomit and remission is often taken to mean ‘cure’. When we analyse doctors who have become patients we realize there is an impasse in communication which no lexicon can remedy. Time itself flows differently for doctors and patients. “Just wait here and the radiographer will be with you right away” may presage a wait of 1 hour, which seems an age to the patient. “We will get the result soon” means weeks to doctors, and before lunch to patients.3 If, when assessing risk, doctors who become patients tend to invert the meaning of “good” and “bad”, is there any hope that we can communicate well with our less rational patients?4 Maybe these rules will help:

  • Give the most important details first

  • Check on retention and understanding

  • Be specific. “Drink 6 cups of water a day” is better than “Drink more fluids”

  • Give written material with easy readability.

Thinking about medicineDon't assume everyone can read: naming the pictures but not the words on our test chart (see inside front cover) reveals this tactfully.

Ensure harmony between your view of what must be done and your patient's. We talk of compliance with our regimens, when what we should talk of is concordance, which recognizes the central role of patient participation in all good care plans.

Anxiety reduction or intensification

A simple explanation of what you are going to do often defuses what can be a highly charged affair. With children, try more subtle techniques, such as examining the abdomen using the child's own hands, or examining their teddy bear first.

Pain reduction or intensification

Compare: “I'm going to press your stomach. If it hurts, cry out” with “I'm going to touch your stomach; let me know what you feel” and “I'll lay a hand on your stomach. Sing out if you feel anything.” We can sound frightening, neutral, or joyful, and the patient will relax or tense up accordingly.

The tactful or clumsy invasion of personal space

During ophthalmoscopy we must get much nearer to the patient than is acceptable in normal social intercourse. Both doctor and patient may end up holding their breath, which helps neither the patient keep his eyes perfectly still, nor the doctor to carry out a full examination. Simply explain “I need to get very close to your eyes for this.” (Not “We need to get very close for this”—one of the authors was kissed repeatedly while conducting ophthalmoscopy by a patient with frontal lobe signs.)

In summary

Our bedside manner must allow our patients to trust us, and enable the consultation to be a healing event in its own right. But it shouldn't be so delightful as to cause endless queues of eager, doctor-dependent patients. As another patient said: “All this babble…is it worth it? Your predecessor Dr W. would have cleared this waiting room in 1 hour, maximum, and then we could all go home.”

Asking questions

We can all attend communications courses on how to make good use of focused and open-ended questions, ask fewer leading questions, and respond to patient cues. Does this influence what we do back at work? Randomized trials say “Yes!”;5 also, additional skills, not apparent at 3 months after courses, become evident, with 80% fewer interruptions, for example.6 One reason for this acceleration of our skills is that good communication makes our work interesting, richer, and deeper. Tactful psychosocial probing is also evident.7 But empathy may dry up over time6 (one reason to refresh ourselves as often as possible).

Leading questions

On seeing a bloodstained handkerchief you ask: “How long have you been coughing up blood?” “6 weeks, doctor”, so you assume haemoptysis for 6 weeks. In fact, the stain could be due to a cut finger, or a nose bleed. On finding this out later (perhaps after expensive and unpleasant tests), you will be annoyed with your patient for misleading you, but he was trying to be polite by giving the sort of answer you were expecting. Leading questions permit no opportunity to deny assumptions. “Is your chest pain sharp or dull?” is a common and commonly misleading question. It's as helpful as speaking to your patient in the wrong language.8 Try “Tell me more about what you are feeling … what's it really like?”([link]).

Questions suggesting the answer

“Was the vomit red, yellow, or black—like coffee grounds?”—the classic description of vomited blood. “Yes, like coffee grounds, doctor.” The doctor's expectations and hurry to get the evidence into a pre-decided format have so tarnished the story as to make it useless (see also [link]).

Open questions

The most open question is “How are you?” The direction a patient chooses offers valuable information during this first ‘golden’ minute in which you are silent. Other examples are gentle imperatives such as “Tell me about the vomit” “It was dark” “How dark?” “Dark bits in it” “Like…?” “Like bits of soil in it.” This information is gold, although it is not cast in the form of ‘coffee grounds’.

Patient-centred questions

In order to consider your patient's viewpoint, learn to weave between finding out about the disease and their illness. Try to understand the patient's unique experience and any effect on their life. What are their ideas?: “What do you think is wrong?” Explore their concerns: “What other things are on your mind? How does having this affect you? What is the worst thing? It makes you feel…” (The doctor is silent.) What are their expectations? “What can we do about this?”9 Share management plans. Thinking about medicineUnless you become patient-centred your patient may never be fully satisfied with you, or fully cooperative.

Casting your questions over the whole family

This is most useful in revealing if symptoms are caused or perpetuated by psychological mechanisms. They probe the network of causes and enabling conditions which allow nebulous symptoms to flourish in family life. “Who else is important in your life? Are they worried about you? Who really understands you?” Until this sort of question is asked, illness may resist treatment. Eg “Who is present when your headache starts? Who notices it first—you or your wife? Who worries about it most (or least)? What does your wife do when (or before) you get it?” Think to yourself: Who is his headache? We note with fascination research showing that in clusters of hard-to-diagnose symptoms, it is the spouse's view of them that is the best predictor of outcome: if the spouse is determined that symptoms must be physical, the outcome is worse than if the spouse allows that some symptoms may be psychological.

Echoes

Try repeating the last words said as a route to new intimacies, otherwise inaccessible, as you fade into the distance, and the patient soliloquizes “…I've always been suspicious of my wife.” “Wife …” “My wife … and her father together.” “Together…” “I've never trusted them together.” “Trusted them together…” “No, well, I've always felt I've known who my son's real father was… I can never trust those two together.” Without any questions you may unearth the unexpected, important clue which throws a new light on the history.

Thinking about medicineIf you only ask questions, you will only receive answers in reply. If you interrogate a robin, he will fly away: treelike silence may bring him to your hand.

What is the mechanism? Finding narrative answers

Like toddlers, we should always be asking “Why?”—not just to find ultimate causes, nor to keep in step with our itineraries of veracity (although there is a place for this), but to enable us to find the simplest level for intervention. Some simple change early on in a chain of events may be sufficient to bring about a cure, but later on, such opportunities may not arise. For example, it is not enough for you to diagnose heart failure in your breathless patient. Ask: “Why is there heart failure?” If you don't, you may be satisfied by giving the patient an antifailure drug—and any side-effects from this, such as uraemia or incontinence from diuretic-associated polyuria, will be attributed to an unavoidable consequence of necessary therapy.

If only you had asked “What is the mechanism of the heart failure?” you might have found a cause, eg anaemia coupled with ischaemic heart disease. You cannot cure the latter, but treating the anaemia may be all that is required to cure the patient's breathlessness. But do not stop there. Ask: “What is the mechanism of the anaemia?” You find a low mcv and a correspondingly low serum ferritin ([link])—and you might be tempted to say to yourself, I have the prime cause.

