Trust me, I'm a doctor: Trevor Turner doubts whether the heroics of ER can save our bacon

New Internationalist, Jan-Feb, 2001 by Trevor Turner

THE HEALTH BUSINESS IS IN CRISIS. Wherever you go in the world, debates about healthcare, funding, new breakthroughs and what we expect of our doctors continue unresolved. For example, patients in Britain are dying while on the waiting list for heart surgery. In the US, the process of `Managed Care' is driving physicians up the wall. You' re allowed two to three days in hospital for acute schizophrenia, even though it takes a month to treat the symptoms of a serious, psychotic illness. In France health workers have been on strike, resisting attempted rationalizations by a government desperate to save money. The ageing population in Western countries adds more pressure -- and we are running out of nurses. Yet the medical news that hits the public headlines is usually about a `major advance' -- designer pigs to provide organs, for example -- or some dreadful scandal such as the paediatric heart-surgery deaths in Bristol, England.

The reason for this scandal was a combination of medical arrogance, regional pride and the sheer complexity of difficult surgery. But surgeons who continue to have a 30-per-cent mortality rate -- that is, a third of their patients die after operations -- rather than the average of say five to six per cent, clearly have a problem. There is a learning curve required to perform the kind of delicate operations that babies need; but it can't go too long. You have to do such operations regularly, that is to say to specialize, and increasingly medicine is dividing up into lots of mini-specialities. Dr X will take out your kidney, Dr Y will sew up your pile, Dr Z will do you a nose job.

There's no big money in being a generalist and the decline of the general physician, with experience across the whole spectrum of medical illness, is hard to slop. This has gone hand-in-hand with doctors preferring to financial reasons and personal kudos to concentrate on high-tech specialties. And who is the real hero -- the chest cutter cracking that difficult lung cancer, or the community physician who persuades schoolkids, over several generations, not to smoke?

The history of medicine tells us quite clearly that if you want to improve people's health, having more and more specially trained doctors, at high salaries, may not be the best way forward. For example, in nineteenth century London there were a number of outbreaks of cholera, typhoid and other infectious diseases. It took a series of Public Health Acts, complex sewerage design and enhanced education to make for the beginnings of a healthy environment. The same applies in the twentieth century, with a decline in tuberculosis (TB) largely created by better nutrition and living conditions. Of course drugs were helpful but the essence of the treatment programme was social and environmental manipulation. In England several years ago one of the Health Authorities refused to fund anti-leukaemia treatment for a six-year-old girl. She had already had two courses of treatment; these had tailed. The chances of a third course being effective were zero. The challenge of treatment was actually taken up by a private-sector unit, but the girl sadly died anyway, as predicted. In other words, the Health Authority was entirely reasonable in refusing to fund an expensive, high-tech, but ineffective treatment, preferring to spend the money, for example, on a couple of community psychiatric nurses.

Disease and delusion

This sad case generated a considerable concern as to the unrealistic pressures being put on specialist units. Diseases long seen as untreatable and usually managed with sedatives or painkillers now have to be thought of as in some sense `curable'. In fact, so as to establish itself as a necessary part of society, the medical profession has seriously over-stretched what it can do, pushing the miracle cures and sophisticated gadgetry which cost more and more to achieve less and less. It's as if society is addicted to delusions of immortality, and doctors are competing for the Pied Piper role. But after several decades of hyped techno-expansion, such as heart transplants, smart drugs and highly sophisticated diagnostic techniques, there is a new understanding emerging of the impact of social and environmental factors in health. In part this is due to the population pressures in many parts of the world and the misery and warfare that they bring. In part it is due to a sense of the cost of things. And people are increasingly seeking medical solutions for personal or social problems because that is how they perceive things going wrong with themselves. Relationships, addictions, bad habits, losing your temper -- somehow it's all neurones and brain chemistry, rather than homes and families.

If you take a common condition like clinical depression, we now have a much wider range of drugs available and licensed. Despite these `advances' in treatment, particularly in the last 20 years, the prevalence of depression is increasing. Is this due to greater recognition, a secondary effect of people wanting to be diagnosed by doctors who also want to label conditions that are treatable; or a change in the meaning of the word `depression'? If expectations are raised, in terms of income, style and personal well-being -- and such images of satisfaction are integral to daily life in the West -- then the corollary is that more people will feed they don't have what they want. Is not having What you want the same as `depression'? Should you just take Prozac, or should you have a think about what you are doing? There is good evidence that treatment called `cognitive therapy' is very effective, involves no drugs, and can tie easily taught as an effective health intervention. But most doctors don't like learning up these techniques which don't have quite the chutzpah and heroic `Dr Kildare' dramatics of a risky and expensive operation. The glamour doctors of our times are the heart-transplant surgeons and the accident and emergency junkies of Casualty and ER -- always shouting, great on technique, often too late.