The Human Side of Medicine
by James Willis
Talk given to the South West Trainers Conference At The Headland Hotel, Newquay, Cornwall
25 November 2004
The title of this talk The Human Side of Medicine – not suggested by me but happily agreed by me – implies that there must be an inhuman side of medicine. Or perhaps it implies that ‘humanity’ in medicine is something that needs arguing for, or defending.
All of this is true. Although describing humanity as a ‘side’ of medicine does raise the question of how many other sides of medicine there may be.
Just one perhaps – in which case humanity is the ‘other side of the coin’ from inhumanity and therefore, at least in that respect, on equal terms.
Or perhaps humanity is just one ‘side’ of an old-fashioned threepenny-bit of medicine, almost encircled by the remaining 11 sides. This may sound paranoid but sometimes it does feel like that.
What I am sure is that if humanity and inhumanity are different sides of any sort of ‘coin’ of medicine they are very much more different kinds of sides than heads are from tails — different kinds of things altogether.
While the inhuman side of medicine is broadly speaking digital (and I will explain what I mean by this) the human side is analogue. In other words these two sides are very much more different than chalk is from cheese. Because chalk and cheese are both material things that can be touched, tentatively tasted, weighed in the balance, and counted.
And in the brave new world, if you can’t count something… it doesn’t count. 'Houston,' as the man at the console once said, 'we have a problem'.
Brave New World
In 1946 Aldous Huxley wrote an introduction to a new edition of his book Brave New World, explaining why he had changed nothing from the original of 1931. He feared that in correcting its errors he might destroy its merits.
But he admitted some regrets; one was his failure to make any reference to nuclear fission in his imagined Seventh Century of Our Ford Utopia. But more importantly, he regretted the starkness of the alternatives which he had offered to his hero the Savage – an insane life in Utopia, or the life of a primitive in an Indian village – which led inevitably to his (the Savage’s) despair and suicide. In 1946 Huxley said he would have offered a third alternative:
…between the utopian and the primitive horns of his dilemma would lie the possibility of sanity…
In this middle way, Huxley said (amongst other things),
…science and technology would be used as though, like the Sabbath, they had been made for man, not (as at present and still more in the Brave New World) as though man were to be adapted and enslaved to them.
This is (*was - see box above)a simple human story (not really a general practice story, but then my remit today is the humanity — or lack of it — of medicine in general) but the story is part of my unmediated, first-hand experience, close to me in both space and time — it is in fact, just the sort of anecdote that doesn’t count, because for one thing it isn’t part of a randomised, controlled trial. But at the same time it is actually the sort of thing that really matters.
And I tell the story to make a very specific point: the way the orthopaedic registrar behaved as though by merely ordering the test specified in the standard procedure he had fully discharged his responsibilities to his patient, regardless of the circumstances and the implications of the six-month delay.It’s not the sort of treatment you’d get from an osteopath, that’s for sure!
Moving OutSo what I want to talk about – is a kind of moving out from personal, seat-of-the-pants practice based on independent professionalism, to a kind of fly-by-wire practice in which, as in so many other aspects of modern life, our dealings are with the front-end, the interface, of some intermediary system rather than with the thing itself. All Process rather than purpose. And the whole system is a) too complex for us to understand and b) not changeable by us even if we could understand it. ‘This is your life’, the message reads, ‘Do not open — no user-serviceable parts inside’.
To a very large extent this is a change we have all accepted. Indeed we equate it with progress itself. Because rational organisation and systematisation are so obviously the heart of the modernisation which has bought such spectacular benefits and made a fortunate few of us who happen to live in the developed world into the most privileged generation in human history. But at the same time we fortunate few are deeply ambivalent towards the new way of doing things. You only have to say ‘It’s Progress isn’t it’ in almost any context, to get a weary laugh. We all sense that this progress is a two-edged sword, which brings bad things as well as good.
I want to share with you, to use the contemporary phrase, some thoughts about what is going on. And what we can do about mitigating those bad things while retaining the good.
Digital and Analogue
This spoof ‘photograph’ shows Albert Einstein counting on his fingers – or in other words, on his digits.
It is a curious fact that we all of us do count on digits, or at least on digital substitutes, like beads, numerals, or clever micro-electronic elements with the capacity to remember whether they represent 0’s or 1’s. Curious because we tend to think of our brains as computers. But if they were computers with their 100 thousand million neurones, which not only Einstein’s but every one of ours have (give or take a few thousand million), not to mention 80 thousand-or-so connections between each of those elements, surely they wouldn’t have to resort to external devices to do simple arithmetic. After all, you don’t see an electronic computer, even the simplest with many orders of magnitude fewer elements than a human brain, picking up an abacus to do its sums.
