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

Climate

Comment

Politics

27 November 2024

7 min read

Neighbours, nimbys, and politician power plays

Is there a politics that takes both love of the land and climate concerns seriously?

Joel Pierce

Joel Pierce is the administrator of Christ's College, University of Aberdeen. He has recently published his first book.

A sign protesting a proposed wind farm stands on flat moorland.

A Scottish wind farm protest sign.

Richard Webb, Wikimedia Commons.

It was easy to forget the fury of the past few winters in the gentle light of the golden autumn which enveloped our corner of rural Aberdeenshire over the past month. The scars Storm Arwen tore through the landscape three years ago, toppling whole hillsides of trees, and the flood-soaked fields of last winter were hard to conjure when faced with the thousand colours that painted the landscape. The smoky green of pine forests in twilight, the shocking scarlet of apples my daughters picked from our neighbour’s tree, the little violet fireworks of elderberry clusters hanging above the path to our house, these chased away worries about the future and the past and demanding attention to the present. Amid this array, it was easy to see why Queen Victoria chose our corner of Scotland for her rural retreat over a century and a half ago. The changing of the season has something of the eternal, sacred, and inviolable in it. “Let the field be joyful and all that is therein; then shall all the trees of the wood rejoice,” sang the ancient Psalmist. Surely, if ever a land was obedient to this command, it was our valley’s, this October. Surely too, it is our duty to preserve it so that it can sing out for a thousand more such autumns?

This drive to preserve is evident in the signs that appear regularly on fences as you drive through our valley. “STOP MONSTER PYLONS” and “NO WINDFARM ON HILL OF FARE” they say in capital letters large enough to communicate their creators’ anger. Our valley, which connects the Highlands to the sea, is prime real estate for the sorts of development necessary to transform the UK economy, which still gets 77 per cent of its energy from burning fossil fuels, into one built on renewable energy. Our hills are ideal for turbines and our land must be crossed if transmission lines are to carry electricity from wind farms in the north to population centres like Edinburgh, Glasgow, Manchester, and London. To many of my neighbours this sort of construction amounts to an industrialisation of the countryside, an irreversible scarring of pristine land in service of interests far away which care little for them. This view is common enough that almost all of the local village councils have expressed opposition to the developments. When my neighbours are characterised by senior government ministers as “the blockers, the delayers, the obstructionists”, I suspect it only hardens their resolve.

It is not hard to imagine Adam the gardener or Abel the shepherd attending to their land and animals with similar care to that of my neighbours.

Sometimes I wonder if what politicians have in mind when they think of my neighbours are the sorts of toffs featured in Rivals for whom the countryside is a playground of upper-class indulgence. I am not rich. Neither are most of my immediate neighbours, many of whom rely on waiting tables at the local farm shop or cleaning holiday lets to make ends meet. My understanding is that most of the local farmers consider themselves lucky if they turn any profit at all from their long and exhausting hours. Every year we wonder if there will be enough pupils to keep our local primary school open. Every winter we prepare for the inevitable interruptions caused by power cuts, school closures, and unplowed roads.

If I had to guess at what keeps my neighbours here it is the land itself, watching and admiring it, caring for it, aligning the rhythms of their life to it. Autumn can be wonderful, but so too is spring. I drive to work past newborn lambs trying out their stilt-like legs, anticipate the sudden return of house martins to their nests under our eves, and enjoy weekend walks up the hillsides amid the sun-yellow mazes of coconut-scented gorse bushes. Each season land presents itself to us, demands our attention, calls for our admiration.

In the two creation stories of Genesis, what it is to be human is to be made in the image of God and to be given the task of tilling and keeping the land, respectively. A way of reading these together is that humans are to be priests to creation, recognising and praising its beauty and caring for it in a way which reflects God’s love for it. In my last article for Seen & Unseen, I discussed philosopher Alasdair MacIntyre’s concept of practices and how the human activities he identifies as practices can order and give meaning to our lives and communities. Another way of thinking about these practices is that they are all, in some way, an expression of this original edenic imperative, to see, to respond to, and to care for God’s creation. If this is true of any practice, it is perhaps most transparent in rural ones. It is not hard to imagine Adam the gardener or Abel the shepherd attending to their land and animals with similar care to that of my neighbours.

