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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GOT COMPASSION FATIGUE? DOC, YOU’RE HEADING FOR BURNOUT

I’ve noticed a concerning trend amongst my hospital registrar colleagues lately. Put them together after-hours, and there’ll be callous, cynical sniping at anyone within their firing range – patients, nurses, and other colleagues.  I know for a fact they are caring, compassionate people. I also know they’re under-supported, over-worked and emotionally exhausted. And I worry they’re burning out.

A little black humour never fails to blow off steam, and it can be a healthy way to acknowledge and relieve some of the emotional burden carried by the caring professions. But at what point does it become unhealthy, and would you recognise it?

Empathy Fail (unable to credit this gem - found it on a twitter feed with no artist reference)

(unable to credit this gem – shared on Twitter with no artist reference)

 Try my BURNOUT QUIZ

  • Are you often negative, cynical or sarcastic about your patients and colleagues?
  • Do you feel like your patients or colleagues are deliberately trying to drive you crazy these days?
  • Do you expend all your energy just surviving the work day, and crash when you get home?
  • Do you dread going to work, or seeing certain patients?
  • Do you feel like you’re not in control, and you’re at the mercy of everyone else’s needs and urgency?
  • Do you suppress your emotions because you don’t have any energy left to deal with your own problems?
  • Are you racing through slap-dash consults with poor notes, OR constantly running late as the day unravels on you?
  • Are you shirking responsibility and leaving your work for others, OR micro-managing and having difficulty handing over the reins?

 If you’re ticking the boxes, you might be burning out.

Interestingly, a Danish study found gender differences in burn-out behaviours for male and female doctors. Men could be completely burnt-out, with serious detachment and cynicism, but still work like an automaton while their personal lives hit rock-bottom. Women on the other hand, would hit emotional exhaustion first, begin to doubt their abilities, feel they weren’t making a difference and lose professional self-esteem.

I’m in General Practice, I left the hospital system because I wasn’t built for that environment and I would most certainly burn out. Plus, I love General Practice – a happy solution for all! But in GP-Land, I deal in people’s daily lives – in the disillusioned, the miserable, and the lonely.  I see the unable-to-copes, the end-of-tethers, and the straw-broken-camels. And when I start to see this in my colleagues, I’m reminded that medicine can be a very, very unhealthy profession, for a combination of factors:

1.    Personality traits: Type-A, Perfectionists and Over-Achievers

You’d probably like your doctor to be all of the above, if you were a patient. But it means they’re a workaholic, who strives to compete and achieve, and is always convinced they’re not quite good enough. Medical schools and specialist training colleges breed competition, one-upmanship and professional insecurity – and bad habits can last a lifetime. Plus, it means they have a REALLY hard time admitting they’re having a really hard time.

2.    Higher Risk and Responsibilities

If the average person makes a mistake at work, the repercussions might be financial – you might lose a sale. If a doctor makes a simple mistake, they might kill someone. Or wreck a life. A contentious doctor has this constantly at back of their mind, every working day. It’s a sobering thought.

3.    Bureaucracy and Limited Resources 

In the public system, there are never enough staff, hours, appointments, beds or programs to provide ‘optimum care’. So there’s a constant pressure on doctors to make judgement calls about how to best utilise limited resources – and arguments from every player involved that their request or demand is the most important. In private practice, this includes the financial and logistic issues involved in running a medical business.

4.    Shift Work and Long Hours

Shift work has been proven to kill you (1,2) and that’s no surprise. But in no other professions are 16-24hr shifts by sleep-deprived workers considered a safe or viable option! They’re inflicted on doctors, because ‘that’s the way things have always been done’, and doctors are considered conscientious and clever enough to ‘withstand’ such unsafe practice. It will probably take many fatal errors with Coroner’s recommendations before the public forces the government to employ more doctors and outlaw unsafe hours.

5.    The Emotional Burden

Doctors and nurses are exposed to trauma, heart-ache, pain, anguish and confronting stories on a daily basis.  We don’t just read about these things – we talk to, counsel and comfort these people.  We have to tell someone they’ve miscarried, or they have cancer. We have to treat angry, grumpy  and manipulative patients to the best of our abilities, despite their behaviour towards us. The emotional toll can be crippling, so you learn to detach.

6.    Learnt Ability to Detach

It’s a survival skill in the caring professions to detach from other people’s suffering, lest you suffer with them. But you can become too good at it – especially if it you start detaching from your own emotions to simply get through the day. Or if you depersonalize patients – allowing cynicism or callousness in your work. Your emotionless detachment can become a habit outside work –  as many a burnt-out doctor’s divorced partner would attest.

So what’s the solution?

