MODERN MEDICINE: A CENTURY OF PROGRESS? George Bernard Shaw’s 1906 ‘Dilemmas’ hold true

George Bernard Shaw was a very clever man, and he wasn’t too fond of doctors. The Irish playwright penned The Doctor’s Dilemma, a sometimes scathing, sometimes sympathetic reflection of Modern Medicine circa 1906. Having shamelessly stolen the off-copyright title for my blog, I thought I better pay tribute to his fascinating insights, and ask the question – have we made much progress in a century?

 While the play itself is certainly insightful, the preface is pure gold. I’ll share some of my favourite George-isms, though I’d highly recommend reading it, as a humbling exercise for the modern doctor. It’s a poignant reminder of the historical (and sometimes current) follies of our profession.  Let’s start with:

   “The demands of this poor public are not reasonable, but they are quite simple. It dreads disease and desires to be protected against it. But it is poor and wants to be protected cheaply….What the public wants, therefore, is a cheap magic charm to prevent, and a cheap pill or potion to cure, all disease. It forces all such charms on the doctors.”

 As a man of science, George lamented the lack of scientific rigor amongst medical men of the time. He thought doctors too often were caving to the public’s push for such magic charms.

   “They are not trained in the use of evidence, nor in biometrics, nor in the psychology of human credulity… Further more, they must believe, on the whole, what their patients believe… When the patient has a prejudice the doctor must either keep it in countenance or lose his patient.”

The dilemma of challenging your patient’s beliefs (at the risk of losing the therapeutic relationship) still applies – as any GP who has refused antibiotics for a snotty child will attest to. It’s also important to point out a common folly still committed today;

   “Doctors are just like other Englishmen: most of them have no honor and no conscience: what they commonly mistake for these is sentimentality and an intense dread of doing anything that everybody else does not do, or omitting to do anything that everybody else does.”

He was concerned that doctors of the time sometimes exchanged scruples for cash, particularly while working as sole traders whose livelihoods depended on their popularity. Remember, of course, that doctoring was a lowly-paid profession in 1906.

   “Private medical practice is governed not by science but by supply and demand; and however scientific a treatment may be, it cannot hold its place in the market if there is no demand for it; nor can the grossest quackery be kept off the market if there is a demand for it.”

George lived through the era of emerging germ theory, and watched it shape the profession. I think this statement holds more merit than any other he penned, particularly on the effect germ theory had on our modern paradigm of disease/cure – and the often-times overlooked art of healing.

   “We are left in the hands of the generations which, having heard of microbes much as St. Thomas Aquinas heard of angels, suddenly concluded that the whole art of healing could be summed up in the formula: Find the microbe and kill it. And even that they did not know how to do.”

Too true, George – and what would a scathing review of the medical profession be without some reflection on doctor’s egos, or self-righteousness? At times, it can feel we haven’t come that far in a century…

   “Make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words “Remember that I too am mortal.”

    “The surgeon, though often more unscrupulous than the general practitioner, retains his self-respect more easily. The human conscience can subsist on very questionable food. No man who is occupied in doing a very difficult thing, and doing it very well, ever loses his self-respect.”

George did cut us a little slack though, towards the end. He honoured the selflessness of the medico in attending people in their hour of need, particularly the country GP.

    “When the baby is suffering from croup, or its mother has a temperature of 104 degrees…nobody thinks of the doctor except as a healer and saviour. He may be hungry, weary, sleepy, run down by several successive nights disturbed by that instrument of torture, the night bell; but who ever thinks of this in the face of sudden sickness or accident?”

    “Every general practitioner is supposed to be capable of the whole range of medical and surgical work at a moment’s notice; and the country doctor…often has to tackle without hesitation cases which no sane practitioner in a town would take in hand without assistance.”

I believe (and hope) we’ve made some progress since 1906. Particularly in evidence-based decision-making and professional transparency, to help remove the public’s doubt that our decisions might be based on a financial interest in our patient’s ill health! At times though, the culture of ‘find the microbe and kill it’, and ‘doing what everyone else does’ doesn’t appear to have changed much in a century. Something for us to work on, perhaps?

Thanks for your eternal wisdom Mr Shaw, and may it continue to give pause to many more generations of doctors ahead of us.

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