Friday, January 02, 2015

The British Medical Association thinks it is bad for doctors to work weekends. Why do we still treat the medical profession as special?

In this age of public cynicism, few professions remain in high public esteem. No one ever liked journalists, politicians or estate agents. But in recent years, bankers and lawyers have become much less-trusted: for good reason you might say. The teaching unions continue with their long campaign to undermine the regard which much of the public still have for their members. But doctors have bucked this trend. Even recent scandals in the National Health Service (conveniently blamed on managers) haven’t really dented the way the public see physicians, or how physicians see themselves.

That isn’t too surprising. Doctors can do amazing things to heal us. They save lives habitually. In some circles, it is sacrilege even to criticise them. But, remarkably, doctors enjoyed a healthy professional reputation even back in the days when they couldn’t really help us at all. The miracle of modern medicine is much more recent than we realise. It was only from the mid-nineteenth century that doctors were more likely to cure than kill. Our expectation that we won’t die of infectious disease dates from after the Second World War.

It’s impossible to overstate just how useless pre-modern medicine was. If you fell ill, there was nothing, and I mean absolutely nothing, that a doctor could do to cure you. Granted, he had plenty of treatments and his learning was considerable. But bleeding, purgatives and the like would do you more harm than good. In essence, doctors were charging fat fees to hasten patients towards the grave.
Actually, I was slightly exaggerating when I said doctors could do nothing. There were some drugs available, like opium, to lessen pain. But you didn’t need a doctor to access these drugs and, although opium could reduce discomfort, you wouldn’t be cured. It was palliative only. Luckily for them, doctors did have another trick up their sleeves, although they did not know it. It’s called the placebo effect.

It’s well known that when you give a patient a sugar pill, something with no active ingredients, it can have marked beneficial effects. The mere fact that the patient thinks that they are being treated with an effective medicine makes them better able to heal themselves. And this effect is even more marked if the doctor himself thinks he is doing some good. That’s why new drugs are tested using the double-blind method. Patients are divided into two groups. One group is given the drug under test and the other is given a placebo. It’s called double-blind testing because the researchers giving the drug don’t know which is which any more than the subjects do. Only a second lot of researchers, who never actually come into contact with the patients, know who has received the real drug and who has received the fake.

So, a doctor in the eighteenth century, with his training and aura of competence, could help his patients cure themselves merely because all parties thought that he could. This might even offset the damage that the doctor was doing by administering dangerous drugs or ordering bleeding. Clearly, the doctors who could best help their patients were the ones who didn’t do anything besides having a reassuring bedside manner and giving out harmless placebos. That’s generally what village healers and cunning folk did. Their magical cures were less likely to hurt you than the treatments of professional doctors. Most effective of all was praying at a saint’s shrine. If you believed in it, prayer would do as much good as a visit to the doctor, and it was unlikely to do you any harm at all. Physicians made their living by cloaking themselves in learning, jargon and professional qualifications. But it was all an illusion. No matter how many long years they studied Galen and Avicenna, they couldn’t help their patients one jot.

Incidentally, that’s how homeopathy got going. It was founded by Samuel Hahnemann in 1796 while doctors were still more likely to be licensed killers than saviours. Now, I hope I won’t offend anyone when I say that homeopathic medicines do precisely nothing. They rely entirely on the power of suggestion – in other words the placebo effect. But when homeopathy was founded, doing nothing could be a huge improvement on conventional treatments. So, it appeared to work better. This meant that homeopaths gained a respected place in British medicine that they have never really relinquished. Homeopathy is still available on the National Health Service.

All this raises a slightly disconcerting question. If doctors could maintain a professional reputation back when they couldn’t help their patients, is some of the reverence in which we hold them today really just a function of good public relations? That’s not to say that today’s medical professionals don’t deserve a large measure of respect. But placing them on a pedestal doesn’t do us or them any good at all. So when the British Medical Association say that doctors are too important to work at weekends, we should treat the suggestion with the scorn it deserves.

