Thinking Otherwise: Royal Victoria Hospital, Wednesday 26^th September 2012

When asked, many months ago, if I would deliver the 2012 Annual Oration, the great sense of honour being accorded easily overcame any anxiety about what I would say. I have to tell you that as the day has drawn closer, I have struggled to appreciate the honour, as a sense of alarm verging on panic has gradually taken over.

Many of us in medicine get used to delivering talks and lectures of one sort and another in front of large audiences. What is it about this occasion that reduces grown men (and perhaps women, there have been one or two) to a state of high anxiety? As I look around, it’s not hard to see the reason. Because as I anticipated this is not some anonymous audience in an unfamiliar place far from home. Here I am, in the hospital where I have spent most of my professional life, which I have grown to love despite its imperfections, surrounded by colleagues, friends, teachers, family and loved ones; in short those with whom I have shared the ups and downs of professional and personal life. I am afraid to say so, but you really are quite intimidating. Nevertheless, I am grateful to you all for coming and I will try not to keep you too long.

Veterans of these occasions will know that the origins of the Oration are in welcoming the new students to the hospital for their clinical studies – to the Belfast General Hospital, which became the Belfast Royal Hospital and then moved to what is now the Royal Victoria Hospital. Even though so-called vertical integration of the curriculum has made the distinction between pre clinical and clinical studies less clear, that purpose remains today. I attended my first Annual Oration in the 1970s having been led there by Dr John S Logan. I won’t name the orator that year, but I do not recall finding it all that compelling. Orations can be something of an acquired taste and perhaps appreciation increases with age. So for those students who have made it along, you do have my understanding, but I still say a warm welcome.

You will have gathered from the title that I do have a few things on my mind, and the first thing I want to do is persuade you that it is appropriate for me to use this occasion and the format of a lecture to unburden myself. Secondly I hope to persuade you that dissent and argument remain key to both good medical practice and the advance of medical science. Thirdly I will argue that there are times when it is the duty of the doctor to bring dissenting views into the public sphere. Finally I will advise you that we should not be complacent about the freedom we have to speak out both as doctors and as citizens.

So is it really appropriate for 150 or more of us to gather here, taking perhaps two hours or more out of busy working lives? Worse still for a couple of rows in the middle it might turn out dry enough for golf. Whatever way you look at it, there are a lot of man hours involved. And then you are told you are going to have to listen to a lecture – a word that in modern usage has picked up a lot of negative connotations. More than that, there is the veiled threat within the title that a medically qualified person in N. Ireland might be at risk of saying something vaguely controversial. Worst of all there is no right of reply, so you will be exposed to the opinions of a middle aged male of a certain background and upbringing without a balancing panel of views - unless there is some heckling from the back which I do not remember as a tradition of these occasions. So I suggest you to hold onto your seats: it could get a little bumpy.

A few years ago the playwright David Hare argued, in his book “Obedience, Struggle and Revolt”, that the set piece lecture remains a critical part of developing ideas and reaching the truth¹. Hare commented on the extreme rarity of uninterrupted speech in both social and academic discourse. His contention was that it takes time to put forward a certain point of view, and that the absence of immediate counterargument should not be a cause for concern. Rapid responses can be unnecessarily defensive with a certain amount of grandstanding and posturing. Indeed, Hare suggested that if you wanted to make sure an hour would pass in which no serious thing was said about politics you would invent the television programme “Question Time”. Medical educational theorists have a low expectation of students’ ability to concentrate. The London Deanery programme² tells us that “a rule of thumb is that real concentration on one activity, such as listening to someone talk, lasts around 10 minutes without a break or change of pace. It is important therefore to keep the session flowing …”

I am not sure how I’m doing so far but, if only out of politeness, you are prepared to stick with me for the next half hour or so – you see I have high expectations of your powers of concentration - another question arises which is should we use this occasion, when we award some of our brightest students their well earned prizes (and may I add my own congratulations), to discuss anything remotely controversial? Indeed I have heard it said that the Oration is purely ceremonial. Well I beg to differ. If it is worth getting you all together, and so long as we avoid unnecessary and gratuitous insult, then I can see no reason why the strongest opinions should not be articulated provided they are in some way relevant to the work of this hospital, the greater Belfast Trust or the health service in general. And if there are those at the end of this morning who feel sufficiently moved to wish to mount a counterargument, could I suggest that you send your application in early to the Chairman of Staff for next year’s event.

