Cure sometimes, care always

Cure sometimes, treat often, comfort always. If not directly from Hippocrates himself, then certainly recorded by those who worked with him as a distillation of his attitude to being a doctor, as well as being reclaimed by others over the years, not least in the 19^th century by Sir William Osler. And at a time when pharmacology and surgery were unknown, it is a testimony to the patient-centred care and integrity of Hippocrates and other doctors of the ancient world that Medicine became established as an honourable calling. Galen, working over 500 years later and facing the pullulating masses of Antonnine Plague times, managed to further confirm the bone fides of the medical profession by his constant visiting, even living with patients for periods, detailed attention to their diets, and genuine care for his charges (albeit in his specific case with an occasional eye on self-promotion and a decent fee). When almost all a doctor could do was care, caring was important.

Is it fair to say that the advancement of science and the development of evidence based drugs increased the risk of the central place of comfort and caring in the role of the physician becoming at best atavistic, at worst obsolete? Penicillin cured the infection whether given with humility or hauteur, and the perception that the doctor was now someone of actual power over disease can have done nothing for his or her humility.

But in the current healthcare climate, the chief danger to care in the surgery or ward is not supercilious belief in the power of science, but the pressures of burnout, stress, tiredness and despair facing many doctors. Taking one’s time with the slightly deaf or slightly confused patient takes a little longer, adds a little stress to the day, pushes lunch a little further into the afternoon. Doctors who have prided themselves for years on always putting patient before self, who are known for their genial manner and bottomless patience with septuagenarian and medical student alike, suddenly find themselves reaching the very limit of their tolerance. Working every day in a service holding on by its fingertips, feeling undervalued, being demonstrably underpaid and then refused leave to attend a wedding or funeral, can easily push conscientious physicians into the zone where an encouraging word for a junior, or five minutes spent chatting to a frightened or lonely patient can seem an unnecessary waste. What difference does it make? Who notices? Who cares?

Most doctors will admit that, when starting out as students, the perhaps naïve desire to help people, and the satisfaction of being part of a historically respected profession motivated by the very best motives, were strong factors in choosing medicine as a calling. But we are not made of bronze. Professionalism is often described as what you do when no-one is watching. And ultimately no-one will know just how many times you explained the same thing to the confused patient, or whether you took enough time to break bad news to a relative, or whether you phoned the colleague out of politeness to say thanks for a favour done. Caring, patience, taking time, simply being a nice person, can be early casualties in a failing system, or in a failing psyche.

Last year, while seeing patients at a clinic running three quarters of an hour late, with new patients incorrectly booked in review time slots and a terrible headache, I was reflecting that at least, on that one morning, the medical student hadn’t turned up to slow down progress further. Just on cue, the nurse came to the door and announced said student’s arrival, almost two hours after the start time, with the inquiry as to whether or not I could accommodate their presence. And on that morning, I decided I could not, as my head was sore, the first patients irritable and the afternoon’s teaching session already looming. And of course, at least the patients and I had managed to turn up on time.

If that student was you, I apologise. There were some excellent teaching cases, the patients were (so to speak) surprisingly patient and I was almost caught up by lunchtime. I took no time to ask if there was a good reason for your tardiness. I was stressed, tired and rather fed up, and did not fulfil my obligation to pass on my learning to you, as I promised to do when taking the Hippocratic Oath.

A few years previous, during the height of the COVID pandemic, I sat with another student in my clinic, she, I and the patient wearing full PPE, and I automatically helped the elderly man get dressed after the examination, even taking time to tie his shoelaces, which he would have struggled to do at the best of times without mask, gown and visor. I thought little of the act, as it is something I have often done. Later the same morning, I left the student with a patient as I went off to find the elusive tendon hammer, (of which all large teaching hospitals possess around one for every 50 doctors) and returned to find she had helped the patient undress, removing shoes and socks and assisting them on to the couch. When I thanked her afterwards, she told me that she had instinctively felt it was the thing to do, but had only done so after seeing my example, as she was still relatively new to the culture of the UK and the world of medicine, and unsure of exactly what the doctor’s role was perceived to be.

Would it ever not be the doctor’s role to help a patient tie their shoes if they were unable to do so? Would I have taken the time to do so at the recent clinic when I felt very acutely the stress of practicing while exhausted in the midst of a chaotic service? Do we remember the difference a single act can have on a patient, a colleague, a student?

There are some occasions when care, in the sense of sympathy, politeness and patience, must take second place to action, with every moment precious in the resuscitation room or managing the operating theatre haemorrhage. But it is vital that such relegation of the human side of medicine, the ‘Art’ as well as the ‘Science’ of the profession, does not become the default setting. If we ever fully recover from the effects of the COVID-19 pandemic on our service, if we ever see proper funding and leadership again in the health service in Northern Ireland, then let us all see to it that we still practice – and teach by example – comfort and care before all else. It might be the last aspect of our practice Hippocrates would recognise.