Tuesday, 31 May 2011

A philosophy of medicine

I have a vivid memory of standing in the Tate Modern a few years ago, looking at a blank canvas that had had a gash slashed into it. The card next to it read ‘Fontana first slashed a canvas with a razor blade in 1958, but he had been making holes in them since 1949.’

This struck me as an extraordinary waste of good canvas, and a poor use of nine years. For many years, the sense of exasperation prompted by that card, and Luciano Fontana’s vendetta with perfectly good canvas summed up my attitude to modern art.

Naturally, I was missing the point. As I wandered around the Miro exhibition at the weekend, looking at paintings that still didn’t speak to me particularly loudly, I realised that I have often misunderstood artistic movements as being purely about the artistic products; I always thought that the debate and arguments that underpinned art were incidental to the pieces of work being produced. Miro helped me to realise that this is not true, that it is sometimes the debate that defines the movement, and that through their art, artists are engaging in true philosophical debate. Understanding the context in which art is produced informs one’s enjoyment of that art, more than simply willing the pictures of sculptures to speak to you.

As I was wandering around, starting to understand the influence of the Spanish civil war, and the struggle for a Spanish Republic on MIro’s work, I began wondering what my philosophy of medicine is, and how this fits in with the world of medicine in which I work.

My own views have undergone significant revision in recent years, and one of the dominant features of my philosophy of medicine is patient-centredness, which I think can be summed up as an approach to medicine in which technical expertise, communication and customer service share equal importance.

Let me take a moment to explain what I mean: one of the red lines of medicine is that the quality of care must measure up to generic standards. In practice, this is not always true, but as I have pointed out in other blogs, patients often do not know whether they have experience good medicine or bad, so ensuring that good practice is the norm is our responsibility.

Secondly, communication is one of my pillars of medicine: individuals deal better with experiences when they have a good idea of what is going on. The challenge of communicating the complexities of medicine and helping patients navigate their way through the experience and the system is a key aspect of good patient care.

Finally, customer focus (perhaps a clumsy term) highlights the importance that I place on designing services around patients and their needs. Too often patients are expected to know how to use complex health services and can even be criticised for not using services ‘properly’. By setting up the system to match both patients needs and patterns of uses is a important factor in patient satisfaction, and part of our obligation to provide comprehensive health care services for the populations that we serve.

I recognise that many other philosophies of medicine abound, and there is nothing particularly ‘right’ about mine. However, there is one particular view that I see often, that worries me. I call this the philosophy of professional self-interest, which can be summed up as the viewpoint of the doctor who always bemoans that new doctors know how to communicate with patients, but do not know what to communicate with them, because they do not ‘know anything’, and who complain about patients expecting more than they should from the health service on offer. This is a caricature, but I hope you know what I mean - they are the people for whom medicine is a technical and intellectual challenge (they want to be the expert in one disease or treatment for example). They are the medical practitioners who resist the idea that medicine has changed - we have a greater range of diagnostic procedures that negate some of the finer points of clinical assessment, and we have better informed patients with higher expectations. The complexities of clinical care are difficult for one individual to master, and the approach to medicine is inevitably more dependent on groups of people working together.

Necessarily, our approach to medicine needs to change to meet these different demands, but it often seems to me that doctors hold on to an old fashioned approach to doing things. We congratulate each other for knowing what Traube’s sign is, and offer criticism for not picking up Corrigan’s sign, even though we all know that the patient will have an echocardiogram anyway.

So my message today is that we should be clear with ourselves about what we think is important in medicine. I do not necessarily want you to agree with me, but I would be chuffed to bits if I could persuade that it is ok to imagine a different way of doing things, and to set out to chase your vision.


  1. One of the great difficulties of The Spanish Civil War, and in fact every war before or after, is that there is justification for each (opposing) view of the conflict. Whether we agree with that justification or the means used towards achieving it does not change the strength of feeling behind that opinion. To quote your own piece, "it is sometimes the debate that defines the movement, and that through their art, artists are engaging in true philosophical debate. Understanding the context in which art is produced informs one’s enjoyment of that art, more than simply willing the pictures of sculptures to speak to you."

    Medicine is an art (Ars longa vita brevis)and what can be a challenge is sometime understanding that the torn, potentially meaningless and upsetting canvas of one practitioner is actually indicative of their honest, ardent, sacrificial drive to deliver that vision, the best, the very best, that they can for their patients.

    I don't like Fontana, Miro is too dark for me and I really don't understand Clyfford Still but I do appreciate they are all trying to express what is important to them. The same is true inmedicine; I don't believe there is a single philosophy of medicine.

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