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With the vast amount of extra money now going into the National Health Service, even hardened sceptics are beginning to say that some things are getting better. But in return for the extra investment, the Government has demanded accountability of a sort that sits uneasily with medical traditions of personal care, self-regulation and trust. Whether the public welcomes or bemoans the changes in their relationships with doctors is not yet clear, but many doctors are showing themselves unhappy. The demise of medical 'professionalism' is a main theme of Raymond Tallis's Hippocratic Oaths,1 and the subtitle, Medicine and its Discontents, warns the reader not to expect a consumerist view. The central character is scientific medicine, born innocent and enthusiastic. Challenges emerge and we feel that her love affair with the NHS may be doomed; but we end with a gleam of hope. Professor Tallis brings to his task the dual skills of a physician and a philosopher. In reviewing the work I too can claim double expertise though of a lower order—that of a senior house officer working in the NHS who has lately become a 'patient'.
Tallis begins by tracing the story of scientific medicine—a happy one in terms of cures and prevention but at the same time sad because of the 'loss of innocence' that comes from exposure of the large areas beyond its reach. Trials and research bring new discontents, with dilemmas over obtaining valid consent and the wayward attention of the media. Tallis focuses on communication as one area where patients are particularly dissatisfied; bad doctors, as he illustrates with some alarming cases, can be good communicators and vice versa. He also deals with the change to a more litigious society, and the repercussions of a culture that requires doctors to avoid blame. As one commentator on the book put it, the modern Hippocrates might say (though possibly more elegantly) 'first cover your arse'.2 Whatever the evils of medical paternalism, there was merit in the old culture whereby doctors could be merciful in the information they gave patients and their relatives and make decisions for them without fear of recrimination. Tallis is outraged that society's demand for rectitude and accuracy does not extend to the media and gives lengthy attention to the misdemeanours of journalists, especially in the MMR affair—the factual errors, the sensationalism, the way the convictions of a single distressed parent received more column inches than a scientific study in thousands. 'The media,' he concludes, 'had collectively made it impossible for the complex voice of true, as opposed to folk, expertise to be clearly heard and understood'. Another victim of his scorn is the target culture now imposed by Whitehall and enforced by local managers, with distortion of clinical priorities, and the mantra of 'patient-centred care' that generates in many doctors the irritation previously induced by 'evidence-based medicine'. In the final section, entitled Medicine's Destination, Tallis examines the notion that the success of medicine is leading to its failures. Increasing life expectancy brings increased demands on the health service by older people—or does it? This is one of the more optimistic chapters. But he soon returns to the gloomy thoughts that caused him to write the book. Will doctors become mere civil servants, doing the will of the Department of Health and abandoning their personal commitment to the individual?
Hippocratic Oaths has been greeted elsewhere with acclaim for the strength of the analysis and the quality of the writing, but it has also been criticized, notably by the former President of the General Medical Council Sir Donald Irvine, for medicocentricity: 'That an inward looking profession, obsessed with its own tribalism, collectively failed to make self-regulation work properly and so protect all patients from avoidable harm, is quietly ignored.'3 Though there is some justice in this remark there is in truth not much space between Tallis and the patient. What does the book say to a person such as me, proceeding up the lower rungs of the medical ladder? I am reluctant to accept that professionalism, in its best sense, is a lost cause. Evidently my seniors feel the same way, because the Royal College of Physicians has appointed a working party to define professional values in medicine and recommend on how these values can be maintained and strengthened.4 Maybe this working party is the beginning of the rebellion demanded by Tallis in order 'to lead medicine to the better future that science will make possible'. As a junior doctor I find that the worst threat to professional satisfaction is not management interference but pressure on time; I would love to spend more time sitting with the patient and talking through the illness and fears it generates. Unfortunately, patients quite often perceive that doctors have neither the time nor the energy to care; it is easy to see where tensions arise. What of my own experiences as a patient? They were overall good, though nobody could enjoy learning that life henceforth will be shaped by 'fate' or factors outside their control. Which is the point; medicine is not fluffy pillows and kind words. For most people, coming in contact with hospital medicine means at the very least a significant life change. Having worked in the NHS I had realistic expectations with regard to waiting, the uncertainties of diagnosis, and the time pressures on doctors. What I valued above all was being diagnosed and treated by individuals I could trust—by doctors who laid out the facts and uncertainties as known, told me the plan for the next stage and did not dress it up in a fancy box tied with a bow or distract me with talk of all the possible things that could go wrong or continuously ask me how I was feeling. Who cares if I had to wait, or the doctor was interrupted, or even appeared busy—as long as I had confidence in what they told me. Their role was to diagnose and treat, not provide a shoulder to cry on. 'I am lucky', I told my father (a paediatrician); but he pointed out that I was not lucky—my experience should be the norm. This is the sort of professionalism that Tallis and I, and even Sir Donald Irvine, would fight to preserve as medicine adapts continuously to social change.
Hippocratic Oaths should now replace Samuel Shem's House of God as the book to be read by everyone who thinks of going into medicine. Wise and humane, it will be enjoyed by anyone with a social conscience. As I struggle to reconcile my clinical commitments with the European Working Time Directive, I take heart that a strong defence is now being mounted for what is best in the professional ethic.