Wrong! Put aside the idea of prime causes, and go on asking “What is the mechanism?” Retaking the history (often the best ‘investigation’) shows a very poor diet. “Why is the patient eating a poor diet?” Is he ignorant or too poor to eat properly? You may find the patient's wife died a year ago, he is sinking into a depression, and cannot be bothered to eat. He would not care if he died tomorrow.

You come to realize that simply treating the patient's anaemia may not be of much help—so go on asking “Why?”: “Why did you bother to go to the doctor if you aren't interested in getting better?” It turns out he only went to see you to please his daughter. He is unlikely to take your drugs unless you really get to the bottom of what he cares about. His daughter is what matters and, unless you include her, all your initiatives may fail. Talk to her, offer help for the depression, teach her about iron-rich foods and, with luck, your patient's breathlessness may gradually begin to disappear. Even if it does not start to disappear, you are learning to stand in your patient's shoes and you may discover what will enable him to accept help. And this dialogue may help you to be a kinder doctor, particularly if you are worn out by endless lists of technical tasks, which you must somehow fit into impossibly overcrowded days and nights.

You never really know a man until you stand in his shoes and walk around in them.Harper Lee; To Kill a Mockingbird

Constructing imaginative narratives yielding new meanings

Doctors are often thought of as being reductionist or mechanistic—but the above shows that asking “Why?” can enlarge the scope of our enquires into holistic realms. Another way to do this is to ask “What does this symptom mean?”—for this person, his family, and our world. A limp might mean a neuropathy, or falling behind with the mortgage, if you are a dancer; or it may represent a medically unexplained symptom which subtly alters family hierarchies both literally (on family walks) and metaphorically. Science is about clarity, objectivity, and theory in modelling reality. But there is another way of modelling the external world, which involves subjectivity, emotion, ambiguity, and arcane relationships between apparently unrelated phenomena. The medical humanities ([link]) explore this—and have burgeoned recently10—leading to the existence of two camps: humanities and science. If while reading this you are getting impatient to get to the real nuts and bolts of technological medicine, you are in the latter camp. We are not suggesting that you leave it, only that you learn to operate out of both. If you do not, your professional life will be full of failures, which you may deny or remain in ignorance of. If you do straddle both camps, there will also be failures, but you will realize what these failures mean, and you will know how to transform them. This transformation happens through dialogue and reflection. We would achieve more if we did less: every hospital should have a department of reflection and it should be visited as often as the radiology department. In fact every hospital has many such departments, carved out of our own minds—it's just that their entrances are blocked by piles of events, tasks and happenings.

Death

We all labour against our own cure; for death is the cure of all diseases. Thomas Browne Religio Medici, 1642

Compared with being born, death should be straightforward. But nothing you can say to your patient can ever be relied upon to tame death's mystery, and preparing people for death is more than control of terminal symptoms (see [link]).

Death is nature's master stroke, albeit a cruel one, because it allows genotypes space to try on new phenotypes. The time comes in the life of any organ or person when it is better to start from scratch rather than carry on with the weight and muddle of endless accretions. Our bodies and minds are these perishable phenotypes—the froth, that always turns to scum, on the wave of our genes. These genes are not really our genes. It is we who belong to them for a few decades. It is one of nature's great insults that she should prefer to put all her eggs in the basket of a defenceless, incompetent neonate rather than in the tried and tested custody of our own superb minds. But as our neurofibrils begin to tangle, and that neonate walks to a wisdom that eludes us, we are forced to give nature credit for her daring idea. Of course, nature, in her careless way, can get it wrong: people often die in the wrong order (one of our chief roles is to prevent this mis-ordering of deaths, not the phenomenon of death itself). So we must admit that, on reflection, dying is a brilliant idea, and one that it is most unlikely we could ever have thought of ourselves.

Diagnosis of death

Although death is a process, there is a need to name the moment of death. This has long been identified by the simultaneous onset of apnoea, unconsciousness and absence of the circulation, yet there is no standardized criteria for when death should be confirmed (irrespective of whether the heart has stopped beating of its own accord, treatment has been withdrawn, or resuscitation attempts have failed).1 Royal College guidance suggests that cardiorespiratory death can be diagnosed after 5 minutes of observed asystole (by the absence of a central pulse and heart sounds ± absence of activity on continuous ecg or echocardiogram). After 5 minutes of continued arrest, irreversible damage to the brainstem will have occurred and the absence of pupillary responses to light, corneal reflex and motor response to supra-orbital pressure should be confirmed. The time of death is said to be the time when these criteria are met.11,12

Diagnosis of death by cns criteria (brainstem death)

If the brainstem is irreversibly damaged, but the heart is still beating, death has occurred and the heart will inevitably stop beating on withdrawal of support. uk brain death criteria (usa criteria differ) have 3 components:

  1. 1 The patient must suffer from a condition that has led to irreversible brain damage

  2. 2 Potentially reversible causes have been adequately excluded (in particular: depressant drugs; hypothermia; metabolic or endocrine disturbances; or reversible causes of apnoea)

  3. 3 Coma, apnoea and the absence of brainstem reflexes are formally demonstrated.

Tests:

All brainstem reflexes must be absent:

  • Pupils unresponsive to light

  • Corneal reflex absent (no blink to cotton–wool touch)

  • Absent oculo-vestibular reflexes (no eye movements on instillation of ice-cold water into the external auditory meatus—visualize the tympanic membrane first)

  • Stimulation in the cranial nerve distributions produces no motor response

  • There is no gag reflex (on touching the palate) or cough reflex (to bronchial stimulation)

  • The apnoea test (perfomed last) demonstrates no respiratory response to an acidaemic respiratory stimulus: ventilation rate is reduced without inducing hypoxia, paco2 is allowed to rise ≥6.0kPa with pH ≤7.40.11,12

Diagnosis is made by 2 doctors competent in the procedure (registered for >5 years, one of whom is a consultant). Testing should be undertaken by the doctors together and must always be performed completely and successfully on two occasions.

Organ donation:

Diagnosis of brain death allows organs to be donated and removed with as little hypoxic damage as possible. Non-heartbeating organ donation is increasing in practice. Don't avoid the topic with relatives. Many are glad to help.

After death

See the relatives. Inform the gp and consultant. Inform the Coroner/Procurator Fiscal (if required). Sign death certificates promptly.

