MD, PhD, FMedSci, FSB, FRCP, FRCPEd

In my last post, I strongly criticised Prince Charles for his recently published vision of “integrated health and post-modern medicine”. In fact, I wrote that it would lead us back to the dark ages. “That is all very well”, I hear my critics mutter, “but can Ernst offer anything better?” After all, as Prof Michael Baum once remarked, Charles has his authority merely through an accident of birth, whereas I have been to medical school, served as a professor in three different countries and pride myself of being an outspoken proponent of evidence-based medicine. I should thus know better and have something to put against Charles’ odd love affair with the ‘endarkenment’.

I have to admit that I am not exactly what one might call a visionary; all my life I have been slightly weary of people who wear a ‘vision’ on their sleeve for everyone to see. But I could produce some concepts about what might constitute good medicine (apart from the obvious statement that I think EBM is the correct approach). To be truthful, these are not really my concepts either – but, as far as I can see, they simply are ideas held by most responsible health care professionals across the world. So, for what it’s worth, here it is:

Two elements

In a nut-shell, good medicine consists of two main elements: the science and the ‘art’ of medicine. This division is, of course, somewhat artificial; for instance, the art of medicine does not defy science, and compassion is an empty word, if it is not combined with effective therapy. Yet for clarity it can be helpful to separate the two elements.

Science

Medicine has started to make progress about 150 years ago when we managed to free ourselves from the dogmas and beliefs that had previously dominated heath care. The first major randomised trial was published only in 1948. Since then, progress in both basic and clinical research has advanced at a breath-taking speed. Consequently, enormous improvements in health care have occurred, and the life-expectancy as well as the quality of life of millions have grown to a remarkable degree.

These developments are fairly recent and tend to be frustratingly slow; it is therefore clear that there is still much room for improvement. But improvement is surely being generated every day: the outlook of patients who suffer from MS, AIDS, cancer and many other conditions will be better tomorrow than it is today. Similar advances are being made in the areas of disease prevention, rehabilitation, palliative care etc. All of these improvements is almost exclusively the result of the hard work by thousands of brilliant scientists who tirelessly struggle to improve the status quo.

But the task is, of course, huge and virtually endless. We therefore need to be patient and remind ourselves how very young medicine’s marriage with science still is. To change direction at this stage would be wrong and lead to disastrous consequences. To doubt the power of science in generating progress displays ignorance. To call on “ancient wisdom” for help is ridiculous.

Art

The ‘art of medicine’ seems a somewhat old-fashioned term to use. My reason for employing it anyway is that I do not know any other word that captures all of the following characteristics and attributes:

Compassion

Empathy

Sympathy

Time to listen

Good therapeutic relationships

Provision of choice, information, guidance

Holism

Professionalism

They are all important features of  good medicine – they always have been and always will be. To deny this would be to destroy the basis on which health care stands. To neglect them risks good medicine to deteriorate. To call this “ancient wisdom” is grossly misleading.

Sadly, the system doctors have to work in makes it often difficult to respect all the features listed above. And sadly, not everyone working in health care is naturally gifted in showing compassion, empathy etc. to patients. This is why medical schools do their very best to teach these qualities to students. I do not deny that this endeavour is not always fully successful, and one can only hope that young doctors make career-choices according to their natural abilities. If you cannot produce a placebo-response in your patient, I was taught at medical school, go and train as a pathologist!

Science and art

Let me stress this again: the science and the art of medicine are essential elements of good medicine. In other words, if one is missing, medicine is by definition  not optimal. In vast areas of alternative medicine, the science-element is woefully neglected or even totally absent. It follows, that these areas cannot be good medicine. In some areas of conventional medicine, the art-element is weak or neglected. It follows that, in these areas, medicine is not good either.

My rough outline of a ‘vision’ is, of course, rather vague and schematic; it cannot serve as a recipe for creating good medicine nor as a road map towards improving today’s health care. It is also somewhat naive and simplistic: it generalises across the entire, diverse field of medicine which problematic, to say the least.

