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The most obvious changes in medicine over the past half-century have been in technology and treatments: new drugs and surgical and laboratory techniques have transformed the way we practise medicine. Yet the heart of medical practice remains, as it has been for thousands of years, the relationship between the physician and the person ‘who is or who believes himself to be ill’. But this too has changed. In the 1950s, many medical practitioners believed their professional secrets were none of the public's business. Medications were labelled cryptically ‘The Mixture’ or ‘The Tablets’, and the dispensing of coloured water as a tonic or the injection of sterile water placebos was acceptable practice. Patients were advised to follow ‘doctor's orders’, and a close interest in the details of their conditions was considered unhealthy. Even 25 years ago, to tell a patient he or she had a fatal illness was thought dangerously radical by some, and hospital records were marked ‘Confidential—not to be handled by the patient’. Nowadays I am bothered when patients are unable to tell me what tablets they are taking; how could they give an adequate history to an unknown doctor in an emergency? Patients who say ‘I take the little white ones—I don't know what they are for doctor’, who would once have been considered well behaved, are now irritating. Like most of my colleagues I tell my patients as much as I can about their condition (subject to the limitations of my knowledge, the medical evidence, their understanding of their bodies and the time available, which taken together often means not much).
As Muir Gray points out in The Resourceful Patient1, this change is part of a wider social evolution as a consumerist egalitarian society replaces a hierarchical bureaucratic one. Professions lose power, the ‘lower orders’ are more sceptical about authority figures, postmodernism and New Age thinkers question medicine's scientific foundations, and in the past few years a new force has appeared, whose impact we are only just beginning to suspect—the Internet. Just as computers have made possible ‘evidence-based medicine’ by allowing rapid and systematic access to research evidence, so the Internet makes medical information previously only found in medical libraries or expensive books potentially available to all who wish to access it. Electronic patient-held medical records will be the norm within a few years. Muir Gray believes these factors will create the ‘resourceful patient’, a person as well informed as the doctor about treatment and prognoses.
How will this affect the doctor—patient relationship? In many instances probably not a lot. Books on car maintenance have been in the public library all my life but I have never chosen to read them; I rely on the competence and diligence of my garage. Many people will I suspect, for good or ill, take the same view of their bodies. For some patients, however, access to this information will change the doctor—patient relationship considerably—as it were from that between primary-school teacher and pupil to that between PhD student and supervisor. The doctor will not be a purveyor of information but a sounding-board for ideas, testing the logic and pointing out issues that the primary researcher—the patient—has overlooked. Muir Gray paints a rather positive vision of this Enlightenment relationship, but there are potential difficulties. Not all the information available to patients is sound; there are lots of people with financial interests only too eager to persuade patients to buy or get their doctors to prescribe drugs of dubious benefit. There are some very strange ideas around about the body and how it works which give rise to what a colleague refers to as ‘lunatic medicine’. Part of the new role of doctors will be to help people sort out this tangle of truth, half-truth and falsehood. This will require new skills and a new attitude from many doctors.
Communicating risk, probability and uncertainty is not something we are good at, and we will need to learn it well and quickly. Most of us pick up what we know about explaining illness by example or trial and error. Communication skills stand in dire need of a sound evidence base. As Muir Gray points out, we will need much better and more rapid access to reliable information than in the past, which will require new ways of working.
Whilst the rational model of the adult patient and her physician supervisor is attractive, not all doctor—patient encounters are so rational. Muir Gray points out that doctors act also as healer, witchdoctor, drug and St Peter—approving access to illness. This does not apply only to the ignorant or foolish: we all need parent—child as well as adult—adult relationships at times. I vividly remember a senior academic sociologist and patient of mine coming in with 'flu and saying with striking insight ‘I need permission to adopt the sick role’.
As with many innovations, these changes threaten to advantage the rich and educated at the expense of the poor and ignorant, who remain marginalized. This is not because the latter group are necessarily stupid or uninterested in what is going on with their bodies: having worked with culturally and socially varied populations I can vouch that this is not the case. But not all will have ready access to the Internet and the time or skills to use it to their advantage. Encounters with resourceful patients take time, and this may well be at the expense of the less resourceful. Muir Gray has written a thought-provoking but in some ways unsatisfying book. It surveys the area and raises many important questions, but does not organise the issues or suggest more than fragmentary answers. It is not clear how he thinks the problems raised here (and many others) should be addressed. It is a beginning not an end; the issues it raises will be with us for a long time hence.