Every generation of doctors needs a book that makes us stand back from the edge and question what we do. For me it was Peter Skrabanek and John McCormick's Follies and Fallacies in Medicine. For previous generations it was Ivan Illich's Limits to Medicine that rattled the cage, though neither book is as funny as the 100 year old tirade in the preface to George Bernard Shaw's The Doctor's Dilemma. I was hoping Ann Dally's book would be the latest addition to a satirical audit trail going back to Molière's Le Malade Imaginaire and before, but it doesn't quite fit the bill.
Figure 1.
Ann Dally
Robson Books, £16.95, pp 239 ISBN 1 86105 373 8
Rating: ★★
The trouble with The Trouble with Doctors is that most of us think we know the answers already. Everyone oversells us, including ourselves. Politicians impose absurdly unrealistic timeframes for untested reforms; the drugs industry seeds the media with stories of wonder drugs of marginal benefit; patients won't accept the inevitability of disease and death; and it's a brave surgeon who'll admit to being below average. And in our blame culture if you don't get it right first time in under five minutes you'll be splashed all over the Sunday Mercury.
The ethicist David Seedhouse defines health as the extent to which what is expected of us matches what we achieve, and by that measure doctors are unhealthy from just about every angle. No wonder so many are in brain meltdown. Yet medicine has progressed enormously in the last 50 years—so why is nobody celebrating? Dally reaches the same conclusion that we all do: unrealistic expectations.
Her contention is that such expectations have arisen because we have failed to appreciate the central role of fashion in medicine and the variability between doctors, not just in ability but in belief and desire. The book has an interesting chapter on motivation—how doctors act in their own interests as well as those of patients—but we're too quickly into the territory of Shipman and Eichmann before she offers the disclaimer, “Killing patients for pleasure or relief of tension is probably extremely rare.” But her end thought—that doctors are human, and we need to get real about their motives—is wise enough.
The bulk of the book is dedicated to fashion: how essential it is for progress but also how often it leads us down blind alleys. All medicine starts with fashion, hoping that evidence will arrive in due course, and Dally documents all our worst excesses, from lancing gums to whipping out an elongated uvula. So, will evidence based medicine ride to the rescue? Sadly not. “This is another fashion, and will eventually be shown to be so,” she says. So why are we no longer whipping out uvulas?
Dally sees a difference between evidence (a good thing) and evidence based medicine (a fashion), but she doesn't clearly articulate this difference. There's plenty of fascinating historical context but no new concepts. Everything here was said by Shaw a century ago, in fewer words and with more humour. Even the bit about uvulas.