One challenge for heath care practitioners is to find the optimal balance between the two elements for the situation at hand. A surgeon pulling an in-grown toenail will need a different mix of science and art than a GP treating a patient suffering from chronic depression, for instance.

The essential nature of both the science and the art of medicine also means that a deficit of one element cannot normally be compensated by a surplus of the other. In the absence of an effective treatment, even an over-dose of compassion will not suffice (and it is for this reason that the integration of alt med needs to be seen with great scepticism). Conversely, science alone will do a poor job in many others circumstances (and it is for that reason that we need to remind the medical profession of the importance of the ‘art’).

We cannot expect that the introduction of compassionate quacks will improve health care; it might make it appear more human, while, in fact, it would only become less effective. And is it truly compassionate to pretend that homeopathic placebos, administered by a kind and empathetic homeopath, generate more good than harm? I do not think so. The integration of alternative medicine makes sense only for those modalities which have been scientifically tested and demonstrated to be effective. True compassion must always include the desire to administer those treatments which demonstrably generate more good than harm.

Conclusion

I must admit, I do feel slightly embarrassed to pompously entitle this post “a vision of good medicine”. It really amounts to little more than common sense and is merely a reflection of what many health care professionals believe. Yet it does differ significantly from the ‘integrated health and post-modern medicine’ as proposed by Charles – and perhaps this is one reason why it might not be totally irrelevant.

17 Responses to A ‘vision’ of good medicine

  • Thank you- for your previous work and for this.

    As a psychiatric nurse and therapist working with vulnerable children and young offenders in the NHS I get – shall we say ‘irked’ – when accused by those who believe in ‘alternative medicine’ of not being ‘holistic’ ‘compassionate’ or even caring sometimes.

    Nurses and indeed Doctors have for centuries relied on their relationship with the patient to promote health and improvements in health and where health cannot be improved, to promote a comfortable existence and eventual death. To think that this skill is limited to an ‘alternative’ approach is to insult us who work day after day often with those groups of patients that are never seen by ‘alternative practitioners’ or who would send them running to the hills at first sight (either because they wouldn’t make money from them or they are just too hard to deal with)

    What also irks me is the media portrayal of the nurses and Doctors in the NHS who deal with the hard stuff every bloody day yet are castigated for not ‘caring’ enough ‘like the alternative practitioners do’ or for being in the pay of ‘big pharma’. Who are passed over for accolade because they get paid for what they do. Who are told day in and day out that they just aren’t good enough.

    Lets lay it on the line – I don’t work in the NHS because of the wonderful pay and working conditions, I don’t work in the NHS because it will get me fame and money – I work in the NHS because that is where I am needed- that is where the real work is, that is where the kids who need the help are – I do it and have always done it with a holistic approach, with compassion, mindfulness and art. What I don’t do is treat the children I see with unproven remedies, quack approaches, superstition and woo-woo. Common sense indeed 🙂

    • Pam the impressions you describe are the work of the media not CAM practitioners and probably originate in parts of the health service that are underfunded, particularly in the area of mental health and care for the elderly. I will never forget the day after the surgery to remove my rectal tumor, a nurse came and changed my colostomy bag. I had this bag for 8 months and never got used to it, every time I had to empty it I was disgusted by it. My nurses changed it every time as though they were wiping sweat from my brow, I have never met people like them and am eternally grateful. They said it was easy because they did not breath through their noses, that did not explain the compassion I saw in their eyes. Every time I am in the hospital now I always pop into to see them. Wonderfull, wonderfull, people and if the Tories dont appreciate you, there are many people who do. If I am ever the leader of a socialist revolution in the UK, I will treble your wages.

      • the impressions you describe are the work of the media not CAM practitioners…

        The idea that conventional medicine is not holistic is an impression that is actively encouraged by many CAM practitioners and proponents of CAM. It is trivially easy, for example, to find CAM-related websites that bandy around the word “holistic”, say that it treats the whole patient, say that it doesn’t just treat the symptoms. The implication is that CAM differs from medicine in this. Many of them are even explicit about this.

        • i could not agree more!
          for instance, i cannot imagine anything less holistic as the assumption that all human conditions are caused by “subluxations” [chiropractic], or can be diagnosed by looking at the iris [iridology] or are reflected on the sole of our feet [reflexology] etc. etc.