The practices we engage in have a way of becoming enmeshed with our identity in such a manner that it can be hard to imagine ourselves without them. That is why, I believe, opposition to wind farms and pylons runs so deep here, and why, as geographer Patrick Devine-Wright has demonstrated, attempts to offset the financial downsides of developments through local grant programmes and other compensation do very little to swing public opinion in favour of development. As he demonstrates, at the root of such opposition is an affective attachment to the land, one that money cannot buy away and which resists even the most well-reasoned arguments which attempt to ignore it.

And yet, I know, my neighbours know, that all is not well with the land. Although we draw sizable crowds on Easter and Christmas, the most packed I’ve ever seen our parish church was when a locally born climate scientist came to present his research on Antarctica. He walked us through what it is like to live there, how scientists survive the winters, and what they eat, but all anyone was interested in the Q&A that followed is what can be done about climate change. It is hard to ignore it. It is there in the good and the bad: in the pleasant, nearly tropical breeze that ushered my children from house to house on Halloween; in a mild winter making ticks and Lyme’s disease a regular visitor; and in the onslaught of storms felling fifty year old forests in a single night and cutting road and railway connections to the rest of Britain for days on end. If we are to keep these changes from becoming more extreme, if we are going to bequeath to our grandchildren a countryside with the beauties admired by Queen Victoria and countless others, we need to slow this change. We need to move away from fossil fuels and to renewably generated electricity and given that, as I said above, 77 per cent of our energy is still made by burning carbon, we need to produce not just a little more electricity, but a lot. The answer to the oft repeated question, “Wouldn’t these be better, if they were built somewhere else?” is that, yes, they will need to be built somewhere else and here, and in many other places, if we are going to get anywhere close to a carbon-free future.

The land will be changed either way. Our choice is some scarring now, or a terminal decline later.

What might a politics look like that both took my neighbours’ attachment to the land and these realities seriously? What it shouldn’t be is one that castigates my neighbours for that attachment. That only feeds suspicions that what is really at play is an exploitation of the countryside to feed the excesses of the cities. Such exploitation runs deep in the folk memory of Scotland. The Clearances only lightly touched our valley, but a little travel here or there takes one by abandoned villages. Those who resisted then, clinging tightly to their land, also might have been called blockers, delayers, and obstructionists by modernising absentee landlords the sitting rooms of their Edinburgh townhouses, intent on replacing them with more profitable sheep.

However, the possibility exists for drawing my neighbours’ attachment to the land into the conversation about why these developments are needed. The land, the planet, is sick, and sometimes the scars of a necessary surgery are a price worth paying for survival. The alternative to roads rising up our hills to turbines and to transmission lines cutting through now fertile fields is a future of longer droughts, hotter heat waves, and more extreme storms, bringing with them infertile fields, forest fires, and landslides. The land will be changed either way. Our choice is some scarring now, or a terminal decline later.

But for such a rhetoric to work, politicians need to be serious about everyone bearing someone of the burden of climate solutions, both here in the UK and across the world. It can be tempting to give up hope in this regard. More than one article about our area has cited farmers complaining about how what we do won’t really matter anyway since China and India will burn away any positive effects of renewables here. But there are problems closer to home too. When UK governments and traders gush about the possibilities of new, power-hungry technologies like AI and cryptocurrency it can give any discussion of net-zero an air of unreality. Turbines and transmission lines can be part of caring for the land and can be shown to be in continuity with those other practices of care, but if other changes aren’t made, they will be as useful as a keyhole surgery on a patient who is bleeding out.