So I don’t think you need more than a normal amount of intelligence to work out that the human brain is not a digital computer. The only amazing thing to me is that as far as I know this is an original idea. So, if those 100 thousand million neurones haven’t evolved to do that – what have they evolved to do? Because it is obvious that human evolution has reached an extraordinary pitch of perfection in every other way – just think of an Olympic gymnast, think of the sophistication of our immune system. And to me the answer is equally obvious – human brains have evolved to model the world. And to model it in all its beauty, sophistication and subtlety. Especially in all its humanity – because mankind has evolved as a social animal par excellence and a huge amount of our brain-power is concerned with social interactions. And the crucial point is that the model is not digital as computer models invariably are, but analogue. Different kinds of things altogether – far more different than chalk from cheese. And I think the belief that the human world can be adequately modelled, or in fact can be better modelled, mathematically and logically, and that that model can be encoded in digital terms, is an error of gigantic historical proportions. The assumption, which is today’s orthodoxy, that ‘progress’ requires change in this direction is at the heart of the perceived inhumanity of modern centrally-directed medicine. I think we have to recognise this reality, talk about it and work towards a wiser and more balanced way, we have to find Huxley’s middle way.
But this wiser view won’t come from the centre, the centre is having a wonderful time bossing doctors about without having to take any of the responsibility or get their hands dirty and has far too much to lose from the approach I am advocating, and anyway from their viewpoint the entire inhumanity problem I am describing is completely invisible – they simply don’t know what people on the front-line are talking about. So my thesis is that general practitioners, and I mean ordinary GPs, the more immersed in the job the better, especially British GPs, and as far to the West as possible (humanity seems to thrive in the Celtic fringes) have a unique contribution to make to this advance whose implications extend far beyond the field of medicine.
The Contribution from General Practice
It may seem pretentious to try and say new things about science from a background in general practice, but that is what we must do. GPs are in a unique position, they have one foot in science and one foot in the most intimate aspects of humanity, they are the last professional generalists and they are experts in balancing apparently incompatible priorities. But as far as the subject I am discussing is concerned GPs have a unique insight into the practical consequences of a great uncontrolled experiment that is going on – the subjection of an immensely complex human-scale activity, general practice, to formulaic control on the population scale – and like front line workers in numerous other walks of life we are finding that this sort of human activity can’t be controlled from the centre in that sort of way.
God discovered this (and it doesn’t matter whether you mean God, or Nature, or both by this) when ‘He’ gave mankind fee-will, in the Garden of Eden allegory, which has survived down the ages presumably because it contains such a kernel of profound truth. If God can cope with this limitation on his activities it really doesn’t seem too much to expect Tony Blair to try and cope with it as well. Good things are not compatible with each other, and neither Blair nor God, and not even both of them at once, can ride over the horizon and solve everything that goes wrong. Not even by setting up systems to make sure that such-and-such-a-balls-up can never happen again. That particular thing may not happen again, but something else will… on and on for ever and ever, Amen. All innovations have unforeseen consequences. Wake up Tony, welcome to reality.
What you (and God) do is set a bare minimum of definite rules; Thou Shalt Not Kill, Thou Shalt Not Steal, Thou Shalt not drive on the right hand side of the road, that sort of thing, but you do not try to direct every detail of behaviour, however good you think you would be at it and however much fun it would be for you if you did. It won’t work. Sorry. The reality is that you have to give people the framework and then let them go, so that their humanity can flourish. You may think that areas like medicine and teaching are so important that they are exceptions to this rule, but actually these are the very areas where freedom of operation (within, as I have said, a minimal but strictly-enforced framework) are even more essential. You may think that ‘he who pays the piper calls the tune’ but actually the first rule of employing pipers is to let them call their own tunes – they know more about it than you do. And actually its more complicated than that anyway, because in the case of the NHS the government only pays the piper as the individual patient’s agent – a principle which was remembered for the first 50 years of the NHS but is now forgotten.
And all this is where professionalism comes in. And it leads us to the importance of exposing the illusion that technology has given us artificial ways to replace professionalism, and other human abilities, with something better.
The illusion is extremely convincing. That is why it is so dangerous. Because the more like reality the artificial model becomes, the easier it is for us to think that it is reality, and the better the inhuman imitation of humanity becomes the easier it is to think that that is humanity, while the difference in both cases remains absolute. Different things entirely. Much more different things than chalk and cheese.
