Article
Care
Comment
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 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
Christmas survival
Comment
Eating
Joy
4 min read

Share some food and find the antidote to despair

Who we eat with says who we are.

Isaac is a PhD candidate in Theology at Durham University and preparing for priesthood in the Church of England.

Three people stand beside a table and smile.
Lewisham Mayor Brenda Dacres with foodbank volunteers.
Lewisham Foodbank.

In my local supermarket a new foodbank collection trolley has appeared with this sign,  

“Gift a toy this Christmas…give a gift this Christmas to those who need it most.” 

 Setting aside the usual ethical dilemma presented by the existence of foodbanks (why do they exist in such a wealthy country?), the sign prompted a thought on the nature of joy. What is more joyful than the surprise of an unexpected gift? After all, Christmas is around the corner, “Joy to the world!”.  

That thought came to mind when I was recently asked; how do we cultivate and foster joy? If I’m honest I was a little stumped by the question. What even is joy anyway?  

We can too easily and readily conflate it with lesser feelings like happiness or pleasure, which by their nature seem to be fleeting, like a chocolate bar: here one moment, gone the next. Thinking about it, joy seems to be thrown into relief when it is set against one of its opposites: despair. We all know what despair looks like; loneliness, isolation, a hopelessness which can yawn like a great dark chasm, without edges to get purchase on, or without a hand to hold. 

Christmas can be an especially potent time for despair. The days are short and often dimmed by heavy cloud and rain. Children’s expectation that Santa will bring all of the latest goodies drives parents into debt to make their hopes come true. Those in dire straits will struggle to scrape together the food that goes into the usual Christmas feast. This combination of dark days and high expectations can and does drive many further into despair. It is this sense of aloneness, of the weight of the world heaped on your shoulders alone, which fuels despair. 

This despair is not only reserved for Christmas. We see the climbing rates of anxiety, depression, and other mental health issues in the younger generations. Having been born into the age of the internet and growing up with social media, the temptation to compare with the heavily edited and curated lives of others, encouraged by the platform algorithms themselves, only serves to make young people feel increasingly alone.  

This feeling is not helped by the propaganda of the age; that we are all rational, autonomous individuals, whose fulfilment looks like self-reliance, status, and wealth, without the need for anyone else. All this breeds the solipsism and nihilism that so often morphs into despair. 

Foodbanks are the proof that this most basic constituent of joy is a struggle for many, from the sheer lack of food to share 

What does this despair tell us about joy? If despair is in isolation, bearing our burdens alone, then joy is in being with other people. To return to that chocolate bar, if happiness (and perhaps the despair which comes from having no more chocolate bar) is scoffing it by ourselves, then joy is breaking off a part and sharing it with another. Human beings are naturally social creatures. It is in our very nature to live with one another. If we remain alone, closed off to others, then we nurture the despair that this breeds.  

An incredibly simple way we remain connected to each other is by sharing food. If despair is the isolation from others then sharing food is the negation of this isolation. Sharing food is universally important, whether it’s the realpolitik of American high school films (the jock table vs the dork table and who’s allowed to sit with who, encapsulated perfectly by Mean Girls), or the mystical heights of the Christian eucharist. Who we eat with says who we are, with all the potential for exclusion the examples above show. But eating with others says what we are. Sharing food, especially in celebration at a time like Christmas, reminds us that our humanity is only ever shared. This reminder that we are not alone is not a fleeting happiness; it is a confirmation in our very flesh and bones that we are made of the same stuff, that we are never alone. 

Many of us will have this joy as part of our everyday lives; foodbanks are the proof that this most basic constituent of joy is a struggle for many, from the sheer lack of food to share. The sign that appeared in my local supermarket is more proof that we already know how simple joy can be. Many foodbanks organise specifically festive food for this season, because we know that not only sharing food, but celebrating in that sharing is crucial to what it means to be human. Even in the morally mixed ecosystem of the foodbank, the need for joy shines through; sharing food in celebration is one of those antidotes for despair. In sharing our food we find our humanity, and what is more joyful than that? 

 

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