Category Archives: medical profession

The Working Time Directive

This legal act of the European Union is, writes Dalrymple,

typical of modern legislation, or perhaps I should say administrative fiat. It appears to confer benefits or rights on those who come under its purview (in this case, almost everyone). As such, it is seen by many of its supposed beneficiaries as benign.

But

the supposed benefits exert a profound and baleful influence on the character of the supposed beneficiaries, always in the direction of increased dependence upon the administrators.

A medical profession, says Dalrymple, that is composed of clock-watching shift workers

will be far easier to control and order around than one that is both self-regulating and has a sense of vocation. The independence of citizens or professions is what the modern administrator fears more than anything else, for it strikes at the heart of his raison d’être and threatens him with actual, rather than merely existential, redundancy.

Shame of the US medical profession

The opioid overdose hecatomb

Dalrymple writes:

More than twice as many Americans have died of opioid overdoses as have been killed in all US military actions combined since the Second World War. Opioid overdose is the leading cause of death of those under 50 in the US.

He points out that this

reflects extremely poorly on at least a portion of the American medical profession. 60% of deaths by overdose involve prescription drugs, and more than four-fifths of heroin addicts begin their career as addicts with prescription drugs. When one considers that, in the great majority of cases, there was no proper medical indication to prescribe these drugs, the medical profession’s responsibility in the production of this hecatomb is clear: and yet, even now, more of these drugs than ever before are being prescribed.

Enver Hoxha, flamur i luftës për liri e socializëm

War flag for freedom and socialism

All kinds of considerations, Dalrymple says in a recent talk (from 4:38), make medicine

a happy hunting ground for the politically correct. Nowhere is this more so than in medical journals.

He has

no objection to the publication of any particular point of view — much to the contrary.

What he finds distressing in the medical journals is

the lack of any other point of view, as if the medical profession were the Albanian electorate in the good old days of Enver Hoxha.

UK physicians are no different from auto assembly workers

Screen Shot 2016-05-04 at 07.55.09Junior doctors in England, writes Dalrymple,

and increasingly senior ones, are now shift workers.

This means

there is no continuity of care, or very little, in British hospitals.

There is, of course,

no better way to ensure that young doctors do not believe themselves to be members of a profession with a glorious tradition than to turn them into clock-watchers, and patients into parcels to be handed on to the next person once the music stops.

Screen Shot 2016-05-04 at 07.28.57Doctors have become

production line workers, no different from people who work in car factories.

Doctors turned spin doctors

Young doctors in training are aware of

the importance of spin-doctoring, for they have prepared ‘personal statements’ to get into medical school. It is an exercise in unctuous insincerity.

A lifetime of this kind of thing

will warp any character, and render it simultaneously self-righteous, politically correct in expressed views, unprincipled and ruthlessly focused on personal advancement. People with such character will be easy to herd and control.

Why is the urge to herd and control so strong in the political class? Perhaps, says Dalrymple,

it is the result of an inner emptiness and lack of deeper culture.

The result is

a soft and creeping totalitarianism.

Harley Street paved with gold

Screen Shot 2016-05-04 at 14.50.13

Harley Street: view from Cavendish Square

Iatrophobia is a serious medical condition (focal sepsis is very often present), though it is sometimes highly treatable — and at the very least can be managed and palliated — if the patient is constrained to undergo a colectomy and adjuvant frontal leucotomy along with inguinal orchiectomy and Metrazol-induced convulsion therapy.

The psychotic delusional condition of iatromisia, on the other hand, though it can be treated with the above methods — applied perforce with much greater intensity and with the addition of comprehensive salvage insulin coma therapy (Insulinschockbehandlung) — is sadly not so tractable.

Harley Street: view from Cavendish Square

Harley Street: view from Cavendish Square

Indeed, writes Dalrymple, carcinoma iatromisia is metastatising,

not among the general public, which on the whole retains its respect for and trust in doctors (a fact borne out by all the surveys), but among the intelligentsia — literary folk, journalists and so on.

This kind of people,

perhaps because their own crafts are held in such low public esteem, believe that doctors should be taken down a peg or two.