Facing and managing death

When you might raise death with your patient and you find yourself thinking it is better for them not to know, suspect that you mean: it is easier for me not to tell. Thinking about medicineMost patients are told less than they want.13

Acceptance

Accepting death may involve passing through stages on a path. It helps to know where your patient is on this journey (but progress is rarely orderly and is not always forwards). At first there may be shock and numbness, then denial (which reduces anxiety), then anger, then grief and then, perhaps, acceptance.14 Finally, there may be intense longing for death, as your patient moves beyond the reach of worldly cares.2JS Bach Ich habe genug

Hope

A dilemma when working with terminally ill patients is to avoid collusion and yet sustain hope. In doing this we need to understand what hope is, and why it can remain hope even when it may sound like despair. Hope nurtures within it the belief that what is hoped for may be realized. Initially this may be hope for recovery, or at least that death is long delayed. Yet for hope to continue developing it may have to move beyond an insistence on recovery and require facing or exploring the possibility of dying. Patients who contemplate dying as part of their hope may find the social support that once buoyed for a hope of recovery works against them—lack of support at this stage can result in resignation and despair. Hope beyond recovery is a more varied hope: the patient may simply hope to die with dignity, or for the continuing success of their children, or that a partner will find the support they need. For most people, such a hope becomes possible, but few find a meaningful hope which they are allowed to affirm.15 Hope beyond recovery may accept death (rather than life at any cost) and find a sense of ultimate meaning in a life lived, or hope in life after death (as a contingency of faith). Thinking about medicineIn patients who are terminally ill, psychosocial and spiritual needs are as important as symptom control.

The active management of death

Death may be regarded as a medical failure rather than an inevitable consequence of life. But when medical treatments can no longer offer a cure and a patient enters the last days and weeks of life, the active managment of death is vital. In the uk there are 10,000 deaths/week16 and few hospice beds, so the chances are that a death will be happening near you soon, and nobody will be in charge. Have courage and take charge. Find out about your patient's wishes, and comply with them. Thinking about medicineGet help promptly from palliative care teams. Take into account gmc guidance17 and current thinking expressed in the Gold Standards Framework.18 If a living will or advance directive is in existence, comply with it and promote your patient's autonomy. Thinking about medicineAt the end of life, autonomy trumps all else.3 Take strength from this clarity. Talk to the patient, relatives, and staff to get (and document4) consensus on what the patient's priority is (eg relief of suffering). Make sure pain relief is adequate, not to cause death, but to leave no opportunity for pain and distress to re-emerge (if that is the patient's implied or stated wish). A good death is one that is appropriate and requested for by a particular patient. It is wrong to assume that everyone's wish is the same. Some patients may choose to ‘rage against the dying of the light’5 and may never accept their end calmly.19 Whatever a patient's wishes, ensure that the resources and skills are available to meet their needs. Thinking about medicineSee pages [link][link] for practical advice on symptom control in those who are dying.

Prescribing drugs

Thinking about medicineConsult the bnf or bnf for Children or similar before giving any drug with which you are not thoroughly familiar; check interactions meticulously.

Before prescribing, ask if the patient is allergic to anything. The answer is often “yes”—but do not stop here. Characterize the reaction, or else you risk denying a life-saving, and safe, drug such as penicillin because of a mild reaction, eg nausea. Is the reaction a true allergy (anaphylaxis, [link], or a rash?), a toxic effect (eg ataxia is inevitable if given large doses of phenytoin), a predictable adverse reaction (eg gi bleeding from aspirin), or an idiosyncratic (unpredictable) reaction?

Remember primum non nocere: first do no harm. The more minor the illness, the more weight this carries. The more serious the illness, the more its antithesis comes into play: nothing ventured, nothing gained. These ten commandments should be written on every tablet:

  1. 1 Explore alternatives to drugs—which often lead to doctor-dependency (p [link]), paternalism, and medicalization of life. Drugs are also expensive (£ billions/yrUK) and prices increase faster than general inflation. There are 3 places to look:

    • The larder: eg lemon and honey for sore throats, rather than penicillin.

    • The blackboard: eg education about the self-inflicted causes of oesophagitis. Rather than giving expensive drugs, advise raising the head of the bed, and avoiding tight garments, too many big meals, smoking, and alcohol excess.

    • Lastly, look to yourself: giving a piece of yourself, some real sympathy, is worth more than all the drugs in your pharmacopoeia to those who are frightened, bereaved, or weary of life. One of us (jml) for many years looked after a paranoid lady: monthly visits comprised an injection and a hug, no doubt always chaperoned, until one day mental health nurses took over her care. She was seen by a different nurse each month. They didn't know about hugging, so after a while she stopped cooperating, and soon it fell to us to certify her death.

  2. 2 Are you prescribing for a minor illness because you want to solve all problems, or perhaps because it makes you feel better? Patients may be happy just to know the illness is minor. Knowing this may make it acceptable. Some people do not believe in drugs, and you must find this out.

  3. 3 Decide if the patient is responsible. If he now swallows all the quinine pills you have so attentively prescribed for his cramps, death will be swift.

  4. 4 Know of other ways your prescription may be misused. Perhaps the patient whose ‘insomnia’ you so kindly treated is even now selling it on the black market or grinding up your prescription prior to injecting himself, desperate for a fix. Will you be suspicious when he returns to say he has lost his drugs?

  5. 5 Address these questions when prescribing off the ward:

    • How many daily doses are there? 1–2 is much better than 4. Good doctors spend much time harmonizing complex regimens. One reason for ‘failure’ of hiv drugs, for example, is that regimens are too complex. Drug companies know this, so keep abreast of new modified release (mr) preparations.

    • The bottle/box: can the patient read the instructions—and can he open it?

    • How will you know if the patient forgets to return for follow-up?

    • If the patient agrees, enlist help (eg spouse/carer) to ensure he remembers to take the pills, or suggest blister packs that organize tablets by time and day.

  6. 6 Discuss side-effects and risk of allergy. We may downplay risk, but our drugs cause 1 million nhs admissions/yr (£1–2 billion/yr). Most drug deaths are avoidable.20

  7. 7 Use computerized decision support whenever you can. If the patient is on 7 drugs and has 5 complaints, the computer will help you find which of the drugs are possible culprits.21 Computers also warn about drug interactions.

  8. 8 Agree with the patient on the risk : benefit ratio's favourability. Try to ensure there is true concordance ([link]) between you and your patient.

  9. 9 Record how you will review the patient's need for each drug and progress towards agreed goals, eg pulse rate to mark degree of β‎-blockade.

  10. 10 List benefits of this drug to this patient for all drugs taken. Specify what each drug is for.

Prescribing in renal failure and liver failure: [link] & [link].

Surviving life on the wards

At the end of every day, with the going down of the sun (which we never see at the coalface of clinical medicine), we can momentarily cheer ourselves up by the thought that we are one day nearer to the end of life on earth—and our responsibility for the unending tide of illness that floods into our corridors and seeps into our wards and consulting rooms. Of course you may have many other quiet satisfactions, but if not, read on and wink with us as we hear some fool or visionary telling us that our aim should be to produce the greatest health and happiness for the greatest number.

