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

Comment

Mental Health

Poetry

15 October 2024

4 min read

Auden and our anxious age

While the tropes of trauma are still with us, how to not die in our dread?

Jack Nicholson

Jack is a graduate of Peterhouse, University of Cambridge and Blackfriars, University of Oxford. He works in local government.

An outdoor vigil is lit by people holding up mobile phone lights.

Oxford's peace vigil.

BBC News.

Faces along the bar

Cling to their average day:

The lights must never go out,

The music must always play . . .

Lest we should see where we are,

Lost in a haunted wood,

Children afraid of the night

Who have never been happy or good.

This week, we mark the 85th birthday of W. H. Auden’s poem ‘September 1st, 1939’. He describes four solitary drinkers in New York on the cusp of the Second World War. September 1st, 1939: Hitler invades Poland. Those four faces struggle to find meaning in their lives.

In a later, much longer poem of 1947 (first UK edition, 1948) Auden built on this theme, having lived through the War, to identify an ‘Age of Anxiety’. He wrote, ‘We would rather be ruined than changed / We would rather die in our dread / Than climb the cross of the moment / And let our illusions die.’

I have been reflecting on this of late, especially in light of a recent night vigil for peace, remembrance, and unity at Bonn Square, Oxford, where I live. This took place on 7 October, the anniversary of the Hamas attack on Israel in 2023: the darkest day in Jewish history since the time that Auden wrote his poems.

In an Age of Anxiety, Auden wrote, ‘the world needs a wash, and a week off’. The gathering in Oxford was especially poignant because some 250 people chose to go out in the rain, on their Sunday-evening time off, and in the darkness, to hear prayers and readings from different communities. It was as if the world was awash with people coming together.

The Bishop of Oxford the Rt Rev’d Dr Steven Croft said, ‘Our purpose is simply to be together.’ People simply had to do ‘something in the face of the helplessness that we all feel, in the face of these terrible events’. Louise Gordon, co vice president of the Oxford Jewish Congregation, described people ‘clinging to hope’. Imam Monawar Husain stressed that togetherness as such is a ‘symbol’, a symbol of hope.

Symbols abounded. Candles were lit. In ‘September 1st, 1939’, Auden described ‘Ironic points of light’ which

Flash out wherever the Just

Exchange their messages:

May I, composed like them

Of Eros and of dust,

Beleaguered by the same

Negation and despair,

Show an affirming flame.

The crowd spontaneously joined in with the protest song ‘Where Have All the Flowers Gone’, which was first sung in 1955.

It is striking that so many of the tropes and themes concerning what has gone wrong with the world, from our perspective, were already apparent and received clear expression from 1939 through to the mid- to late-1950s, in terrible events, then in thought, poetry, and protest song, in an age of anxiety.

If there are similarities between Auden’s age and our own, then we should be encouraged by that.

Sociologists described the ‘lonely crowd’ in 1950. This suggests that people seek more approval and acceptance from others as the physical distance between them diminishes and society becomes increasingly geared toward consumption. The capacity to come together for peace, remembrance, and unity becomes far less likely.

Philosopher Max Picard lamented the loss of the ’World of Silence’ in 1952: the capacity to be still. And later, in 1958, the word ‘meritocracy’ was first used to describe a dystopian world in which merit (IQ + effort) reigns, replacing previous relational bonds, a sense of togetherness, exemplified in the gathering in Oxford in 2024.

C. S. Lewis, in Oxford in the late 1950s, identified friendship as a kind of love which is regarded 'in the modern world' as 'quite marginal; not a main course in life's banquet', which is especially true if we bypass the banquet and spend our time at the bar (or, worse, online, at home). Louise Gordon, at the vigil, also spoke of the way in which people were counterculturally 'clasping hands in friendship'.

When sociologists today describe the ‘lonely century’ (Noreena Hertz) or when so many sigh over our inability to sit, or stand, in silence, in some sense at least they have not identified anything new. War crimes are, sadly, all too familiar to us. And recently, the lawyer Stephen Toope identified an ‘age of anxiety’ today.

It is not as simple, however, as saying that we have been anxious for the last seventy years. Auden’s age was also one of creativity of which the Anglosphere has been proud, for instance, around the foundation of the National Health Service in 1948. His generation stared into the abyss. They did not die in their dread.

If there are similarities between Auden’s age and our own, then we should be encouraged by that. Lamentation is as old as love, and the choice is as stark as he put it in his poem 85 years ago: ‘love one another or die’.

The notion of vigil is equally old. Today, vigils are held for peace, remembrance, and unity. In Christian liturgy, however, a vigil is specifically a watch during the night, looking forward to the dawn of a new day. ‘As the night watch looks for the morning’, likewise the people wait for Christ, their saviour.

That silent watch is far removed from the solitary ‘faces along the bar’ who ‘cling to their average day’. Horrible events such as those which took place on September 1st, 1939 or October 7th, 2023 bring people together in common purpose, simply to be together and to cling instead to hope for a better tomorrow.

Anxiety is replaced by hope.

Candles are lit. It may well rain. But song will be sung. And people of good-will, having climbed ‘the cross of the moment’, will show what Auden described: that great ‘affirming flame’.