Harley Street: view from Cavendish Square

Harley Street: view from Cavendish Square

Dalrymple says there are two main charges against doctors, particularly hospital consultants:

  • they are on the golf course most of the time
  • they are making a fortune from their private practices

These two complaints, Dalrymple points out,

are not strictly compatible. Doctors are often quite clever people, but even they have not mastered the art of being in two places at once, and the only way of making money out of private practice is to work very hard at it. Doctors are not paid for a birdie three or an eagle two.

On the part of journalists and the literati, Dalrymple observes,

141 Harley Street

141 Harley Street

the primordial antagonism towards doctors is not fully rational: it is a little like anti-Semitism.

Jews, to the anti-Semite, are simultaneously

  • capitalist plutocrats
  • communist agitators

In the same way, doctors, to the iatromisiac, are simultaneously

  • incredibly lazy
  • ferociously avaricious
Crœsus of consultants: Thomas Horder, 1st Baron Horder, lords it over his patients in his consulting-room at 141 Harley Street. Note the photograph of Neville Chamberlain on the mantelpiece

Crœsus of consultants: Lord Horder at 141 Harley Street. Note the framed photo of Neville Chamberlain

How fortunes are made effortlessly from private practice

The golf course is to iatromisia

what ritual murder is to the anti-Semite: a myth to keep a hatred warm.

Dalrymple explains that

doctors as a group are better than many groups of comparable size.

Of his own professional circumstances he writes:

I am on duty one night in five, and have been for years. I do no private practice, apart from some medico-legal work. I never refuse to get up in the middle of the night to see a patient, and if I do get up, I still have to go to work the following morning, however tired I may feel. My pay is adequate, and I do not complain about it: my wife, who is also a doctor, and I live well but not extravagantly. Certainly, many people with less strenuous lives earn much more than we do. As far as I am aware, I have not lost a single patient through carelessness in all those years.

Harley Street looking north from Weymouth Street

Harley Street looking north from Weymouth Street

And what Dalrymple does

is only what thousands of other doctors do.

To be told that he belongs to

an avaricious, power-mad, privileged and lazy cabal by people whose prerogatives are distinctly those of the harlot sticks a little in my throat.

Dalrymple does not claim to love humanity,

Harley Street looking north from Weymouth Street

Harley Street looking north from Weymouth Street

but I do get up at 3am if I am required to do so. It is far, far easier and less demanding to write an editorial; I know because I have done both.

Iatromisia, he points out,

coheres with governments’ increasing fear of professions that escape their complete control. Disproportionate criticism of the medical profession by journalists and authors serves governments’ goal of a totally managed society.

91 Harley Street. At left, the chauffeur keeps the Bentley engine running, ready to take the consultant to the golf course or the bordello at any time of the day

91 Harley Street. Note the parked Bentley. The chauffeur keeps the engine running, ready to take the consultant to golf course, club or bordello at any time of day

91 Harley Street

91 Harley Street

13 Harley Street

13 Harley Street

Consulting-room at 13 Harley Street. Note the painting of a young Margaret Thatcher

Consulting-room at 13 Harley Street. Note the painting of a young Margaret Thatcher

73

73 Harley Street. Architect: W. Henry White

73 Harley Street. Architect: W. Henry White. The French Loire style, brick with plenty of terracotta decoration on a small, playful scale (Pevsner)

73 Harley Street. ‘The French Loire style, brick with plenty of terracotta decoration on a small, playful scale’ of which there are several specimens in and around Harley Street, ‘characterised by heavy curved door canopies, shallow bay windows, Tudor mullions and transomes, steep gables’. (Pevsner)

83 Harley Street

83 Harley Street

Fireplace in a consulting-room at 83 Harley Street. The consultant stands before it, delivers a homily — with the patient maintaining a respectful silence — on bowel regulation or the virtue of broccoli ingestion, then it’s off to the links, his club or his mistress's Belgravia flat

Fireplace in a consulting-room at 83 Harley Street. The consultant stands before it, delivers a homily — with the patient maintaining a respectful silence — on bowel regulation or the virtue of broccoli ingestion, then it’s off to see the mistress in her Belgravia flat, or else to the links or the club. Yes, life is good

88 Harley Street

88 Harley Street

88 Harley Street

88 Harley Street

92 Harley Street

92 Harley Street

92 Harley Street

92 Harley Street

Harley Street viewed from Cavendish Square

Harley Street viewed from Cavendish Square

May my surgeon be human-hearted

Screen Shot 2016-04-04 at 08.49.19Dalrymple points out that the media’s attitude towards medicine

swings between lauding a miracle cure and excoriating the murderous incompetence of doctors, leading to a dialectic between unfounded hopes and hostile suspicion.