When we hear this, we don't expect cheering from the tattered ranks of midnight on-call junior doctors: rather, our ears are detecting a decimated groan, because these men and women know that there is something at stake in on-call doctoring far more elemental than health or happiness: namely survival. Within the first weeks, however brightly your armour shone, it will now be smeared and splattered if not with blood, then with the fallout from very many decisions that were taken without sufficient care and attention. Not that you were lazy, but force majeure on the part of Nature and the exigencies of ward life have, we are suddenly stunned to realize, taught us to be second-rate: for to insist on being first-rate in all areas is to sign a death warrant for our patients, and for ourselves. Perfectionism cannot survive in our clinical world. To cope with this fact, or, to put it less depressingly, to flourish in this new world, don't keep re-polishing your armour (what are the 10 causes of atrial fibrillation—or are there 11?), rather furnish your mind—and nourish your body. Regular food makes those midnight groans of yours less intrusive. Drink plenty: doctors are more likely to be oliguric than their patients.22 Don't voluntarily deny yourself the restorative power of sleep. A good nap is the order of the day—and for the nights, sleep for as long as possible. Remember that sleep is our natural state, in which we were first created, and we only wake to feed our dreams.

We cannot prepare you for finding out that you are not at ease with the person you are becoming, and neither would we dream of imposing on our readers a recommended regimen of exercise, diet, and mental fitness. Finding out what can lead you through adversity is the art of living.

Junior doctors’ first jobs are not just a phase to get through and to enjoy where possible (there are often many such possibilities); they are also the anvil on which we are beaten into a new and perhaps uncomfortable shape. Luckily not all of us are made of iron so there is a fair chance that one day we will spring back into something resembling our normal shape, and realize that it was our weaknesses, not our strengths, which served us best. The jobs of junior doctors encompass huge swings in energy, motivation, and mood, which can be precipitated by small events. If you are depressed for more than a day, speak to a sympathetic friend, partner, or counsellor. Thinking about medicineWhen in doubt, communicate. And use an integrative philosophy of medicine, as described in this next section, to reclaim yourself.

Integrative medicine: beyond biopsychosocial models

The biopsychosocial model is the medical teacher's Grand Theory of Everything. It's like a game of ‘stones, scissors and paper’: the patient presents with a physical symptom, and the clever doctor trumps you, who had taken the symptom at face value, by revealing the social background that allowed the symptom to flourish. If the problem is social (eg poor housing), the clever doctor reveals the hidden asthma that this is causing, and if the symptom is purely psychological, the doctor reveals and manages the social effects of this for the patient's family. It's a powerful game,23 and much good comes from it.24 But like all orthodoxy it needs challenging.25 Let us consider Mr b, the builder, who comes to a&e having nailed his testicle to a plank. Everybody gathers round, but the clever doctor is annoyed that nobody is listening to his biopsychosocial diagnosis. The nail is removed; the testicle is repaired, but Mr b does not go on his way rejoicing. A nurse, a better listener than our doctor, uses an individually tailored moral–symbolic–existential approach to reveal that the injury was self-inflicted. A spiritual–cultural–ritualistic model may be needed for his care.26

As the author of the biopsychosocial model knew, there is more to medicine than stones, scissors, and paper, or any triad that does not integrate a rethinking of the task of medicine with infrastructure of relationships and beliefs.George Engel 197727,28

Quality, qalys, and rationing of resources

Resource allocation: who gets what

Resource allocation is about cutting the health cake—whose size is given. What slice should go to transplants, new joints, and services for dementia? Cynics would say that this depends on how vociferous each group of patients (or doctors) is. Others try to find a rational way to allocate resources. Health economists (econocrats) have invented the qaly for this purpose. nb: focusing on how to cut the cake diverts attention from how large the cake should be (is it better to spend money on space exploration or incontinence pads?).

How much is a life worth?

Some countries will spend $2–10 million to find a man on a life-raft; others will spend nothing (“he's just one more mouth to feed”).29,30 Totalitarian capitalist states (eg China) will take a different view to liberal democracies. In France, one life is worth a hundred cherry trees, if the blossom is fine.31

What is a qaly?

1 year of healthy life expectancy is worth 1 ‘quality adjusted life year’. 1 year of unhealthy life expectancy is worth <1 qaly (its value is lower the poorer health is)32. If you are likely to live for 8yrs in perfect health on an old drug, you gain 8 qalys; if a new drug would give you 16yrs but at a quality of life you rate at only 25% of the maximum, you would gain only 4 qalys. The dream of a health economist is to buy the most qalys for his budget. Health assessment organizations (eg nice) keep arbitrary figures in their head (∼£30,000/qaly—not evidence-based). If an intervention costs more than this, reasons for recommending it have to be all the more explicit or approval may be refused (the drug may be effective, but the cost is not). qalys can be recalculated (on very dubious grounds)33 after weighting for age and disease-seriousness34 to give the politically correct answer, for example in granting extra value to prolonging the last months of life.

qalys do help in rationing, but problems include pricing and invidiousness in choosing between people; a snag is that if we accept that the quality of our life is the quality of our relationships (Anthony Robins), and that this value is unquantifiable (1 wife is good, but 2 wives are not exactly twice as good),6 then we can see why bodies such as nice get excoriated over issues such as dementia drugs, when seemingly small improvements can cause disproportionate joy, as when a demented man becomes able to recall his wife's name.35,36 Should spouses put their own qalys into the sum?

The inverse care law & distributive justice

‘Availability of good medical care varies inversely with the need for it in the population served. This operates more completely where medical care is exposed to market forces… The market distribution of medical care exaggerates maldistribution of medical resources.’

There is much evidence in support of this famous thesis formulated by Tudor Hart.37 Premature death and long-term limiting illness are both strongly associated with deprivation.38 It is not just availability of care but access to services that matters. Those who need healthcare the least use services more, and more effectively, than those with the greatest need.39 Distributive justice is the fair distribution of health resources, based on the premise that all are equal in terms of healthcare provision (see also [link]). Ideally, sufficient healthcare would be provided to all, but the health cake isn't big enough for this. So, resources should preferably be distributed in relation to need, within a society that has equal access. In the uk, medical care does exist in deprived areas, but this does not ensure that services are accessed, or that they are of good quality.40

There is no doubt that if one wants to make a positive contribution to health, it is no good just discovering pathways, blocking receptors, and inventing drugs. The more this is done, the more urgent the need for distributive justice—that unyielding and perpetually problematic benchmark against which we are all judged.

If those who shout loudest get heard first, we need to know when to train our ears to be deaf.