Discuss this post at the Quodlibeta Forum


Jamie Robertson said...

Oh, now that's rather unfair. Most hospital doctors DO work weekends, in the context of a reduced service (so fewer nurses, clerks, radiographers, etc as well), on a rota. Some doctors, especially in A&E, end up working most weekends, with the impact on social and family life that you would expect. All very junior doctors and all those training for hospital medicine or surgery will do this. Some consultants can choose not to do them, but their pay will take a hit as a result.

The issue here is rather the idea of a "7 day week" where every weekend has a full service as exists monday to friday. That's NOT something all organisations or businesses do. It may well make the patient experience better, hospital stays shorter and the weekend spike in mortality go down, and that's why the BMA supports the idea in principle. Some units have already implemented it locally on a small scale. What the BMA wants is evidence that it can work despite (1) shift work being bad for your health and quality of life, and the subsequent difficulties in recruiting for posts, and (2) the need to pay staff (not just doctors) for all these antisocial hours they'll be doing in a time when the country is skint and the NHS is wobbling at the knees. This is to avoid a repeat of the Health & Social Care Act, where a daft idea was passed into law rather like a steamroller trundling inexorably over the panicking pleas of the poor folk who would actually have to implement the damn thing, and who could see just how catastrophic it might be

Banshee said...

Actually, some herbs and medieval cures are relatively effective. Medieval medical texts often feature a good bit of shrewd observation that has been recently rediscovered by medical science. (For example, the medieval advice on sleeping on your left side to avoid acid reflux, and that you should shift to the right side in the middle of the night as digestion continues.) So if one has an interest in it, there's still stuff one can use at need. (Although obviously one should only play around individually with harmless stuff like indigestion cures and non-poisonous plants.)

The problems were that you couldn't really control dosage, since natural things vary a lot in the amount of active ingredient present; things that were strong enough were often strong enough to kill you; there wasn't enough experimentation to figure out the real rules vs. humor theory; and people were starting out in less good health, because they couldn't get all their vitamins year round in any easy fashion, and living conditions were harsher.

So yeah, you can sometimes get some really decent medicine and wellness tips from medieval books on physic or those home cuisine/medicine books meant for Dr. Mom. It would be a shame for people to totally forget that, or to leave the good bits to be enjoyed by nobody except health food nuts.

But there's also stuff that does nothing, does the opposite of what's advertised, or will kill you unless you're lucky. So it helps if you are educated about toxic plants, etc.

Banshee said...

I forgot to mention that you should take a glance at pages about side effects and allergies whenever you're eating, drinking, or applying some herb for the first time (including totally harmless herbal teas from grocery stores). Also, if you're allergic or sensitive to anything, be very cautious about anything that's in the same family.

I knew a woman who had a very bad reaction to a very small amount of ginger, for instance; and I once had a very rare bad reaction to a very popular European tea that old ladies like (linden).

Since I can usually eat or drink anything, this was really embarrassing. But because I'd looked up the rare side effects beforehand, at least I knew what was bringing on the heart palpitations; and if it had gotten worse and I'd had to go to the hospital, I would have been able to tell people what was happening. (Everything turned out okay, though.)

Still, there's something to be said for knowing that you can drink some valerian tea (stinky as it is) instead of taking a sleeping pill.

Ron said...

I appreciate your posts in general, but as someone in health care this one is a bit unfair towards physicians who by any standard of measure are quite overworked and undervalued as it is. Salaries significantly falling where it's not worth the investment of years and effort including opportunity costs to be a physician at the same time as workload ever increases.

Jonathan said...

I'd add there have been recent strikes by physicians against the PM for effectively lowering their overall salaries by 30%-40%. (The base salary has been slightly raised to make it appear as if salaries have been increased, but penalty rates or 'overtime' has been drastically cut, yet doctors are expected to work significant amounts of 'overtime'.)

Anecdotally, I don't know any of my physician colleagues who want to work for the NHS. Either they're planning a way out or they've already left for brighter shores (e.g., Canada, Australia, New Zealand).