Yet very occasionally it perhaps ought to be acknowledged that medicine,

for all its deficiencies and the carping of its critics, is a noble enterprise.

Doctors must act

in the absence of definitive knowledge. Sometimes this leads to tragedy, sometimes to triumph.

Screen Shot 2016-04-04 at 08.20.47A paradox

Everyone who comes under the knife

wants his surgeon to be as highly trained and as experienced as possible: but how is the surgeon to come by that training and experience unless he practises on people while he is untrained and inexperienced? Someone has to be operated on by tyros, even if they are under the supervision of more experienced surgeons. In practice, for compelling practical reasons, that supervision may be light: senior surgeons cannot be everywhere at once. What is true of surgery is true of other specialities: decisions of vital importance to individuals are taken by people who are still learning.

In the old days,

Thomas Rowlandson, 1793

Thomas Rowlandson, 1793

perhaps explanations of treatment options were less elaborate or full than they are today, but they were still given and consent to such treatments was still sought.

Patient autonomy as the single most important guiding principle of medical ethics has drawbacks.

Patients who are very ill are often in great pain, or severely weakened. Their concentration is poor, they may be irritable or in a state of panic. This is not generally the best moment to ask them for a reasoned assessment between two or more alternatives, each with its own advantages, side-effects and chances of failure. The insistence that they do so is often a form of disguised cruelty.

Dalrymple says that when he has been seriously ill or injured,

I have wanted my doctors just to get on with it as best they could, without any interference from me. So far, at any rate, my confidence in them has not been misplaced; and the paradox in the doctrine of autonomy is that the person may — in fact, often does — wish to abrogate it.

Surgeons

need human as well as technical understanding, and kindness is at least as important as respect for patient autonomy.

How a surgeon of experience and integrity acts

Screen Shot 2016-04-02 at 17.58.19Dalrymple has an example in his family history

of a surgeon who acted in a way that would now be deemed ethically reprehensible, and perhaps actionable, but which seems to me to have been in the very highest tradition of his profession.

His name was Cox,

and I don’t know whether he is still alive: by now he would be very old. I thanked him insufficiently at the time.

Dalrymple was in Africa when he telephoned his mother.

She was about to go to America on a visit, but she told me that she had been bleeding intestinally. I told her she must abandon her visit and see a surgeon at once, which she did.

It was cancer.

She underwent an operation within the week. I returned home before the operation.

Dalrymple mère

said that she wanted nothing hidden from her; she wanted to be told everything, and made me promise that I would hide nothing.

Dalrymple mère exuded

pride in her own rationality.

After the operation, the surgeon Cox

spoke to me. Whether he was franker with me than he would have been with a son who was not a doctor I do not know; but he told me that, while he had excised all the cancerous tissue that he could see macroscopically, histology demonstrated that my mother’s prognosis was very bad. There was an 80% chance of recurrence within a year.

Dalrymple said that Dalrymple mère had made him promise that he would tell her everything.

The surgeon said that, on his estimate of my mother’s character and personality, this would not be a good idea. He advised me against this course of action; and since he was clearly a man of experience and integrity, I took his advice.

Dalrymple mère asked Dalrymple, when she had recovered sufficiently from the operation, what the surgeon had said.

I told her that, as far as he could see, he had cut out all the cancerous tissue. This was the truth, but of course not the whole truth, and I rather dreaded further questions, to which I might have to reply with outright lies: and I might not prove to be a very convincing liar. My mother was perfectly well aware that removing all cancerous tissue to the naked eye was not the whole of the matter, but to my surprise – and relief – she enquired no further. Despite her protestations beforehand, she did not want to know everything.

In the event, Dalrymple mère

lived another 19 years without recurrence and relatively free of anxiety about her cancer because the surgeon had ‘cut it all out’.

Dalrymple was impressed by the surgeon Cox.