Psychiatry on medical and surgical wards

Thinking about medicinePsychopathology is common in colleagues, patients, and relatives. Thinking about medicineSeek help for your own problems. Find a sympathetic gp and register with him or her. You are not the best person to plan your assessment, treatment, and referral.

Assessing mental state

‘Move gently through her thoughts, as one might explore a new garden’.Ian McEwan Atonement What is in bloom now? Where do those paths lead? What is under that stone? Focus on: Appearance (dress, cleanliness, physical condition); behaviour (eye contact, rapport, anxious? suspicious?); speech (volume, rate & tone); mood (subjective & objective); perception (hallucinations); thought form & content (formal thought disorder? delusions? obsessions? plan to harm self/others?); cognition (concentration, orientation, memory). Note insight (are his experiences the result of illness?). Non-verbal behaviour often gives more valid clues than words, ohcs p324.

Depression

This is common, and often ignored, at great cost to wellbeing. Thinking “I would be depressed in his shoes” may sap our will to help, and as biological features (early waking, ↓appetite, ↓weight, loss of interest in sex/hobbies) are common on all wards, we may not realize just how bad things have got. The central clinical features of depression can be assessed by asking:41Have you been bothered by feeling down, depressed, or hopeless in the last month?” If so, “Have you been bothered by lack of interest or pleasure in doing things?” If “yes”, depression is likely. There may also be guilt and feelings of worthlessness. Thinking about medicineDon't think it's not your job to treat depression. It is as important as pain. Try to arrange activities to boost the patient's morale and confidence. Share your thoughts with other team members, as well as relatives, if the patient wishes. Among these, your patient may find a kindred spirit who can give insight and support. Thinking about medicineIf in doubt, try an antidepressant. For ssris (eg citalopram, 20mg/24h), see ohcs p340. Cognitive interventions are just as important as drugs (ohcs p370), so liaise with the patient's gp pre-discharge.

The violent patient

Recognize early warning signs: visible distress, tachypnoea, clenched fists, shouting, chanting, restlessness, repetitive movements, pacing, gesticulations. Your own intuition may be helpful here. Thinking about medicine At the first hint of violence, get help. If alone, make sure you are nearer the door than the patient.

  • Do not be alone with the patient; summon security or the police if needed.

  • Try calming and talking with the patient. Do not touch him. Use your body language to reassure (sitting back, open palms, attentive).

  • Get his consent; if unforthcoming, emergency treatment can still be given to save life, or serious deterioration (under common law ‘necessity’ in England): You are acting against your patient's wishes but in order to adequately carry out your duty of care. Enlist the help of nurses who know the patient.

  • Use minimum force to achieve his welfare (but this may entail 6 strong men).

Causes:

Anger (long waiting times 46%, dissatisfaction with treatment 15%, disagreement with the physician 10%),42 alcohol/alcohol withdrawal (a common cause of problems on the ward; [link]), drugs (recreational; prescribed), hypoglycaemia, delirium ([link]), psychosis, psychopathy. Check blood glucose. Before further tests, haloperidol may be needed: 2–10mg im (allow 30mins for effect; max. 18mg/24h; monitor pulse, temp., and bp every 15min for 1h then every 30mins until ambulatory).

After a violent event:

Attend to your own and others’ wounds (get help as needed); report the event. Flashbacks, depression, insomnia, and need for time off are common.43

Capacity

If a rational adult refuses vital treatment, it may be as well to respect this decision, provided the patient has ‘capacity’. A person lacks capacity if they are unable to:

  • Make a decision because of a permanent or temporary impairment of, or disturbance in, the functioning of the mind, and are unable to: (≥1 of)

  • Understand the information relevant to the decision

  • Retain that information long enough to make a decision

  • Weigh up the information to make a decision, or

  • Communicate the decision. Capacity is decision and time specific and is rarely all or nothing, so don't hesitate to get the opinion of others. See [link] for the principles of capacity.

Mental Health Acts

Familiarize yourself with local procedures and laws pertaining to your country before your period of duty starts (ohcs p402).

The elderly patient in hospital

Thinking about medicineAgeing reflects the cumulative effects of stressors (eg free radicals) and mechanisms for dealing with them. For most of human history, life expectancy was <40yrs. An ageing population is a sign of successful social and economic policies.44

Healthy ageing

Health isn't just ‘complete mental and physical wellbeing’ (who) but also ‘a process of adaptation, to changing environments, to growing up and ageing, to healing when damaged, to suffering, and death. Health embraces the future so includes anguish and the inner resources to live with it.’Ivan Illich 1974 Medical Nemesis So healthy ageing is not a contradiction. Thinking about medicineContrary to stereotype, most old people are fit and at the happiest stage in their lives.7 , 45 80% of those over 85yrs live at home; 70% can manage stairs. Any deterioration in an elderly patient is from treatable disease until proved otherwise. Find the cause; don't think: this is simply ageing. Old age is associated with disease but doesn't cause it per se.46 Do not restrict treatment because of age—age alone is a poor predictor of outcome.47

Differences of emphasis in the approach to old people48

  1. 1 Multiple pathology: Several diseases may coincide (eg cataract + arthritis = falls).

  2. 2 Multiple causes: One problem may have several causes. Treating each alone may do little good; treating all may be of great benefit.49

  3. 3 Non-specific presentations: The ‘geriatric giants’50 of incontinence ([link]);51 immobility; instability (falls); and dementia/confusion ([link]) are common and any disease may present with these. Typical signs and symptoms may be absent (eg mi without chest pain; pneumonia, but no cough, fever, or sputum).

  4. 4 Rapid worsening if treatment is delayed: Complications are common.

  5. 5 More time is required for recovery: There is less ‘physiological reserve’.

  6. 6 Impaired metabolism and excretion of drugs: ∴ drug doses may need lowering.

  7. 7 Rehabilitation: Helps maximize independence, eg improving mobility and balance.

  8. 8 Social factors: These are central in aiding recovery and return to home.

Special points

Take a biopsychosocial approach ([link])52 (look for and manage interactions between physical, psychological and social aspects of a person's life).

  • Drug concordance ([link]): How many different tablets can he cope with? Probably not many more than 2. So which are the most important drugs? If difficulty in managing medicines, consider prescribing blister packs.

  • Social network: Are family and friends nearby? Do they visit regularly?

  • Care details: Are carers needed? Can meals be delivered? Are District nurses involved?

  • Make a holistic care plan. Include nutrition. If food is dumped beside a blind man and no one helps cut it up, he may starve. A passing doctor may arrange a ct ‘for cachexia’, when what he needs is food and cataract surgery.

Discharge planning

Thinking about medicineStart planning discharge from day 1. A very common question on ward rounds is: “Will this patient get on ok at home?” In answering this, take into account:

  • Does the patient live alone?

  • Does any carer have support?

