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Care
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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. 

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America
Comment
3 min read

America: two nations under God?

Red, blue, and rarely purple.

Graham is the Director of the Centre for Cultural Witness and a former Bishop of Kensington.

a tattered American flag flies against a blue sky.
Mario Sessions on Unsplash.

I've just come back from the USA. A few days on the east coast was a chance to take the temperature of America after its recent election, a brief impressionistic sense from conversations, reading the runes – and the blogs. In short, I had heard much about the divided state of America. I didn’t realise quite how divided it was.  

America has always made a great deal of unity. The vision for the USA imagined immigrants from different nations across the world invited to forge a new life in a new continent, leaving behind the divisions of the old world. It was the coming together of varied States across the vast continent into one Union. The language is everywhere. Most cities have a ‘Union Square’, Street or Turnpike. The chosen name itself was the United States of America. The slogan E pluribus unum – “out of many, one” was first featured on the original 1776 design of the Great Seal of the United States and formally adopted by the U.S. Congress as the nation's official motto in 1782. The American civil war of the nineteenth century was such a trauma for the nation precisely because it threatened that union. “One nation under God” says the pledge of allegiance, recited by every American child. Yet today it feels that a more realistic description would be two nations under God. The Disunited States of America. 

The split is pretty even. 73.7m people voted Democrat. 76.4m voted Republican. That itself is no great cause for alarm. What does cause alarm is the utter divide between the two groups. New York, for example. is pretty solidly Democrat. Someone who voted Trump told me they would never admit to it publicly because of the public shame it would bring. The same is true in the red states. To admit you voted Democrat in some Southern Baptist churches in Texas would be to invite social ostracism. Many Evangelical pastors who have their doubts about Trump have to keep quiet otherwise they would lose the support of their congregations and quite possibly their jobs. As a result, the only Evangelicals that tend to criticise Trump will be academics or journalists who have little to lose. 

As a taxi driver joked, if a young Democrat goes out on a date with someone they've met on Tinder, and discover their partner voted Republican, there is unlikely to be a second date. A Christian visitor centre in Washington DC tells me that they are looking forward to Trump being President again, because the flow of evangelical Republicans visiting the capital dried up during the past four years as they felt it was Biden’s town. It’s well known that nearly 80 per cent of white Evangelicals voted for Donald Trump. Such families were more likely to come to DC to see the seat of government if they knew ‘their guy’ was in the White House.  

It seems that in the current version of the USA, who you voted for is the number one identity marker. And the two groups rarely talk. In New York I preached in an Episcopal church. The Bible readings for the day spoke of ‘wars and rumours of wars’ – ‘everything will be thrown down’ – apocalyptic texts that invited me to talk about the election in the light of Jesus. Beforehand I asked the Rector what the voting pattern of the church was. “It’s genuinely purple” he said – “a mix of red and blue, Republican and Democrat, Trump and Harris. At least here they do talk to each other.” That seemed a rare thing in this deeply divided country.  

Jesus once said: “Every kingdom divided against itself will be ruined, and every city or household divided against itself will not stand.” Trump may well fix the economy and illegal immigration. Yet such deep division, especially in a nation whose identity rests of unity is perhaps a more existential threat.