It seemed to me then, and seems to me still, that he had acted as the model of a fine medical practitioner. He was technically accomplished, it goes without saying; the operation went smoothly, with no avoidable complications. But more than that, he had given consideration to my mother as a person, as a human being; and on the basis of limited acquaintance with her – at most, a few examinations in the clinic – he had come to a shrewd and, I believe, accurate assessment of what was best for her, better indeed than my assessment.

Surgeons

are often accused of being brash, mere technicians without human subtlety, but this was certainly not the case with him.

The surgeon Cox

is a hero to me.

His

understanding of the requirements for decency was much more sophisticated than that of modern medical ethics. He understood that people generally live in a social situation, not as isolated beings, and that it is sometimes right for relatives to know more about an illness than the ill person him or herself.

Dalrymple is sure that the surgeon Cox

knew that truthfulness can descend into indifference to suffering or even to sadism. To try to force people to know what they do not want to know can be cruel, and ineffective into the bargain.

Screen Shot 2016-04-02 at 17.36.46

David Rijckaert III, The Surgeon, 1638. Musée des beaux-arts de Valenciennes

Who on earth would want to be a doctor?

Screen Shot 2016-03-24 at 21.04.40Dalrymple points to the

steep decline in the attractiveness of medicine as a vocation, profession and career.

And no one

who ever experienced an ordinary Soviet hospital will be in any doubt as to what a decline in the prestige of the profession meant to patients.

It has long been the goal of the government, he points out,

to deprofessionalise medicine and to turn its practice into a mere job. An independent profession, with its high standards and old traditions, is dangerous to the government, especially when it is as respected as the medical profession, in a way in which a mere group of shift workers will never be. Shift work dehumanises patients and deprives the work of most of its satisfaction. It is also grossly inefficient.

The independence of doctors

has eroded almost completely, and you cannot expect highly educated people who have undergone a long and strenuous training to remain contented for very long with being harried and reprimanded by people who are of lower calibre than themselves.

A vivid exemplification of the New Hospital Order is the noticeboard in the corridor of the hospital in which Dalrymple works, which

informs the public of the senior staff of the hospital. The senior consultants, all men of considerable distinction, appear on the fifth and bottom row, under four rows of bureaucrats. The impression is given that they are of very minor significance.

The shortening of training,

both graduate and postgraduate, is another straw in the wind. New hospital consultants do not have the breadth of experience that old consultants had at their appointment, and this is because doctors are increasingly regarded as technicians and nothing more.

Une certaine idée du corps médical

Screen Shot 2016-03-09 at 08.38.44Dalrymple writes that he has

always had a certain idea of the medical profession, and industrial action (by which, of course, is meant inaction) has never been a part of it.

Doctors should not refuse to work

except if the seriously unethical is demanded of them by their employers, or perhaps if they are paid starvation wages; and though various British governments in the past decades can be reproached with many things, they have never demanded the seriously unethical of British doctors nor paid them starvation wages.

Rent-seeker on the march

Rent-seeking is the idea here

The assurance that industrial action will not harm patients, is, says Dalrymple,

mystifying. What is it, then, that doctors could refrain from doing that would not harm patients, and whom would they harm by it instead? Surely everything a doctor does should be to the benefit of patients, either directly or indirectly; and if there is something that he does that is not for the benefit of patients, he is wasting his own time and the money of those who pay him.

Doctors, having had fat years, might become acquainted with slightly leaner ones.

The increased expenditure on the NHS, of which a considerable part found itself into the pockets of the doctors, was responsible in no small part for the financial mess in which we now find ourselves; it is not only necessary, but just, that they should now have to retrench. And even after this retrenchment, they will have more than a living wage.

When doctors strike, it

reinforces the impression that those who work in the public service are motivated more by the desire for private gain than by the desire to serve the public. Doctors are among the best-paid of all public servants, and quite a number of them have the opportunity to supplement their incomes by private work. No one likes to see his income decline, but there are some things that ought to be accepted and suffered in dignified silence.

Public service

will be undermined by the naked rent-seeking behaviour of doctors. Of course, this rent-seeking, which is bound to become more desperate and ferocious the more the economy, with few prospects of real growth, comes to be seen as a zero-sum game, will not be confined to the doctors.

Doctors who vote for industrial action enter

a downward spiral of public mistrust of their motives.