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Care

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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

Books

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Community

15 October 2024

6 min read

The elegies that fail the forgotten places

Storytelling’s not about giving people a voice, it's about listening to what they’re singing.

Elizabeth Wainwright

Elizabeth Wainwright is a writer, coach and walking guide. She's a former district councillor and has a background in international development.

A book's front cover beside a portrait of the author, JD Vance

J.D. Vance book promotion, 2017.

Does it matter who tells the story of a place? It’s a question I’ve sat with as a writer, a community worker, and as someone who returned to my native West Country after a long time away. My departure and return to this place brought with it a sharper awareness of the labels this rural region could invite; of the way its people could be portrayed; of how easily they can be reduced to a one-dimensional stereotype that fosters little understanding.

And I am both reducer and reduced. I am a proud Devonian, rooted in soil thick with my ancestors, whilst also craving the culture and variety of elsewhere. My story of life in this place is complex. It’s a story that’s mine to tell, and not representative of anyone else from here – just as the people I’ve worked with in communities here and across sub-Saharan Africa taught me too: this person is not this place. This story is not this people.

Stories matter – stories told; stories hidden. They shape our identity, our opinions, our possibilities. John Steinbeck wrote that:

“A man who tells secrets or stories must think of who is hearing or reading, for a story has as many versions as it has readers. Everyone takes what he wants or can from it and thus changes it to his measure. Some pick out parts and reject the rest, some strain the story through their mesh of prejudice…”

Stories told reflect stories carried, like light refracted through a prism. A story’s colours tell us something about who tells the story and how they see the world. Which is one reason perhaps that JD Vance’s memoir Hillbilly Elegy: A Memoir of a Family and Culture in Crisis came under scrutiny, especially since he was named Donald Trump’s vice-presidential running mate in the forthcoming US election.

Hillbilly Elegy tells the story of Vance’s white working-class family, from his grandparents in the Appalachia region of Kentucky to his own coming of age in Middletown, Ohio. Vance raises questions about how local people, including his own family, are responsible for their own misfortunes, including poverty and addiction. His book came out in 2016, at just the right time to give many Americans an insight into why so many people like Vance’s relatives and past neighbours had voted for Donald Trump. It was painted as the voice of a forgotten community, and it became a bestseller, admired by some for its portrayal of Appalachian culture by someone from the inside. But reading people who know the places he talks of, it becomes clear that the book is “rife with stereotypes and classic Republican talking points peddled under the guise of lived experience,” as one commentator said.

Sarah Smarsh, author of books including Bone on Bone: Essays in America by a Daughter of the Working Class, said in a Guardian piece published in 2016,

“that the media industry ignored my home for so long and left a vacuum of understanding in which the first glimpse of an economically downtrodden white is presumed to represent the whole.”

A Bitter Southerner article responding to Hillbilly Elegy said that generalisation means that “…complexity gets simplified, the edges get rounded out[…]Appalachia has been written about and photographed in such a compelling (if fabricated) way that the descriptions of passersby took on more weight than the lived experiences of the people being described. What remains is a concept of a place that is both wildly romantic in its natural beauty and backward enough to justify the destruction of that very nature.”

We live in divided times, but often I find it hard to discern real division versus the media-created story of division. Theirs is a story that gets things wrong. Smarsh reflects how “countless images of working-class progressives…are rendered invisible by a ratings-fixated media that covers elections as horse races and seeks sensational b-roll. This media paradigm created the tale of a divided America…” This is why it matters that we hear stories that do not fit that paradigm. A many-voiced 2019 publication Appalachian Reckoning: A Region Responds to Hillbilly Elegy offered some of those stories in response to Vance’s painting of Appalachia.

Vance thought he could write the story of a 13-state region, but many Appalachians were unhappy about him becoming their spokesperson, especially when he seemed to blame the poor for their poverty. Appalachian Reckoning is a graceful counter to this: not silencing Vance’s own story but offering many more views and stories from Appalachia. Its co-editor Meredith McCarroll said she wanted to “complicate any singular view simply by including multiple ones. I wanted to create a chorus of voices, “each singing what belongs to him or her and to no one else,” to borrow from Walt Whitman’s view of place.” The publication offers cultural nuance, emotional connection, and a “context for some of the claims Vance makes in his book when it moves beyond memoir, and to pass the mic to a wider range of writers, poets, photographers, activists, and artists who make Appalachia a place far too complex to capture and far too dynamic to die.”

This approach feels important now, in the world as is it, with a media that often overlooks nuance, and with a culture that has become so visual that the way things are styled and framed and presented to us online can often be quite different to the reality. It is important to know the difference, and stories can help us discern that.

This symphony of existence can, if we give each voice its space, subvert paradigms of division and fear.

There are stories that are easy to peddle and easy to buy into. In charity work, I saw how the story of the benevolent professional outsider could shape things, leaving little room for local stories and experience. In politics I saw how the story of opposition got in the way of all the people getting on with the everyday work of restoring and caring for their communities across lines of difference. We can, unknowingly, make a place and a people shrink or even disappear with the stories we carry or amplify, or ignore.

Stories wielded unwisely can shrink faith as well as people and places. The Jesus who I did not grow up with but came to know slowly as an adult is a Jesus of nuance, compassion, and deep listening. He would not, I think, recognise the brand of Christianity that can be used to justify particular politics. That religion and politics have in places become so intertwined is perhaps a reflection of the reduction of the vastness of the Bible and the many diverse voices it contains into one story that serves a particular group of people. Jesus again and again subverted what empire and hierarchy and tradition expected of him. He invited people into his story over and over, curious about their own story but never using it as a reason to include or exclude.

When I think about who tells the story of a place – or of a people, a time, a faith – I see that really, there is never one story anyway. There is a chorus of voices, each a little different, each part of a vast harmony that – if we have the ears and heart to hear it – sings a song of challenge and joy, of despair and illumination. Former US president Woodrow Wilson said, “the ear of the leader must ring with the voices of the people”. Storytelling is not about giving people a voice – something I heard a lot in charity work. It is about listening to what they’re already singing. This symphony of existence can, if we give each voice its space, subvert paradigms of division and fear, of biased framing and selective storytelling. It can sing us back to ourselves, helping us see each other. And isn’t that what softens hearts, isn’t that why we tell stories? Author Kazuo said in his Nobel acceptance speech that “stories are about one person saying to another: This is the way it feels to me. Can you understand what I'm saying? Does it also feel this way to you?” Stories are not tools of manipulation or power, but pathways to encounter, to relationship, to understanding. They are, perhaps, the only way through divided times.