Consider the difference between an vinyl recording and a CD. One analogue – the other digital. Producing a sound which is, except to a few people who insist they can hear a difference, indistinguishable. It’s easy to picture how a vinyl record reproduces its sound, once you know that sound takes the form of a wave. So the sound wave of the music is transmitted to a cutting device to make a miniature version of that wave along the record groove. When the record is played the needle wobbles along the groove to reproduce the original wave. That wobble is amplified, and comes out through the speaker. The needle has to wobble very fast – 440 times a second for the A in the treble clef for example, and double that every time you go up an octave, but it is imaginable.
Digital is completely different. The recording equipment includes a computer which measures the height of the sound wave at intervals which are chosen to be sufficiently frequent for it to be possible to reconstruct the shape of the wave from the figures. To make high quality digital recordings like those on CDs these measurements are made at 48 kilohertz – that’s 48 thousand measurements a second. And then these measurements are encoded in binary form as a series of pits on the surface of the disk. So one kind of recording is a shape – a smooth curve, which actually is the wave, – which remains smooth at any level of magnification, while the other is a series of numbers which you can no more magnify than you can magnify a football league-table, magnification in this context being a meaningless concept. The numbers are exact, final, immutable, they can be reproduced perfectly through unlimited numbers of generations (to the dismay of the recording industry) while analogue recordings become less true to their original every time they are copied. Completely different kinds of things. Although they sound the same and even the discs don’t look all that different.
The mysteriously profound changeIt is no exaggeration to say that the mysteriously profound change which has come about in our world, which in barely two or three decades has overturned the way humankind has done things since the dawn of civilisation (a change which, as I have said, we see from some perspectives to be obvious progress and from others to be madness) corresponds directly to this change from analogue to digital recording. And it is no coincidence that the historical change has coincided exactly with the advent of the micro-chip (another change not envisaged by Aldous Huxley because it didn’t arrive for three decades after he wrote the introduction to the post war edition of Brave New World I have referred to).
This historical change is nothing less than a wholesale transformation by our society from storing records and making decisions in the kind of way the human brain operates to doing these things in the kind of way a digital computer operates. Much more different than chalk from cheese. And yet the change is being forced through by people who haven’t seen that difference, because from where they are sitting they can’t hear any difference in the music that comes out of the system.
Doctors know about this sort of thing. They know about innovation. They ought to be able to see that we are in the throes of an uncontrolled trial on a massive scale in which not to be alert for signs of unwanted effects would be the height of folly. We should all be seeking warning voices, not ignoring them. One of the ironies of the situation is that rigorous sceptical inquiry is the cornerstone of the scientific method which is now supposed to be the correct way of doing things.
But here as elsewhere, the powerful think they are exempt from the rules that they apply to everyone else. One way of putting this is to repeat the well known fact that the policy of restricting medicine exclusively to those of its aspects which can be based on empirical evidence is not, itself, evidence based. Nobody knows whether it is doing more harm than good because nobody has done a trial to find out, certainly not in the long term. Perhaps, as in the case of Thalidomide, an innovation celebrated (and indeed advertised) for its safety, could have disastrous side-effects of a kind never previously encountered.
Michael Balint talked about the drug ‘doctor’ and its effects and side-effects. That was an old drug at the time, he just pointed it out, but here we have a new one – the drug ‘robo-doctor’, or the drug ‘medical systematisation’, or the drug, ‘any-doctor-will-do-because-its-all-in-the-computer’. At the moment we are in the gee-whiz phase with this new ‘drug’ and we may not have yet found the BIG SNAG which will cause it to be summarily withdrawn. My worry is that the advantages of the human kind of modelling of reality (by analogy) are hidden and vastly larger than we realise while the advantages of the mechanistic kind of modelling (digitally), while being blindingly obvious are much smaller than we realise.
The human mind as exemplified by general practice
I wrote my book The Paradox of Progress during the decade which followed New Year’s Eve, 1984, when I had been inspired to start a personal project by a BBC documentary exploring the extent to which George Orwell had got it right in his book of warning (not, as he hoped, prediction) 1984 – which of course is often bracketed with Brave New World. My project is still in progress, in fact I could have called this talk The Progress of the Paradox. But my starting point remains my foundation – my belief that the GP has the benefit of unique insights, for example by comparing his mental records (his memories) of patients with the fixed records of the same events which are in the notes.
