There are things that make you despise humanity – going shopping at IKEA on Saturday afternoons, or attending one of the European parliament’s stagiaire-feeding Tuesday evening buffets, come to mind.
Talking to Professor Raymond Tallis, a geriatric specialist at Manchester University, makes you despise patients.
It is the view from the other side, as it were. I am not saying the highly intelligent, thoughtful prof Tallis, named by Prospect magazine one of Britain’s top 100 thinkers, perhaps the UK’s top medical philosopher, is a misanthropist but, reading between the lines, sand removing his caveats, one gets the sense of frustration put on consultants feel about the behaviour of patients to a greater or lesser extent – even, perhaps, you.
Complaints against doctors about the poor communication skills are on the rise, Tallis notes in Hippocratic Oaths, his recent memoir of life in the medical profession. He tries to explain how this has come about, through explaining the constraints of the profession and the inevitable differences in the patient/doctor perspective..
The conflicts begin when, having worked on his internal narrative as to what is wrong with him, the patient encounters the doctor for the first time. The doctor is, as it were, a late entrant into the conversation between the patient and his inner self, between patient and relatives and friends. The doctor will discard some of the things the patient says – even though they will be of great personal importance to the patient. – as extraneous, and upgrade other things that patient may regard as minor.
Tension will arise. A medical retelling of the story, designed as a basis for appropriate action, might be seen as a “defoliation” of the personal tale the patient has nurtured. The passage of history taking from open to closed questions presage a physical examination where the patient ceases to become a speaking subject and becomes a proffered body-as-object.
Doubtless journalists and writers who have been giving the medical profession such a hard time over the years would see this process as a power struggle between God like consultant and powerless patient, where the patient is doomed to lose his “humanity”. But in fact, what the consultant is supposed to bring to meeting is not personal knowledge of the patient’s travails but impersonal expertise which allows the problem the patient has brought to the clinic to be solved. It is this objectivity that enables him to do his job,
If eliciting information about the patient leads to tensions enough, deciding what to tell the patient about his conditions leads to even greater difficulties. How much should the patient be told? How much technical information would he or she comprehend? How much can they cope with? How much do they want to be told?
Many patients’ interests groups, claiming to speak on behalf of patients, would say: everything. But some patients want to be kept in the dark. With other patients there is no set limit to how much they want to know – the name and the star rating of the surgeon, even though the surgeon might not be selected until a very late stage. Patients who want to know it all might have entirely appropriate demands, but this pays no heed to the unbearable time pressures consultants often suffer; there are other patients, in the waiting room, also wanting their share of attention.
Communication with the patient is often limited by his ability or knowledge to comprehend the vast new areas of biological information now relevant to him; the diagnosis is the beginning of a journey of learning – and yet it is often felt the consultant is incumbent on effecting complete understanding in the patient, in one session.
As diagnosis comes to medical action, one problem is that of consent, required for any procedure that carries significant risk. But what is significant risk? British doctors have a rule of thumb that anything with a 1/200 chance of happening, and anything with a much lower chance of happening if that side effect could cause death or serious injury. Since there are so many things that could go theoretically speaking wrong that the patient’s life – as Tallis demonstrates in an example involving his mother – is sometimes in danger as a long list these days has to be checked off before the operation can go ahead. Nevertheless, there will be operations carried out, for which there is an infinitesmally small chance which the patient isn’t told about, which then happens, and leads to a disappointed and angry patient saying they would not have had the operation had they known of this risk. One example is that of Jo Knowlesly, who ha ppened to be a Mail on Sunday journalist, and who wrote about her ordeal in her paper.
She was admitted to hospital for laparoscopy, a common procedure in which, though a small incision and through using a cleverly designed scope, the doctor is able to examine the abdominal cavity for diagnostic purposes. It is an essentially safe procedure, and a vast improvement on earlier diagnostic methods. In Knowlesly’s case there was a perforation of the abdomen, which only happens once in 2,000 cases. A larger incision had to be made to stitch up the perforation; as a result Knowlesly spent three days longer in hospital. When she woke up, despite being apologised profusely to, she was very angry because she hadn’t been told of this risk, and that she would not have consented to it – even if the probability was much lower than the 1.200 chance. Even though she fully recovered she wrote a four page article about her ill treatment by the NHS and sued the hospital.
Poor communications are just one source of dissatisfaction with the modern doctor; I will spare you for the moment the others,. Summarising his chapter, Tallis writes that the “causes range from the incommensurability of personal experience of illness with the scientific understanding of it, to the impossibility of finding the limits of what should be should be communicated.”
