Article

Care

Comment

21 June 2023

5 min read

The healing touch in an era of personalised medicine

As data powers a revolution in personalised medicine, surgeon David Cranston asks if we are risk of dehumanising medicine?

David Cranston

David Cranston is emeritus Professor of Surgery at Oxford University. As well as publishing academically, he has has also authored books on John Radcliffe, and mentoring.

A doctor looks thoughtful will holding a stethoscope to their ears.

Photo by Nappy on Unsplash.

In 1877 Arthur Conan Doyle was sitting in one of Dr Joseph Bell’s outpatient clinics in Edinburgh as a medical student, when a lady came in with a child, carrying a small coat. Dr Bell asked her how the crossing of the Firth of Forth had been on the ferry that morning. Looking sightly askance she replied;

“Fine thank you sir.”

He then went on to ask what she had done with her younger child who came with her.

Looking more astonished she said:

“I left him with my aunt who lives in Edinburgh.

Bell goes on to ask if she walked through the Botanic Gardens on the way to his clinic and if she still worked in the Linoleum factory and to both these questions she answered in the affirmative.

Turning to the students he explained

“I could tell from her accent that she came from across the Firth of Forth and the only way across is by the ferry. You noticed that she was carrying a coat which was obviously too small for the child she had with her, which suggested she had another younger child and had left him somewhere. The only place when you see the red mud that she has on her boots is in the Botanic Gardens and the skin rash on her hands is typical of workers in the Linoleum factory.

It was this study of the diagnostic methods of Dr Joseph Bell led Conan Doyle to create the character of Sherlock Holmes.

A hundred years later and I was young doctor. In 1977 there were no CT or MRI scanners. We were taught the importance of taking a detailed history and examination. Including the social history. We would recognise the RAF tie and the silver (silk producing) caterpillar badge on the lapel of a patient jacket. We would ask him when he joined the caterpillar club and how many times he had had to bail out of his plane when he was shot down during the war – a life saved by a silk parachute. We would notice the North Devon accent in a lady and ask when she moved to Oxford.

The patient’s history gave 70% of the diagnosis, examination another 20% and investigation the final 10%. Patients came with symptoms and the doctor made a presumptive diagnosis – often correct - which was confirmed by the investigations. Screening for disease in patients with no symptoms was in its infancy and diseases were diagnosed by talking to the patients and eliciting a clear history and doing a meticulous examination. No longer is that the case.

At the close of my career, as a renal cancer surgeon, most people came in with a diagnosis already made on the basis of a CT scan, and often small kidney cancers were picked up incidentally with no symptoms. The time spent talking to patients was reduced. On one hand it means more patients can be seen but on the other the personal contact and empathy can be lost.

Patients lying in in bed have sometimes been ignored. The consultant and the team standing around the foot of the patient’s bed discussing their cases amongst themselves. Or, once off the ward, speaking of the thyroid cancer in bed three or the colon cancer in bed two. Yet patients are people too with histories behind them and woe betide the medic, or indeed the government, who forgets that.

With computer aided diagnosis, electronic patient records and more sophisticated investigation the patient can easily become even more remote. An object rather than a person.

We speak today of more personalised medicine with every person having tailored treatment of the basis of whole genome sequencing and knowing each individual’s make up. But we need to be sure that this does not lead to less personalised medicine by forgetting the whole person, body mind and spirit.

Post Covid, more consultations are done online or over the telephone -often with a doctor you do not know and have never met. Technology has tended to increase the distance between the doctor and patient. The mechanisation of scientific medicine is here to stay, but the patient may well feel that the doctor is more interested in her disease than in herself as a person. History taking and examination is less important in terms of diagnosis and remote medicine means that personal contact including examination and touch are removed.

Touching has always been an important part of healing. Sir Peter Medawar, who won the Nobel prize for medicine sums it up well. He asks:

‘What did doctors do with those many infections whose progress was rapid and whose outcome was usually lethal?

He replies:

'For one thing, they practised a little magic, dancing around the bedside, making smoke, chanting incomprehensibilities and touching the patient everywhere.? This touching was the real professional secret, never acknowledged as the central essential skill.'

Touch has been rated as the oldest and most effective act of healing.

Touch can reduce pain, anxiety, and depression, and there are occasions when one can communicate far more through touch than in words, for there are times when no words are good enough or holy enough to minister to someone’s pain.

Yet today touching any patient without clear permission can make people ill at ease and mistrustful and risk justified accusation. It is a tightrope many have to walk very carefully. In an age of whole-person care it is imperative that the right balance be struck. There’s an ancient story that illustrates the power of that human connection in the healing process.

When a leper approached Jesus in desperation, Jesus did not simply offer a healing word from safe distance. he stretched out his hand and touched him. He felt deeply for lepers cut off from all human contact. He touched the untouchables.

William Osler a Canadian physician who was one of the founding fathers of the Johns Hopkins Hospital in Baltimore, and ended up as Regius Professor of Medicine in Oxford, said:

“It is more important to know about the patient who has the disease than the disease that has the patient”.

For all the advantages modern medicine has to offer, it is vital to find ways to retain that personal element of medicine. Patients are people too.