For years I wrote down and analysed things which I found surprising, because surprise is an infallible guide to the fact that something you have observed conflicts with your previous assumptions. And I came to the conclusion that our previous assumptions vastly underestimate the power and sophistication of our minds, not just in the seemingly-impossible size of the experience they somehow embody, but the power and sophistication of the mechanisms which they use to shape that experience into a continually-evolving personal model of the world around us, whilst at the same time protecting us from conscious awareness of all but the minute fraction which is at any particular time necessary for our functioning.
Equally interesting to me was the extension of these ideas to see how they related to artificial brains, computers - which entirely lack the features I have just mentioned. We don’t realise this because we jump to the assumption that a computer is a kind of ‘brain’ and we can’t imagine any ‘brain’, especially a brain that is so obviously better than us at doing sums, not having the features which are so basic and automatic that we are not aware that they are even being necessary.
This filling-in of fragmentary information to make a ‘best fit’ with something we know about already is another hidden and amazingly powerful mechanism of our minds. It is what happens when we recognise a syndrome in clinical practice and it explains why that process can be so disconcertingly instantaneous. Disconcerting, that is, for the onlooker, not least the patient. Of course we have to test the conclusions we jump to, that’s the next stage of responsible practice, but our initial impression is often surprisingly (that word again) accurate and this is one reason why seat-of-the-pants (or human) medicine is so unexpectedly efficient, if we allow it to be, compared with the protocol-dictated medicine which, in the new way of doing things, is supposed to be such an improvement.
So all we are doing here is being responsible practitioners and testing an initial assumption – in this case we think that we have recognised a brain because we have seen something which has some of the features of a brain, it can do sums very well and it remembers very well (both things we tend to think of as signs of quality in brains) and it can model after a fashion. So it is much more like a brain than anything else in our experience is and so we jump to the conclusion that it is a brain.
That jumping to conclusions is something which can be very misleading – you could say it is a fault of our minds that we have to protect ourselves against – for it leads us to overlook the fact that this new ‘brain’ thing we are looking at, while it can certainly remember very well, can’t actually forget, and that while it models after a fashion, that fashion is (as I have kept on saying) utterly different from the way real brains do their modelling. Come to think of it, it leads us to overlook the fact that digital computer ‘brains’ don’t jump to conclusions and then test them!
Again as I have kept saying, this relationship between the human brain and the ‘inhuman’ brain look-alike, the digital computer, is the same relationship as the one between the primitive, human way of doing things (Huxley would say the ‘Savage’ way) and the new, systematised, organised, codified, mechanised way of doing things which is characteristic of the modern world and to which we have these hopelessly mixed feelings. But here again, the advantages of the new way are obvious, while the disadvantages have to be looked for.
The Utopian illusion.
The media phenomenon, which has led to so much of our experience of the world coming through artificial channels, has added another potent distortion to this mix. And here again we have forgotten those hidden mechanisms of the human mind – the ability to subconsciously store away the torrent of congruent information about our environment which is received by our senses – so that while we only consciously become aware of things that matter, subconsciously we still maintain a picture of everything else. Now, when we see the world through the media telescope we jump to another of those assumptions – the media present to us exclusively the things that ‘matter’, the things that stand out because they are unusual, or incongruent. But our minds assume that the congruent ‘everything else’ is being dealt with subconsciously as well. That’s the way we expect brains to operate. But actually the filtering has been done already – our brains are not being silently fed a torrent of information to place the news headlines in their proper context. And that is why we get things so ludicrously out of proportion – every GP is a potential Shipman, immunisations cause nothing but terrible reactions.
And this is another reason why unmediated, first-hand, personal experience is a much more reliable source of wisdom that is currently supposed, and it is another reason why the view from on high is so relatively unreliable. Stand far enough back from life and nothing is safe and nobody can be trusted. From the official view risks cannot be tolerated. It is almost as though our society as a whole has ‘raised its gaze’, and is now viewing issues of every kind with this new media scale perspective.
Before I bring this long polemic to a conclusion, there is one more thought that I want to weave into my explanation of what is happening in the world, and once again it hinges on something we ‘admire’ in machine intelligence because it is something we can’t do very well ourselves. It concerns absolutes. Almost nothing in life – in humanity that is – is absolute. Everything in life is relative – there is a whole chapter with that title in The Paradox of Progress which gives a whole lot of examples. Yet we yearn for absolutes, for certainty, and what-do-you-know - machine intelligence, and systems of rules, algorithms, formulae, are absolutely brilliant at dealing with absolutes – they deal exclusively in absolutesa. Yes, it’s that absolute difference again. And yes, there is another clever trick our own brains play which we forget because it is so automatic. Our brains deal in relatives. Everything in them is expressed in terms of everything else. They are perfectly adapted to model life in the relative terms that it actually consists of. And one of the cardinal errors of our modern predicament is that as a society we treat things as absolutes which are really relative.