  • Is your patient in fact a carer for someone even more frail?

  • Is the accommodation suitable? Stairs? Toilet on the same floor? (If not, can he transfer from chair to commode?)

  • Is the family supportive—in practice as well as in theory?

  • Are social services and community services well integrated? Proper case management programmes really can help and save money (∼20%).53

uk nhs national service framework (nsf) for old age: 8 care-standards

Person-centred care: Enabling older people to make choices about their own care.

Intermediate care: Promoting independence by providing intermediate care.

Hospital care: Delivering specialist care by staff who have the right set of skills.

Rooting out age discrimination: Providing services regardless of age.

Stroke: Treatment and rehabilitation of stroke patients by a specialist service.

Falls: Falls and fracture prevention through a specialist falls service.

Promotion of mental health: Ensuring effective diagnosis, treatment & support.

Promotion of health and active life in older age.

Solving diagnostic puzzles

Penny-dropping moments (pdms)

All pleasures are sensory—apart from those to be had by doing crosswords and diagnostics: both can give us delicious penny-dropping moments which come from combining logic with intuition (pdms, fig 1, [link]). With over 14,000 diseases to choose from,54 finding the diagnosis is a challenge (often thwarted by unconscious forces, see box). The process of how we diagnose receives little attention—it is assumed (wrongly) to entail collating information, which is then forced through a surgical sieve,8 which somehow leaves the correct diagnosis clinging to its sides.

Diagnosing by recognition

For students, this is the most irritating method. You spend an hour asking all the wrong questions, and in waltzes a doctor who names the disease and sorts it out before you have even finished taking the pulse. This doctor has simply recognized the illness like he recognizes an old friend (or enemy).

Diagnosing by probability

Over our clinical lives we unconsciously build up a personal database of diagnoses and outcomes, and associated pitfalls. We unconsciously run each new ‘case’ through this continuously developing probabilistic algorithm—eventually with amazing speed and effortlessness.

Diagnosing by reasoning

Like Sherlock Holmes, we must exclude each differential diagnosis, then, whatever is left, however unlikely, must be the culprit. This process presupposes that your differential does include the culprit, and that we have methods for absolutely excluding diseases. All tests are statistical rather than absolute, which is why this method is, at best, fictional.

Diagnosing by watching and waiting

Some doctors need to know immediately and definitively what the diagnosis is, while others can tolerate more uncertainty. The dangers and expense of exhaustive tests can be obviated by the skilful use of time.

Diagnosing by selective doubting

Traditionally, patients are ‘unreliable’ and signs are objective, and tests virtually perfect. When diagnosis is difficult, try inverting this hierarchy. You will soon realize there are no hard signs or perfect tests. But the game of medicine is unplayable if you doubt everything: so doubt selectively.

Diagnosis by iteration and reiteration

A brief history suggests looking for a few signs, which leads to further questions and a few tests. The process of taking a history never ends on this view, and as the process reiterates, various diagnostic possibilities crop up, and receive more or less confirmation. For example, when assessing a patient with atrial fibrillation ([link]) you notice finger clubbing and make a note to do a chest x-ray for signs of cancer. This leads you to ask about smoking, and then alcohol, which elicits excessive drinking due to recent redundancy.

Thinking about medicineThinking about thinking55-57

The rapid decision-making that is often required of doctors can be aided by heuristics—rules for cognitive shortcuts to quick decisions (conscious or unconscious) which are made without full information or analysis. Understanding how we use heuristics (ie by considering how a decision is made) can help us make effective choices, but there are pitfalls. Failed heuristics (biases) interfere with judgement and can lead to diagnostic error. Important examples include:

Anchoring:

A significant feature in the history is ‘anchored’ onto too early in the diagnostic process and is not adjusted for in light of later information. Adjusting probability by incorporating new information can help you become an intuitive thinker. Anchoring can be compounded by confirmation bias—the tendency to look for, notice and remember information that fits with pre-existing expectations.

Availability:

This explains our tendency to judge something more likely if it readily comes to mind. A recent experience with a disease increases the likelihood of it being diagnosed—problematic if the disease is rare, or has not been seen for a while.

Representativeness:

If diagnosis is driven by the extent to which a patient resembles a classic case of a disease, atypical variants will tend to be missed.

On being busy: Corrigan's secret door

“I work much better in chaos.” Francis Bacon58 Chaos is not always an enemy: certainly there is no shortage of it in hospitals, consulting rooms, and other battle-grounds. Can we prepare ourselves to use chaos well? Being forewarned allows us to be forearmed, enabling us to adapt to being busy, or at least to wink at each other as we slide down the cascade of long hoursexcessive paperworktoo few bedseffort–reward imbalancecompromised care from too few resourcestrouble with superiorsdifficult patientstoo many deaths59failure to reconcile personal and family life with professional roles.60 Logistic regression shows that our consequent problems are predicted by 5 stressors:

  1. 1 Lack of recognition of own contribution by others.

  2. 2 Too much responsibility.

  3. 3 Difficulties keeping up to date.

  4. 4 Making the right decision alone.

  5. 5 Effects of stress on personal/family life.61

We may think that it is modern medicine that makes us ever busier, but doctors have always been busy. Sir James Paget, for example, would regularly see over 60 patients each day, sometimes travelling many miles, on his horse, to their bedsides. Sir Dominic Corrigan was so busy 180 years ago that he had a secret door made in his consulting room to escape the ever-growing queue of eager patients.62

We are all familiar with the phenomenon of being hopelessly over-stretched, and of wanting Corrigan's secret door. Competing, urgent, and simultaneous demands make carrying out any task all but impossible: the junior doctor is trying to gain iv access on a shocked patient when his ‘bleep’ sounds. On his way to the phone a patient is falling out of bed, being held in, apparently, only by his visibly lengthening catheter (which had taken the doctor an hour to insert). He knows he should stop to help but, instead, as he picks up the phone, he starts to tell Sister about “this man dangling from his catheter” (knowing in his heart that the worst will have already happened). But he is interrupted by a thud coming from the bed of the lady who has just had a below knee amputation for non-healing leg ulcers: however, it is not her, but her visiting husband who has collapsed. In despair, he turns to the nurse and groans: “There must be some way out of here!” At times like this we all need Corrigan to take us by the shadow of our hand, and walk with us through a metaphorical secret door into a calm inner world. To enable this to happen, make things as easy as possible for yourself—as follows.

