Has medicine fallen victim to healthcare?

MEDICAL MATTERS:A BOOK with the title The End of Medicine and the Last Doctorwas always going to grab my attention. Written by Sidney Lowry, a retired oncologist from Co Down, it is, at times, a provocative book about what the author claims is the end of medicine as we know it. He sees a sea change taking place in medicine with the "changing roles of doctors and, just as significantly, the changing expectations of patients".

For me, the saddest part of Dr Lowry’s thesis is the demise of the physical examination in the practice of medicine. And he is absolutely right to use the word demise: during a recent conversation I had with a consultant renowned for his clinical teaching, he told of his despair as newly qualified doctors rely ever more heavily on investigations such as MRI scans and less on the basic skills of history-taking and examination. He described a process whereby, for example, a complaint of knee pain was sufficient to prompt a scan, with no attempt to ascertain what part of the knee might be affected or the kind of pain experienced by the patient.

Lowry says he has heard the physical examination of patients derided as “poking and prodding”. He claims patients carry some responsibility: “Often they don’t want to be examined. They want an MRI. Moreover, reports of new discoveries and breakthroughs have increased demands for the latest advances.”

However, doctors must shoulder the bulk of the responsibility for the new primacy of technology over clinical skills. According to the author, there are several reasons for this.

“First, it is easier and faster, especially if his or her clinical skills are diminishing. Second, it keeps the patient happy. Third, it provides some degree of cover against litigation . . . It is clear where this is heading. The physician has abrogated responsibility. The nurse assistant can do the job, order the test(s) and, as we shall see, occasionally interpret the results, and even prescribe the treatment.”

But what role has a machine got when it comes to the art of medicine? Who is going to deal with the person’s experience of illness, when machines and protocols are programmed to identify and treat textbook disease? People experience a single disease in so many different and changing illness patterns, and are aided by the ancient artistic skills of “doctoring” to help them come to terms with the experience.

“One of the casualties in the decline of medicine is the loss of compassion . . . Gradually the physician is being replaced by the machine. The machine has no feelings, no compassion. Even the Dalai Lama has written a book on the subject. What is this elusive quality called compassion, and can it be measured? Can it be recovered? And does it matter?” Lowry asks.

It is hard to argue with his contention that compassion is a form of altruism. “It has been defined as caring for others as you would wish for yourself. In medicine, it is a feeling of distress for the suffering of patients and a desire to alleviate their misfortune,” he contends. And however nobly old-fashioned and benignly paternalistic that may sound, it is neither in the interests of physicians nor patients that we lose sight of compassion and empathy as central to doctoring.

In his envoi, Lowry writes: “One may ask, how can medicine be finished, given that we are spending more on healthcare than ever before? The answer is that healthcare is no longer about medicine: it has become something else. The job of medicine has been to eradicate premature disease. That task is almost finished and the focus has moved on. Life expectancy has expanded into the 80s. The new goal is immortality or life extension. Healthcare is now a colossal commercial enterprise, promoting investigations, medications and longevity.”

While he argues strongly that this is the end of a chapter for medicine, is it really the end of the book?

It’s a question, and a debate, that the profession needs to address as a matter of urgency.

The End of Medicine and the Last Doctorby Sidney Lowry is published by the Royal Society of Medicine Press

mhouston@irishtimes.com