So all these factors, and some others like them, come together to produce what we might call the Utopian Illusion. As a society we have jumped to the conclusion that systematisation and science are not only capable of delivering certainty about the perplexing issues of life, but that they are capable of eliminating error and abolishing risk. In this wonderful, inhuman, dream world, everything that goes wrong is thought to have been potentially avoidable (‘In in this day and age, doctor!’ ‘Something’s got to be done doctor!) and is therefore somebody’s fault. It is the lawyers full moon. It is the practitioner’s nightmare. Because practitioners have to deal with the reality, not the illusion.
If we think we have reproduced a human brain with our electronic computers, yes, even with electronic computers that can beat us at chess, and some people do appear to think that, we are like primitive tribesmen with a totem pole who think they have made a man. The answer we are looking for is not exactly under our noses, but an inch or two above and behind our noses. If we want to make the world work, the best tool by far we have is the individual human mind. We have fantastic tools to enhance that ability, I couldn’t possibly have developed my ideas over the years and written this talk without the use of innumerable computerised aids of wonderful sophistication, (not to mention endless fascination – they are wonderful toys) but in the end we must make it clear who is boss. Mechanical systems of all kinds are there to serve humanity, we must never allow them to become master.What shall we tell the registrars?
Which brings us back to the orthopaedic registrar. Any doctor who thinks his responsibility is over when he has ticked the next box in the protocol is, I believe, no longer a real doctor. However much he is paid. That is one thing we must pass on to the registrars. We have to show them by example that doctors cannot be blind rule-followers. It is quite possible that you will go for an entire year with your registrar without once deviating from standard management procedures, and that is quite right and proper if the procedures are as good as they ought to be, but the principle stands that a doctor takes advice, not instructions, and that as a doctor you base your actions first and foremost on understanding. As I have said the difference may not show at all from the outside, but from the inside the difference is absolute – different kinds of things altogether.
The crucial principle they must understand is that as a doctor they have the choice of saying no, indeed a duty to say no if they believe what they are being advised to do the wrong thing. They must be prepared to justify their decision as doctors always have been in the past, but a doctor is never wrong just because he hasn’t followed a rule. What is wrong for a doctor is to follow a rule blindly when professional judgement, based on a human understanding of the whole situation ought to have overruled it.
It is time to put the emphasis back on Understanding-based medicine and make sure it is restored to its rightful place, with Evidence-based medicine as its (albeit powerful) tool, not the other way round. It is time to restore the NHS executive to its rightful place, as servant and facilitator of medicine, not the other way round. Otherwise there is a real risk of a generation of rule-following pseudo-doctors growing up who cannot see the point of going to the colossal life-long discipline of maintaining that internal representation of the corpus of medical knowledge because they are constantly second-guessed by the system. And then when something new turns up – something which hasn’t been thought of – like the two parts of the Mars probe which didn’t work together because the different development sites used different units, or like that wobble on the millennium bridge, there will be nobody around who understands the basics of the situation, everybody’s expertise will lie in dealing cleverly with the interface, not the real thing. That’s what I mean by the dangers of fly-by-wire life.
Education Education Education
Vocational training is and always was a misnomer anyway, GP registrars need education, not training. Training is what you do to a performing animal, and even that is well on the way to being made illegal. Education is open and building, training is closed. Almost anything at all is a legitimate part of the education of a GP so that he or she becomes a fully rounded professional – the explanation for another surprising fact – the fact that so many excellent GPs, I suspect some of you here, came to general practice by routes that are barred in the brace new world.
Without this human breadth the doctor isn’t a doctor in the semi-mystic sense that patients expect and which produces so much of the potency of the ‘drug’ that Balint so rightly said they are. Doctors occupy a natural niche in all societies and at all times in history and neither they or governments are free to change that role. Retaining that role whilst enhancing it with the colossal benefits of modern technology is our greatest challenge. And we must teach society to respect the role and to give doctors the space they need to fulfil it properly, which means exposing the folly the Utopian illusion, e.g. by realising that the slogan you can’t be too careful is absurd – of course you can be too careful! - and restoring to independent professionals the respect that they deserve - requiring them to switch off their common sense is the height of folly. Because the world needs the human qualities of its professionals more today than it has ever done because our current naïve infatuation with information technology is putting us in mortal danger of losing them.