First, however lonely you feel, you are not usually alone. Do not pride yourself on not asking for help. If a decision is a hard one, share it with a colleague. Second, take any chance you get to sit down and rest. Have a cup of coffee with other members of staff, or with a friendly patient (patients are sources of renewal, not just devourers of your energies). Third, do not miss meals. If there is no time to go to the canteen, ensure that food is put aside for you to eat when you can: hard work and sleeplessness are twice as bad when you are hungry. Fourth, avoid making work for yourself. It is too easy for junior doctors, trapped in their image of excessive work and blackmailed by misplaced guilt, to remain on the wards reclerking patients, rewriting notes, or rechecking results at an hour when the priority should be caring for themselves. Fifth, when a bad part of the rota is looming, plan a good time for when you are off duty, to look forward to during the long nights.

However busy the ‘on take’, your period of duty will end. For you, as for Macbeth:

  • Come what come may,
  • time and the hour runs through the roughest day.

Riding the wave

In Macbeth, toil and trouble go hand in hand, but sometimes we work best when we are busy. This is recognized in the aphorism that if you want a job done quickly, give it to a busy (wo)man. Observe your colleagues and yourself during a busy day. Sometimes our energy achieves nothing but our own inundation. At other times, by jettisoning everything non-essential, we get airborne and accomplish marvellous feats. As with any sport, we have to break into a sweat before we can get into the zone, where every action meets its mark.

But note that what keeps us riding the wave of a busy day is not what we jettison but what we retain: humour, courtesy, a recognition of the work of others, and an ability to twinkle. A smile causes no delays, and reaches far beyond our lips.

Health and medical ethics

In our public medical personas, we often act as though morality consisted only in following society's conventions: we do this not so much out of laziness but because we recognize that it is better that the public think of doctors as old-fashioned or stupid, than that they should think us evil. But in the silences of our consultations, when it is we ourselves who are under the microscope, then, wriggle as we may, we cannot escape our destiny, which is to lead as often as to follow, in the sphere of ethics. To do this, we need to return to first principles, and not go with the flow of society's expectations. To give us courage in this enterprise, we can recall the aviator's and the seagull's law: it is only by facing the prevailing wind that we can become airborne, and achieve a new vantage point from which to survey our world.

Our analysis

starts with our aim: to do good by making people healthy. Good9 is the most general term of commendation, and entails four cardinal duties:

  1. 1 Not doing harm. We owe this duty to all people, not just our patients.63

  2. 2 Doing good by positive actions. We particularly owe this to our patients.

  3. 3 Promoting justice—ie distributing scarce resources fairly ([link]) and respecting rights: legal rights, rights to confidentiality, rights to be informed, to be offered all the options, and to be told the truth.

  4. 4 Promoting autonomy. This is not universally recognized; in some cultures facing starvation, for example, it may be irrelevant, or even be considered subversive.

Health

entails being sound in body and mind, and having powers of growth, development, healing, and regeneration. How many people have you made healthy (or at least healthier) today? And in achieving this, how many cardinal duties have you ignored? We cannot spend long on the wards or in our surgeries trying to ‘make people healthy’ before we have breached every cardinal duty—particularly (3) and (4). Does it matter? What is the point of having principles if they are regularly ignored? The point of having them is to provide a context for our negotiations with patients to form, where possible, a beneficial synthesis.

Synthesis

When we must act in the face of two conflicting duties, one is not a duty. How do we tell which one? Trying to find out involves getting to know our patient.

  • Are the patient's wishes being complied with?

  • What do your colleagues think? What do the relatives think? Have they his or her best interests at heart? Ask the patient's permission first.

  • Is it desirable that the reason for an action be universalizable? (That is, if I say this person is too old for such-and-such an operation, am I happy to make this a general rule for everyone?—Kant's ‘law’.)10

  • If an investigative journalist were to sit on a sulcus of mine, having full knowledge of my thoughts and actions, would she be bored or would she be composing vitriol for tomorrow's newspapers? If so, can I answer her, point for point? Am I happy with my answers? Or are they merely tactical devices?

  • What would a patient's representative think, eg the elected chairman of a patient's participation group (ohcs p496)? These opinions are valid and readily available (if a local group exists) and they can stop decision-making from being too medicalized.

Red flags on your wigwam

For each patient use a check-list to avoid skating over ethical issues. If a red flag pertains, ethical aspects are likely to be very important.

  • Thinking about medicineWishes of the patient are unknown (find out if a living will is in existence).

  • Thinking about medicineIssues regarding confidentiality/disclosure (eg hiv+ve but partner unaware).

  • Thinking about medicineGoals of care: are these confused and contradictory in any way?

  • Thinking about medicineWants to discharge himself against advice. Is he fully informed and competent?

  • Thinking about medicineArguments among relatives as how best to proceed: have you listened to all sides?

  • Thinking about medicineMoney problems relating to cost of care or earnings lost through illness.64

Troubled, troubling, and troublesome patients

Unless both the doctor and the patient become a problem to each other, no solution is found. Jung's aphorism67 is untrue for half our waking lives: for an anaesthetist there is no need for the patient to become a problem in order for the anaesthetic to work. But, as with all the best aphorisms, being untrue is the least of the problems they cause us. Great aphorisms signify because they unsettle. Our settled and smug satisfaction at finishing a period of duty without any problems is so often a sign of failure. We have kept the chaos at bay, whereas, if we were greater men or women, we would have embraced it. Half our waking professional lives we spend as if asleep, on automatic, following protocols or guidelines to some trite destination—or else we are dreaming of what we could do if we had more time, proper resources, and perhaps a different set of colleagues. But if we had Jung in our pockets he would be shaking us awake, derailing our guidelines, and saluting our attempts to risk genuine interactions with our patients, however much of a mess we make of it, and however much pain we cause and receive. (Pain, after all, is the inevitable companion to lives led authentically.)11 To the unreflective doctor, and to all average minds, this interaction is anathema, to be avoided at all costs, because it leads us away from anaesthesia, to the unpredictable, and to destinations that are unknown.

After proposing that ‘deep Thinking’ can only be attained by someone capable of ‘deep Feeling’, Samuel Taylor Coleridge, in 1801, went on to calculate on the back of a jocular envelope that ‘the Souls of 500 Sir Isaac Newtons would go to the making up of a Shakespeare or a Milton…Mind in his system is always passive…and there is ground for suspicion that any system built on the passiveness of the mind must be a false system”.68 Newtonian models of the consultation in which the doctor remains unmoved are all tainted by this falsity. So when you find yourself being irritated, moved, or provoked by your patient, be half-glad, because these feelings welcome you to Shakespeare's and Coleridge's world where the imagination ([link]) is the Prime Mover in the task of bringing about change in our patients.