So Chairman, Ladies and Gentlemen, if I might move to my second theme; that dissent and argument, challenging orthodoxy, remain key to good medical practice and science.

The Germans have a nice word “andersdenker”, one who thinks the other thought or thinks otherwise. In medicine, as in other walks of life, we should all be prepared to be, from time to time, andersdenker. History is littered with instances of great minds, and of course some not so great minds, who have run up against the prejudice of established opinion whether that opinion is held within cliques, oligarchies, majorities or even, sad to say, within democracies, for it was they, the democrats in Athens in the 5^th century BC, who sentenced Socrates to death – as depicted by Jacques-Louis David in this picture now hanging in the Metropolitan Museum of Art in New York (figure 1).

Fig 1.

The Death of Socrates by Jacques-Louis David. With permission from the New York Metropolitan Museum of Art through the Images for Academic Publishing initiative.

Socrates chose to die rather than give up the right to express his opinion. What was that great thinker’s crime? He was part of no faction, he commanded no arms. It appears he just went round Athens talking to people. It is strange how disturbing those in authority found logical argument.

And the connection here, you may ask, with medicine? Well, Plato tells us that Socrates dying wish was that a cock be sacrificed to Asclepius³, the mythical physician-hero eventually worshipped as a god. Asclepius also came to a sticky end, struck down by Zeus with a thunderbolt for overstepping his physicianly powers and upsetting the natural order – a point I will return to.

It is not hard to find examples of less than divine physicians who ran into difficulty when they challenged conventional opinion. There may have been others thinking along similar lines to William Harvey when, in 1628, he published his great treatise, Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus. In just 72 pages he distilled the results of years of careful experimentation, comparative anatomical dissection and clinical observation, and described the circulation of blood around the body as we now know it. Quite quickly, opposition arose from those who adhered to the traditional views of the ancient Graeco Roman physician Galen. In contrast to Harvey one of his most vociferous opponents Primerose managed to write his book, published in 1630, inside a fortnight⁵ – no real need to check the data if there are no data, which remains the standard approach of many alternative medicine advocates today.

Some of you may have been lucky enough a few years ago to see the Lyric Theatre production of Molliere’s “Le Malade Imaginaire”. Mr Diafoirus, the physician, is depicted railing against the circulators - the adherents of Harvey’s view⁵. Diafoirus may well be based on the Parisian physician Gui Patin who, when not opposing the circulators, was obsessed with purgation and bleeding. That “Le Malade Imaginaire”, written in 1671, 43 years after the publication of “De motu Cordis”, was able to satirise critics of Harvey’s ideas probably indicates that opposition to Harvey was by this stage on the decline. This ties in nicely with Max Planck’s remark “a new scientific truth does not triumph by convincing its opponents but rather because its opponents eventually die, and a new generation grows up that is familiar with it”⁶.

A sceptical and questioning approach is not just a matter for medical scientific inquiry. It is part of everyday medical practice and teaching. The discipline of learning by questioning is often loosely called the Socratic method, after our friend Socrates of Athens. Challenging a series of hypotheses – does the evidence fit - is usually how we establish a diagnosis. It is also the method most of us use in our bedside teaching as we challenge students with the complicated jigsaw of observations that make up the presentation of illness. Socrates was accustomed to say that he did not himself know anything and that the only way in which he was wiser than other men was that he was conscious of his own ignorance⁷. This is a good starting point for learning and perhaps emphasises that we need to come to our patients with an open mind.

But a few words of warning are also necessary. Socrates was against the absolute scepticism of the sophists. That well known medical writer and thinker, Petr Shrabanek, made the point that too much scepticism can hinder scientific inquiry if it goes so far as to become an inability to recognise the absurd – what he called irrational scepticism. Irrational scepticism risks becoming a dogmatic belief in the absurd and a tentative unbelief in reason⁸. The danger is that one’s mind stays so open that the brains fall out.

Acceptance of what is termed alternative medicine falls into this category. It is understandable for frustrated patients, with chronic or incurable illnesses, or with symptoms which doctors have failed to acknowledge or explain, to turn to alternative medicines and unorthodox practitioners. But for those, who have been trained at much expense to become medical practitioners and others who should know better, to fail to recognise what is patently absurd is scepticism gone mad.

My third theme is that there are times when it is the duty of the doctor to speak out. The need to do so may appear obvious, in other instances less so.