  • It is essential for practitioners of alternative therapies to try to differentiate themselves in some way. It is only those involved in manipulation who can actually provide muscle temporary relaxation beyond the placebo response. The rest offer little more than than a change in the patients perception about their condition. When one has only a change of perspective to offer there is no choice but to make this sound special. The only way to make this sound special is to misinform patients about the nature of EBM. For some reason this misinformation goes down well with a significant part of the population who have little interest in the actual science involved.

    One thing that makes it hard to frame the discussion about the value of evidence is the perception of the value of personal experience. The most people will accept that if something makes sense, then it is likely to be true. Experience and making sense of things works well enough most of the time that people fail to understand how easy it is to fool ourselves. It is counter intuitive question what seems to make sense. As a result if a lie seems to make sense it will often be accepted. When dealing with people who are willing to lie, being right is not enough. One also has to find a way of being convincing.

    • David I would say most clinicians realise there are no guarantees in health care, I would be suspicious of any practitioner who guaranteed a cure even were the “evidence” to suggest 90% success rate for the intervention. Trading standards would be onto practitioners promising cures and rightly so. Thats why the practitioners experience in the Art and their ability to understand what the evidence actually states and its relevance to the individual standing before them is so important. I dont think a Jehovah’s Witness should be forced to have a blood transfusion to save their life because its not compatible with their values despite the evidence. However if it was one of their children its a different decision. It makes perfect sense to many ill Catholics to go to Lourdes and seek divine intervention from the virgin Mary. If I was to suggest that to a client it would be a lie, however if it was their priest who made the recommendation, I would not call it a “lie”. The primary carer of the patient may take the view their patient may benefit from the trip and encourage the patient to do it, while its not something the practitioner would chose for themselves, if they found themselves in a similar situation. “Evidence” alone can not help with these decisions, its down to the experience of the practitoner and their ability to evaluate its importance to the patient.

      A diagnosis of terminal cancer would depress most people, Wilko Johnson speaks of the strange “euphoria” he has experienced since being diagnosed with terminal cancer. The former Dr Feelgood guitarist said the news made him feel “vividly alive” – and lifted the bouts of depression he had previously experienced. http://www.bbc.co.uk/news/entertainment-arts-21187740 everybody is different andrespond differently to illness. With chronic illness how the patient feels is usually far more important than what the evidence states, in Wilkos case just a few extra months of life.

  • Bloody hell Edzard if you keep writing like that us quacks might pay more attention to what you wrote, I would disagree with very little you have written. I would say when talking about good medicine in the EBM model described by Sackett you have only covered two of the pillars he based his EBM model on, the Art and Science. The third pillar “patient values” he described as the “unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient”

    So when you say “we cannot expect that the introduction of compassionate quacks will improve health care; it might make it appear more human, while, in fact, it would only become less effective”; I would say, that depends on the patient and what their personal beliefs are. Presumably “patient values” are why places like the Royal Marsden “offer” a range of CAM services to patients, the oncologist does not say see the aromatherapist, but if you wanted it its available. When I met my consultants after getting the “bad news” and they outlined the treatment plan and how it would take over a year, I did not know how to respond so I thought I would be funny and asked ” what do you think of homeopathy”? No one batted an eyelid and left me feeling embarrassed for expecting a reaction. We are very open minded here; the surgeon said, do what ever makes you feel better. Patient values is what is missing from a model of “Best Medicine”, in my opinion.

    • i might also say, “do whatever makes you feel better”. BUT I WOULD NOT ADD:” AND LET US ALL [THE NHS] PAY FOR YOUR FOLLIES!” patient values [in my model tacidly included in several of the listed features] are impotant but, in my view, they cannot over-ride reason, common sense and external evidence.
      the art of medicine also includes the skill of the professional to guide the patient such that the most effective treatment is administered. you would not approve of a situation where a patient’s values dictate you to give a bone-marrow transplant to a person who does not need it, would you?