So, every so often, be pleased with your difficult patients: those who question you, those who do not respond to your treatments, or who complain when these treatments do work. Often, it will seem that whatever you say is wrong, misunderstood, misquoted, and mangled by the mind you are confronting, perhaps because of fear, loneliness, or past experiences that you can only guess at. If this is happening, shut up—but don't give up. Stick with your patient. Listen to what he or she is saying and not saying. And when you have understood your patient a bit more, negotiate, cajole, and even argue—but don't bully or blackmail (“If you do not let your son have the operation he needs, I'll tell him just what sort of a mother you are…”). When you find yourself turning to walk away from your patient, turn back and say “This is not going very well, is it? Can we start again?” Don't hesitate to call in your colleagues’ help: not to win by force of numbers, but to see if a different approach might bear fruit. By this process, and by addressing the psychosomatic factors perpetuating your patient's illnesses, you and your patient may grow in stature. You may even end up with a truly satisfied patient. And a satisfied patient is worth a thousand protocols.

We all seek the reason for our own existence, and as we sit beside troubled, troubling, and troublesome patients we may dimly comprehend part of the reason, albeit in the background of our minds—even if, in the foreground, we are wondering why on earth this difficult patient has to exist, especially now when we are so busy and so stressed. The patient is likely to have their own unspoken metaphysical questions, for which you can be the midwife: “Why me?” “Why now?” Don't strangle these questions at birth: give them space to breathe, and who knows?

Medicine, art, and the humanities

If only we could live long enough to suffer from every disease, then we doctors could be of real service to our patients. There would be no need for medical humanities, as we would understand angina from the inside, and the fire of zoster's pain would no longer mystify us. We could die a thousand deaths for our patients. But still death would be untamed, and our self-anecdotal knowledge of disease would be irrelevant to patients from foreign lands. All patients inhabit foreign lands, and even our own hearts are alien to us unless melted by narrative streams. It is only through the humanities that, prude or peasant, prince or prostitute, we can extend our horizons and universalize anecdotal experience, so that nothing human is foreign to us.

Doctors’ and artists’ methodologies overlap, as we both create new realities: artists do this by bewitchment and by suspending reality. Doctors do it by listening and suspending judgement. A patient of ours had been trapped in an abusive marriage for 52 years. She had tried telling one other person, who had not believed her. The relief of being believed and listened to shone through her tears, as we collaborated over plans to bring change to her life. It is good to aim to listen to our patients with as rapt attention as we display when reading a good book. While reading, there is no point in dissembling. We confront our subject with a steady eye because we believe that, while reading to ourselves, we cannot be judged. Then, suddenly, when we are at our most open and defenceless, literature takes us by the throat, and that eye, which was so steady and confident a few minutes ago, is now misting over, or our heart is missing a beat, or our skin is covered in a goose-flesh more immediate than ever a Siberian winter produced. As the decades go by, not much in our mundane world sends shivers down our spines, but the power of art to do this ever grows, and sensitizes us to our patients’ narratives, and shows us there are many valid routes to knowledge other than the strictly objective.

The reason for the ascendancy of art over science is simple. We scientists, when we are not adopting our listening role, are only interested in explaining reality. Artists are good at explaining reality too: but they also create it. Our most powerful impressions are produced in our minds not by simple sensations but by the association of ideas. It is a pre-eminent feature of the human mind that it revels in seeing something as, or through, something else: life refracted through experience, light refracted through jewels, or a walk through the woods transmuted into a Pastoral Symphony. Ours is a world of metaphor, fantasy, and deceit.

What has all this to do with the day-to-day practice of medicine? The answer lies in the word ‘defenceless’ above. When we read alone and for pleasure, our defences are down—and we hide nothing from the great characters of fiction. In our consulting rooms, and on the ward, we so often do our best to hide everything beneath our avuncular bedside manner. So often, a professional detachment is all that is left after all those years inured to the foibles, fallacies, and frictions of our patients’ tragic lives. It is at the point where art and medicine collide that doctors can re-attach themselves to the human race and re-feel those emotions that motivate or terrify our patients. We all have an Achilles heel: that part of our inner self which was not rendered invulnerable when we were dipped in the waters of our first disillusion. Art and literature may enable this Achilles heel to be the means of our survival as thinking and feeling human beings.

If it is true that all the great novels, songs, and drama defy any single interpretation it is all the more true for the patient sitting in front of us. If we are not getting very far it is because we are using light when we could be using shade—or harmony in place of disharmony, or we are only offering a monologue when what we should be risking is dialogue—and the forging of new meanings.

The American approach is to create Professors of Literature-in-Medicine and to conjure with concepts such as the patient as text, and most American medical schools do courses in literature in an attempt to inculcate ethical reasoning and speculation. Here, we simply intend to demonstrate, albeit imperfectly, in our writings and in our practice of medicine, that every contact with patients has an ethical and artistic dimension, as well as a technical one.

Notes:

1 Make full & extensive attempts to reverse any contributing causes (hypoglycaemia, acidosis, hypothermia or drug intoxication). Patient's wishes via an advanced decision to refuse treatment must be respected.

2 Bach's cantata in contemplation of death Ich habe genug (I've had enough) expresses contempt for worldly life and a yearning for death and the life beyond. Inspired by Simeon's prayer Nunc Dimittis, it surrounds Simeon's encounter with Christ. Simeon had been told he would not see death until he had seen the Lord.

3 Provided our humanity remains intact (nb: good palliative care will, in general, enhance humanity).

4 Establish & document that: Thinking about medicineThe patient is dying and has initiated the request Thinking about medicineYou have discussed drug doses with an experienced Dr Thinking about medicineDose increases are proportionate and needed for symptom control.

5 Do not go gentle into that good night was written by Dylan Thomas for his dying father.

6 This is an example of a non-parametric quantity, ie a quantity where simple ordering may be valid, but not operations such as addition or multiplication. Most medical statistics are assumed to be parametric; this is often false, invalidating much research. statsoft.com/textbook/stnonpar.html

7 A big study (n=28,000) found the odds of being happy increased 5% with each decade. Contentment entails being socially active and accepting: “It's fine I was a schoolteacher, not a Nobel prize winner”.

8 When your mind goes blank, calm yourself by reciting the surgical sieve: The heart, the lung, the blood, the guts/The liver kidney spleen/The brain, the bones, the skin, the nodes/The bits that's in between.

9 Don't think of good and evil as forever opposite; good can come out of evil, and vice versa: this fundamental mix-up explains why we learn more from our dissolute patients than we do from saints.65

10 There are problems with universalizability: only intuition can suggest how to resolve conflicts between competing universalizable principles. Also, there is a sense in which all ethical dilemmas are unique, so no moral rules are possible or required—so they cannot be universal (Sartre, Nietzsche).66

11 “Some say that the world is a vale of tears. I say it is a place of soul making”—John Keats, the first medical student to formulate these ideas about pain. They did not do him much good, as he died shortly after uttering them. But his ideas can do us good. Perhaps if each day we try at least once for authentic interactions with a patient, unencumbered by professionalism, research interests, defensive medicine, a wish to show off to our peers, or a wish to get though the day without fuss.