Between Art and Science Sits the Patient

‘Ars longa, vita brevis’.

The Latin inscription is above the entrance door to the Postgraduate Medical Centre at the Hull Royal Infirmary. It is a salutary reminder to the physicians and surgeons who gather there in the pursuit of furthering their medical knowledge. Translated into English, the phrase enjoins us to remember that ‘art is long, life is short’. The original quotation was not in Latin but in Ancient Greek, and can be found at the beginning of a medical text book written by that well-known ancient physician, Hippocrates. The rest of his quotation reminds us that ‘opportunity is fleeting, experiment dangerous, and judgement difficult’.

Although written sometime between 460 – 370 BC, Hippocrates’ aphorism is as pertinent now as it was 2,400 years ago. The ‘art’ he speaks of is not that which we would commonly think of as art today (paintings, sculptures, literature etc.). Hippocrates’ art is the art of medical practise, and in the early years of the 21st century medicine remains just that; an art. Today, however, the modern physician would extend the concept by saying that medicine is ‘an art based on science’. The word science is also of Latin origin, meaning ‘knowledge’. The phrase ‘evidence-based medicine’ is perhaps the commonest way modern physicians refer to the inter-relationship of art and science when applied to medical practise.

What this all means is that medicine is far from being able to offer a perfect solution to every single ailment that besets humankind. In the consulting room, the most a doctor can be expected to do is to diligently apply (the art) the most contemporary knowledge (the science) to a patient’s presented problem. Sometimes great cures are brought about; occasionally there is little that can be done; more often than not, the work of the doctor is to modify the symptoms suffered by the patient in order to make life more pleasurable. The latter is summed up in another (19th century) aphorism: ‘to cure sometimes, to relieve often, to comfort always’, which neatly returns our thoughts to Hippocrates and his idea that ‘judgement is difficult’.
Doctors make judgements all the time; judgements are the end results of their application of art and science to patients’ problems. Judgements are not perfect and, ipso facto, neither are doctors or medicine; which is one reason why I believe that it is the duty of responsible newspapers not to be over-dramatic about small gains in medical science. Often a small scientific gain presents doctors with just another tiny piece of knowledge in the vast jigsaw of medicine, based on which judgements are made. It is rare that significant life-changing discoveries are made which will greatly influence the treatment of today’s patients.

A good example is the recent national press coverage of how the effects of certain drugs in combination can (by something called their anticholinergic effect on the nervous system) increase the risk of cognitive impairment (confusion and dementia-like symptoms) and death in people over the age of 65 years. No doubt my colleagues across the country had patients arriving in surgery clutching those newspaper cuttings, anxiously querying the effect of their drugs. The fact is the survey was based on drugs commonly used in the early 1990s. Twenty years later, many of those drugs are no longer used, or are rarely used in the combinations stated. Science has moved on and thus, too, has our art.

When I was a cub scout in the 1960s, we would salute our Arkela with the words ‘Arkela...we’ll do our best’. As far as doctors are concerned, the words of Hippocrates are more erudite than the ‘grand howl’ of the cubs. Nonetheless, the meaning is the same. Patients...we’ll do our best; but please remember we practise an art based on science; a science which is not, and never can be, perfect.

First published in the Scunthorpe Telegraph, Tuesday 12th July 2011.

Being Human

Have you ever wondered what is it that makes us human? What are the particular aspects that make you and me different; not only from other animals, but from every other one of the seven billion people alive today on this planet? The permutations are enormous. However, it is the small variations in physical and personal attributes which allow us to identify one person from the next.

Yet, amidst this pot pourri of the world’s humanity there are emotional traits which allow us to empathise with our next door neighbour, sympathise with struggling tribes in Africa, go to war with other countries, or fall in love with someone far removed from our own community. These are the complex peculiarities which bind us all together in that group called human-kind or humanity.

Stemming from the same Latin origin as the word ‘human’ is the term ‘humanities’; the academic disciplines that involve the study of that which we term the ‘human condition’. Included within this group are literature, art, music, languages, law, history, philosophy and ethics. By increasing our knowledge of these topics we can begin to really understand what it is to be human.