Let’s start with a fairly extreme example. In 1946 twenty doctors and three administrators were charged with war crimes and crimes against humanity for their part in the human experimentation in the Nazi concentration camps. The defence argument was that they were engaged in necessary wartime research and that they were following the orders of their superiors. Sixteen were convicted and either hanged or sent to prison⁹. It is hard to find evidence that any wrestled with their conscience. One or two expressed remorse later. All of us can agree that , however difficult, they should have spoken out or refused to carry out their orders. Loyalty to an organisation, institution or regime was not a valid excuse.

Of course, it is an extreme example. None of us is likely to be in a position like this today. Or maybe not. Steven Miles has told us¹⁰ that at prisons in Abu Ghraib, Iraq and Guantanimo Bay, Cuba “at an operational level, medical personal evaluated detainees for interrogation, and monitored coercive interrogation, allowed interrogators to use medical records to develop interrogation approaches, falsified medical records and death certificates and failed to provide basic medical care.” The Red Cross accused physicians of flagrant abuses of medical ethics. I don’t equate the Nazi doctors with those in Iraq or Cuba in any scale of evil, but it is clear that the modern doctor must remain vigilant

This applies in today’s NHS in the form of so-called “whistleblowing” with respect the practice of either an individual colleague or an organisation. In all such situations we have been given clear advice by the General Medical Council about how to raise and act on concerns about patient safety¹¹. So-called gagging clauses have been quite rightly condemned and doctors instructed not to sign them. And of course making concerns public must be an option, but only when other appropriate channels have been exhausted.

In the aftermath of the Mid Staffordshire NHS Foundation Trust scandal, the House of Commons Medical Committee called on the General Medical Council to send out a clear signal to doctors that they are as much at risk of being investigated for failing to report concerns about a fellow doctor as they are from poor practice on their own part¹². No one would defend remaining silent if we become aware of poor performance by a colleague, which is putting a patient at risk. There is, however, some danger of putting this type of thinking at the heart of our practice. In building team working of health care professionals an element of trust is essential. My concern is that the Health Committee message will have the effect of creating an atmosphere of fear and distrust of the sort seen in communist block countries before 1989. In my experience nearly everyone in the NHS is trying to do their best. No amount of compulsive checking can induce excellence if motivation and morale are at rock bottom.

As opposed to speaking out about deficiencies in care, I am rather more concerned about whether the profession has contributed, or some would say been allowed to contribute, to decisions that have shaped the health service in NI over the last 30 years. As the Compton Report has pointed out we face a situation where poorly developed community services are failing to stop the flow of patients by default through the Accident and Emergency and outpatient departments of our hospitals¹³. In these same hospitals resources are spread too thinly around too many sites with the result that levels of manning of essential emergency and other rotas is at breaking point.

Could this all have been avoided? Probably not. But the unrealistic nature of much discussion about the service has not helped.

Doctors do need to use every opportunity to bring their professional opinion to bear. It is helpful if our ideas can be directed through the filter of collegiate discussion. Since the scrapping of the Specialty Advisory Committees to the Department of Health, it is not clear to me how the Department of Health in N.Ireland obtains independent medical advice. Contrast the situation in Scotland where there are close links with the medical Royal Colleges.

If we are to take a more active part in public debate, we need to make it clear in what context we speak; as doctors or as individuals. And there are dangers that, speaking as doctors, we may involve ourselves in matters that we have no business getting involved in. Michael Fitzpatrick, a General Practitioner working in London, has warned that doctors, and governments acting through doctors, have become associated with the “regulation of lifestyle in the name of health … for deterring vice and disciplining society”. In the introduction to his book¹⁴ “Tyranny of Health” he states “On a bitterly cold February day in the winter of 1987 I had to break into the house of an elderly couple who had succumbed to a combination of infection and hypothermia. While I waited for the ambulance I found unopened on the doormat, a copy of the government’s “Don’t die of ignorance” leaflet which has been distributed to twenty-three million households as part of the campaign to alert the nation to the danger of AIDS. Around half of these households contained either an old couple or an old person living alone. One elderly woman wrote to a national newspaper inquiring do you think this caring government would swap my AIDS leaflet (as new) for a bucket of coal”. Fitzpatrick is perhaps a little hard on a well intentioned initiative, but it does highlight that in our professional role it is best to confine ourselves to stating professional opinion and leave it to individuals to take decisions about how they behave.