  • Demand a culture change in medicine – Gen Y and the growing proportion of female medical graduate (54% at last count), are going to push for a paradigm shift in medicine over the next 10-20 years, one that values a work-life-balance and is kinder to families.
  • Don’t obstruct them, to appease hospital management and budgets, or because you think ‘they should slog it out like I had to.’ Work with them, and advocate for a better, healthier profession for everyone involved. Patients don’t win with burnt-out doctors either.
  • Don’t lose touch with reality – constantly evaluate your work experience against what a ‘normal’ work experience should be, and make changes where you can – would working 4 days a week mean you’re not going to burn out in the long run?
  • Learn your limits – and know when to take time off. There’s no need to race to the finish line in training, and if it takes an extra year but you’re sane, that’s a damn good trade.
  • Don’t heal thyself – seek help if you need it. Have your own good GP, and check in with them if you’re not coping – sometimes just admitting you’re struggling to someone can lift a weight from your shoulders and help you find practical solutions.
  • Watch out for your colleagues, and check-in with them if they’re exhibiting the burnout list symptoms above.

For more excellent advice, see www.thehappyMD.com. And look out for yourselves!

BAD BABY NAMES: THEY’LL MAKE YOU SICK

My name is Marlene. That’s pronounced Mar-lane-ah, as in Marlene Dietrich.  Over the years, I’ve cursed my non-phonetic name when I’m ordering pizza, or coffee at Gloria Jeans. In their defence, my parents were schoolteachers and didn’t want to use the name of any memorable kid they’d taught over the years.

At least Marlene is a real, bona-fide name. According to a study* of over 4000 kids in Perth, this name protected me from serious childhood illness. Not surprisingly, there was a strong correlation between Nomenclatural Adventurism and rate of admission from ED to the kids’ ward.

(And yes, before I get howled down, it’s unlikely to cause ill health. But who ever let truth get in the way of a good statistic?)

Do parents realise that doctors, nurses and teachers collect bad baby names and trade them later for laughs? Like Meadow Lea, and Anarchy Reign.  Though at least those are actual words, if not real names. My absolute favourite non-word, non-name is Abcde. It’s pronounced Ab-si-dee. Uncurl your toes now.

Interestingly in Australia and NZ, you can’t use numbers in names. Which is lucky for baby Number 16 Bus Shelter, whose name was rejected. One wonders whether the parents’ inspiration was similar to the parents of baby Midnight Chardonnay? And perhaps the parents of Kiwi twins Benson & Hedges were romantics, inspired by a post-conception cigarette they’d shared.

But if you think laterally enough – which is not a virtue, by the way – you can slip in numbers using Roman numerals. Like Kviiitlyn. Yes, that’s K(VIII)lyn. Or you could try Kviiite. Have you figured it out how to pronounce it yet?

You CAN use apostrophes and dashes as liberally as you want, unfortunately. Like T’Neal, or Max-ine, or Ad’m.  Or you could be really clever, like the parents of La-a, and Ka-a. Yes, that’s La(dash)a, and Ka(dash)a. Read it and weep!

Personally, I’m waiting to meet baby Chlamydia. Doesn’t it sound pretty? I do know there’s a Candida out there. While we’re on bad names, I’d like to point out that all boys with a J-name are naughty: Jai, Jett, Jamie, Jack, Jordan, Jonas, Jayden, Jaiden, Jax, Jaxon, or even Jaxxon. Save yourself the jail visits later, and give them a nice well-behaved name like Larry, or George.

Why not wait for your baby to become a unique little person, instead of giving them such a unique name that they’ll probably change their name by deed poll the minute they’re a legal adult? Happily, for ‘Talula Does The Hula From Hawaii’, the NZ Family Court stepped in first and forced a name change in 2008 when she was 9 years of age, because it was “embarrassing, and made a mockery of the child.”

Such names are no doubt capable of causing psychological trauma. But what about physical? These naming categories, identified with the study, were statistically proven** to correlate with ill-health in your baby, and should therefore be avoided at all costs:

Popular Culture Names

  • Avoid the likes of Bella, NarniaArya, or Narla

Apparently Unique Names

  •  Like poor kids Rysk, Zaniel, Rilo or Kaixin

Surname as First Name

  • Watch out for Connor, Harrison, and Mackenzie

The best test? If you can imagine a news reader announcing  “Prime Minister <name> met with the Surgeon General today…” without collapsing in fits of giggles, then you’ve got yourself a real bona-fide name.  And hopefully a healthier future for your child than J’Adore, Drifter or Xenon will get.

* Children’s Nomenclatural Adventurism and Medical Evaluation Study J Paediatr Child Health. 2009 Dec;45(12):711-4. Princess Margaret Hospital for Children, Perth, Western Australia, Australia.

**  Never trust the phrase statistically proven without reading the fine detail. Correlation does not equal causation. Moustaches are statistically proven to be correlated with injury. That’s because men grow moustaches AND do more stupid things. It’s not the moustache that causes the injury.