However, here lies a conundrum. We often turn to the doctor, and most specifically the GP, for help at times of both physical and emotional difficulty with the expectation that he or she will understand what it is that we are experiencing. After all, that is what doctors are trained to do, isn’t it? Paradoxically, the reality is that this is one area where doctors have the least training, and the problem starts early on when we are choosing A Level subjects. Traditionally, budding medical students are encouraged to study biology, chemistry and physics; three sciences that assist us to understand the physical nature of the body, and enable us to diagnose and repair it when something has gone wrong. We are academically forced, at a formative stage, to abandon those subjects which are equally important to achieve a rounded education and produce experts in understanding human-kind.

This omission is what has led some universities to now include a humanities module within their training programme for medical undergraduates. In addition, it is now possible to study for a Master of Arts degree in medicine and literature; investigating the interaction between the two disciplines. After all, some of the world’s greatest authors knew a thing or two about what being human really entails. Think, for example, of the works of Emily Brontë (Wuthering Heights), Shakespeare (A Midsummer Night’s Dream), Tolstoy (Anna Karenina), James Joyce (Ulysses), Thomas Hardy (The Woodlanders), Charles Dickens (Bleak House), Charlotte Brontë (Jane Eyre), D H Lawrence ( Women in Love), E M Foster (A Passage to India), and Evelyn Waugh (Decline and Fall). The list is endless. All these authors explored the emotional depths of humanity; that is why their works have found a lasting place in our collective souls; their characters are reflections of what it is to be human; to be you and me in all our times of trial and happiness.

So next time you wonder whether your GP is up to date, don’t ask which medical journals he or she is reading; ask whether your GP has recently read a classical novel. If the answer is ‘yes’, you may have found a doctor who really understands what being human is all about.

First published in the Scunthorpe Telegraph, Wednesday 15th June 2011

How Useful is the Establishment of a Duty of Care for our Armed Forces?

Much has been written in recent months regarding the ‘duty of care’ this country has to its armed forces. Such a duty does not have to be enshrined in statute law and the establishment of such a duty is often left to the common law to determine in respect to individual cases. However, it is a welcomed fact that the duty is being enshrined within the Armed Forces Bill currently moving its way through parliament.

That said, whilst many people were, through the media of press and television, publically rejoicing at the Government’s decision, I was led to consider what such inclusion might mean in reality, and whether it was just a statement of the existing situation rather than a positive move towards establishing that which most people really want; that is, practical care of our serving forces personnel and their families, along with appropriate after-care when they leave the forces (and especially so if they are injured). The best way I can describe my concerns is to consider the duty of care which exists in respect to the role of healthcare personnel to our patients.

The Oxford Dictionary of Law defines ‘duty of care as ‘The legal obligation to take reasonable care to avoid causing damage’. Clearly, that is an understandable duty in respect to the actions of a doctor, for example. However, the same concept does not translate very well to a soldier serving in the front line of a war zone. In medicine, it is a duty which has been established in common law and is enshrined within the General Medical Council’s Code of Practice for doctors. From a patient’s perspective, the purpose of establishing a duty of care is to ensure that the patient is treated well. The flip side is, of course, that a patient might seek legal remedy should there be the perception that something has gone wrong in the process of that duty being performed. Therein often resides the difficulty, for establishing negligence (and thus being eligible for compensation) is a tortuous path to tread.

To establish negligence a patient must first show that there existed a duty of care; that done, the next step is to prove that there was a failure on the part of the doctor to fulfil that duty. Finally, it has to be shown that the failure directly led to the injury for which the patient seeks compensation. If there is no injury sustained, or the causal link between the three factors cannot be proven, then there is no remedy in law as negligence has not been established.

In medicine, the whole process is often confounded at the second hurdle, as what constitutes good or appropriate care is not always clear-cut within a profession that is only partially based on science. The Bolam test is often quoted, being a judgement stemming from a 1957 court case (Bolam v. Friern Hospital Management Committee), when it was established that ‘a doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art’. So, if it is as difficult as that within the realm of healthcare, what hope does the family of an injured soldier have, where the boundaries are even less clear? I fear that the current inclusion may be a good start, but the victory may still prove to be very hollow in a practical sense.

First Published in the Scunthorpe Telegraph, Monday 30th May 2011