Article

Attention

Comment

War & peace

1 November 2024

5 min read

Put poppy politics in the past and give Remembrance a hopeful future

Memory without hope will lead us to a dead-end.

Mark Gilbert

Mark is a research mathematician who writes on ethics, human identity and the nature of intelligence.

A woman walls along a war memorial wall covered in red poppies.

War memorial in Canberra.

Raelle Gann-Owens on Unsplash.

Remembrance Day is complicated. A nation shows its gratitude for the service and sacrifice of its armed forces and tries to connect to its history. Never far away, are poppy politics, along with anxiety about identity and forgetting, and fears about nationalism and militarism. Is this the way to remember?

Last November, protests in solidarity with Gaza dominated the headlines. On Armistice Day, hundreds of thousands of people marched through central London to demand a ceasefire. In the preceding weeks, there was vigorous debate about whether the march should be cancelled. There were several motivations for this: there were genuine fears of violence and extremism, and of disruption at the Cenotaph, but also questions of whether marching on Armistice Day was inappropriate or disrespectful.

The march itself was organised to minimise the risk of disrupting public commemorations of Remembrance. It started several hours after the two-minute silence and followed a route several miles from the cenotaph. It was mostly peaceful, although there were arrests for anti-Semitism, open support for terrorism and violent attacks on police officers. Armistice Day did see violence around the cenotaph, but this was from the self-described ‘Cenotaph Defenders’ who had organised a counter-demonstration against the Gaza march. The group of football hooligans and far-right EDL members gathered with poppy emblazoned banners declaring ‘Have some respect for British Heroes’. Within a few hours, the calls for respect had degenerated into violent attacks on serving uniformed officers, in this case the police.

The far-right’s adoption of remembrance symbolism can be seen as an extreme form of a wider entanglement of poppies and politics. The red paper poppy is a symbol of remembrance, but it has other connotations. For some it invokes patriotism and feelings of pride in their country, for others it represents conformity and militarism. Whether television news presenters are wearing them attracts disproportionate attention. In 2019, one Australian TV network had a very tasteless segment denouncing a rival station whose newscasters failed to wear poppies. The non-poppy wearing hosts were accused of failing in their duty to respect their country and to help preserve its culture and traditions. Regardless of the presenters’ actual reasons, this feels like a lot of baggage to load onto the delicate poppy, a symbol of quiet remembrance and gratitude.

Unsurprisingly, this has led many to question whether Remembrance Day has become detached from its original purposes. Twelve years after the death of the last British First World War veteran, there is little living connection to either of the two world wars. With this passage of time, there is a growing danger of mistaking the symbols of ceremonial Remembrance for the thing itself.

The focus of remembrance can shift away from the sheer horrors of war, from awe at the sacrifice of our forebears, and from the resolved ‘never again’ to fixing our gaze on the processed goods: the ceremonial silence, the poppies themselves and even the quality of our own emotional response.

Some commentators have suggested that organised Remembrance has served its purpose and is best forgotten, and that too much remembering is a bad thing, fuelling grudges and sectarian conflicts. Personally, I’m not convinced, but I do think our current Remembrance is missing something.

With a strong grounding in a shared past and a common hope, we would talk frankly about the times our country has fallen short without a sense of betraying our history or identity.

Reflecting on the importance and difficulty of memory, the writer and Holocaust survivor Elie Wiesel emphasised the importance of hope. Despite the horrific experiences of the twentieth century, for Wiesel it is hope that “summons the future”. Memory without hope would lead us to a dead-end, where we grip onto the past while feeling it slip like sand through our fingers. Many of the anxieties around Remembrance point to a hope deficit.

How can we remember with hope?

We need to broaden our perspective and engage better with our shared national story. We need to be grounded in our history, stories and myths but we also need to be drawn forward by the good things we have and will have. If this story is big enough then it will be a large tapestry of interwoven strands, and we will be able to generously incorporate new strands, other cultures with their own relationship to the past into it. We will also be better prepared for our remembering to deal with difficult questions about our nation’s history. With a strong grounding in a shared past and a common hope, we would talk frankly about the times our country has fallen short without a sense of betraying our history or identity. Hope would connect us better to our neighbours overseas and to the men and women who risk their lives to serve their country.

Last Remembrance Sunday, I helped our church’s under-7s make big paper poppies out of red paint and paper plates. The older children made origami peace cranes, and both the big red poppies and the peace cranes were placed by the altar. Here the focus is on remembering, but not just on our own memory. For me and countless other Christians, God’s memory is the real focus. God remembers us in our broken and war-torn world, and as Jesus, chose to join us in it, experiencing the worst of suffering while dying a painful death. All our personal and collective stories of pain, loss and sadness are met in this sacrifice. More than this, in the promises of restoration Jesus gave when He rose from the dead, they find a concrete hope.

What does Remembrance look like when it’s really grounded in hope? I think there would be a few noticeable signs. It would be less precious about itself. It would be more open to different emphases of remembrance such as the Peace Pledge Union and the white poppy, and excited about new creative expressions of remembrance like the ‘poppy walks’ organised by the Royal British Legion. More patient to the concerns of those who find the religious elements of Remembrance difficult. More integrated into our attitudes to current and ongoing conflict around the world. Most of all I hope it would make us really hungry for both peace and for righteousness.