      • Interesting point. If I claim drinking a bottle of red wine a day makes me feel better would altmed practitioners endorse coverage by Heath System? Or if praying makes feel anyone better should religion be covered?

  • If tax payers are expected to pay for a treatment of course it should be shown to be effective. It was outrageous when NICE decided that Relenza was not an effective intervention for flu some years ago after intensive lobbying rather than evidence of efficacy, resulted in it being recommended the following winter. The patient should not “dictate” the “medical” treatment they will have, its not their area of expertise, its a clinical decision. Likewise its not the place of the medical doctor to tell the patient they are foolish because they go to mass every day in the belief that they will heal quicker and go to heaven, its about respecting the choices people make, unless of course criminal activity is involved.

    • I would never say a patient is foolish, if he feels better he can do it, but not wasting money of the community. This applies also to medicines, if a med shows being useless it should not be covered by healthcare system. When my mother was dying of breast cancer she often told that during prayer she felt warm in the chest and everything went better and I obviously didn’t point out it probably was the fentanyl-pad she had on her chest. But spiritual support is free and if altmed supporters believe they can make patients feel better they are allowed doing it for free, because if you ask for money you have to provide more than a placebo.

  • this is a classical straw-man: no good cinician would tell a patient that she is foolish; this would not be providing guidance by dishing out insults. in med school, we learn that this is not the best approach – perhaps chiro colleges should do that too?

  • With due respect Edzard you are constantly telling people they are “foolish” for trying things when there is no scientific evidence to support a “complementary” treatment they may have chosen. I found it particular hard when you made comments about cancer patients like myself, desperately looking for light at the end of the tunnel and you seemed to get great pleasure in raining on their parade.

    Speaking now as a chiropractor and your above comment about subluxation and holism. You claim to be knowledgeable about chiropractic in the UK so presumably you realise that the majority of UK chiropractors are not what one might call “subluxation” practitioners. In fact in the UK the chiropractic profession have four different associations to represent their diverse opinions, in addition there are individuals like me who are not part of any organisations and am a subluxation practitioner. Unfortunately there is little consensus between these organisations, however I can say with certainty not one of these bodies believe that that “all human conditions are caused by subluxations” and if you have information that one of them does please share it or if you have information that a chiropractor anywhere believes that subluxations cause “all human conditions” I am interested.

    I do know having functioning spinal joints free of subluxations helps me run better, got rid of my cervicogenic headaches and how manipulation can open up the Eustachian tube allowing mucus to drain from the middle ear of some children and “equalise” the painful pressure on the ear drum. I am assuming you understand the anatomy and physiology involved, if not am more than happy to answer any questions you have on subluxation theory.

    • i would not say this in a therapeutic encounter!!!
      come on, richard, do read the comment for what it is. this is a blog; and i am not giving medical advice here.

  • I think comments on a blog are very different to comments on twitter, on a blog you can see the context the comment is being made and various opinions on the topic and visitors can read the responses. On twitter its different because individuals will focus on a particular comment and extrapolate much from it, because of who Professor Edzard Ernst is , so not a “theraputic encounter”, however your opinion is that of a medical doctor that may be the second opinion to many patients and it may scare them unnecessarily. I am more that aware of how CAM practitioners have misunderstood the scientific process and will make claims based on an a few undergraduate studies, thinking this is EBM practice. However that can be a starting point a basis for a physiological theory on why the intervention might work and a basis for dialog. Surely you did not set out to alienate the entire CAM community when you wrote that first article in the Independent back in 1998. The Alan Hennes mass complaint was a big wake up call to the chiropractic profession, In my opinion chiropractors need to look at what they are saying and move away from the language of medicine and quantitive research model of medicine to a qualitive model. UK chiropractors thought Meade 1990 was the proof that chiropractic worked, by treating the “cause”, not thinking that if the back pain is caused by someone sitting all day and being over weight the “subluxation” or spinal joint dysfunction is hardly the cause, however it may be a biological factor that should be explored further.

    • yes, there is a difference, of course. yet i stand by my comments and terminology; “foolish” and other expressions need to be used in the context of this blog. when i give lectures to patients i do speak much more carefully – the central messages, however, is the same.

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