My final theme is that we should not be complacent about the freedoms that we have and think we have. There remain many vested interests which stand in the way of legitimate expression of opinion. The poet and critic Tom Paulin has argued in his book “Crusoe’s secret; the aesthetics of dissent” that huge sections of English literature are a sort of coded criticism of establishments of their time¹⁵. You may think it fanciful if I suggest to you that we may again have to disguise reasoned scientific opinion within the pages of literature, but perhaps consider these cases. Three years ago Dr David Nutt, government scientific advisor, gave a public lecture at which he expressed the view that certain drugs, specifically ecstasy and cannabis, should be regraded from class B to class C, that is labelling them as less dangerous than previously. This contradicted the Government line and he was sacked by the then Home Secretary Alan Johnston¹⁶.

David Nutt may have erred in making a direct criticism of the minister who did not take his advice. From what I saw of Alan Johnston he appeared to be a very competent Minister. I accept that classification of drugs is a high profile and emotive issue, and my own personal view tends to be proscriptive in the matter of drugs of abuse. But essentially Alan Johnston, in sacking David Nutt, conceded his inability either to argue the contrary case on scientific grounds, or, as a politician, articulate the view that public opinion which he represented did not agree with the scientific opinion expressed. Sadly those elected democratically to lead us, just as in Socrates day, can be oversensitive to logical argument. You might say why should Governments not appoint whom they want to give them advice? Well they can do exactly that, but of course the danger is that they appoint those whose opinions they like to hear.

As well as overbearing government, the dangers posed by claimant friendly libel laws have received much attention. For example, there are numerous instances of large pharmaceutical companies suing doctors for comments made during scientific meetings. These cases have stimulated a vigorous campaign to reform the libel laws, which currently place an onus on the defendant to prove the truth. This may not be easy. Even victory in a libel case can leave the defendant paying huge legal expenses. This goes well goes beyond individuals. Medical journals have felt it wiser to desist or pay up without fighting the case.

One note of optimism was the victory at the Court of Appeal by Dr Simon Singh, a medical journalist¹⁷. Dr Singh was sued following an article he wrote in which he criticised the British Chiropracter Association for defending chiropractors who as he put it “happily promoted bogus treatments”. They finally dropped their case in April 2010. The Appeal Court judges drew on the statement of Judge Easterbrook of the US Seventh Circuit Court of Appeals; “scientific controversies must be settled by methods of science rather than by the methods of litigation. More papers, more discussion, better data – not larger awards - mark the path towards superior understanding of the world around us.”

So, finally, how is the argumentative doctor to proceed? There are some lessons to be learned from the playwright Henrik Ibsen. In his play “An Enemy of the People”, completed in 1882 and based on real events, Ibsen tells how the well intentioned Dr Thomas Stockmann speaks out after he learns that the spa waters of the town in which he practices are a source of typhoid and other diseases¹⁸. These spa waters are also the town’s main source of wealth as a tourist attraction. They are run by the Baths committee, of which Dr Stockmann’s rather pompous brother is Chairman as well as being mayor of the town. Stockmann sadly makes a number of mistakes. He is certainly tactless in his dealings with authority. Pinching and wearing his brother’s grand mayoral hat makes good theatre, but does not improve filial love and respect, the equivalent of leaving your car in the Chief Executive’s parking space. Don’t let it get personal. Stockmann displays complete ignorance of the economic impact of his proposals to solve the problem, a characteristic not unknown amongst modern medical men. He is inclined to be hot headed and rushes to the press with his scoop. His near fatal mistake is to trust the press to remain on his side after the catastrophic impact of his findings on the town’s house prices becomes clear. He does not mashal his evidence clearly and assumes the public will have no difficulty following the logic of the scientific argument. The public have a perfect right not to like the facts and an even more important one which is to ignore them altogether. Perhaps most seriously Stockmann allows a degree of self interest to influence his actions which extend beyond the strictly medical. He believes that publishing his findings in the press will enhance his reputation and overturn the town’s ruling clique. In short his handling of the situation lacks many of the skills that would be required for survival in the modern NHS. Despite the rightness of his cause he is declared an enemy of the people, his house is stoned by the mob, and he loses his position and practice.

So if there are any new students here, and don’t we all need to consider ourselves new students of something, my advice is certainly to challenge conventional opinion, and speak out when necessary. Take a little care when tackling Governments and others with big budgets and large public relations departments. Watch out for false friends in the press, and be sure that your motivation is at all times - beginning , middle and end - to improve the lot of the patients under your care.