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M Dixon and K G Sweeney, Abingdon, Radcliffe, 2000, 157 pages, £17.95
Given that in England and Wales triage, access and treatment based on national frameworks are increasingly important for politicians and therefore for the National Health Service (NHS), clear advocacy for the human effect in medicine is timely. The NHS plan for England proposes an end to single-handed general practices, and the huge investment in NHS Direct with its dependence on binary chain logic to assess patients' needs may lead to this being the single gateway to primary health care. So, whilst in the foreword of this book Denis Pereira Gray says that “the pendulum has started to swing back to the personal” he clearly refers to academia rather than health policy.
Reviewing the theory of the subject in the first of three sections in the book, Kieran Sweeney assesses the philosophy and history of medical practice. In common with the rest of the book, the human effect being examined is almost exclusively patient-doctor rather than the broader range of care professions. He traces scientific rationalism and the relationship between objectivity and subjectivity in medicine from the Hippocratic tradition through Descartes to the evidence based medicine movement. Professor David Sackett's statement: “in all this, the assumption is that medicine is rational and so are you” is effectively erected as an edifice which the remaining review attempts to tear down. Through the recounted history, there is much to trouble the rational view of health and disease: hypertension is a disease in Germany but not in the UK; are alcoholism and chronic fatigue syndrome diseases at all? There are also many delights in such a canter through history: Aclepius, Hygeia, Koche and Harvey all feature.
Sweeney analyses the relationship between doctor and patient and its contribution to health and health care. There is a clear demonstration that to discount the human effect and the importance of patients and clinicians is to overlook essential elements of health and wellbeing. This first section of the book draws to a close with a reference to Michael Balint's 1952 book, The Doctor, His Patient and The Illness.1 The reference begs the question, whether this review of the succeeding years has added to Balint's thesis. Two new elements have been introduced by Sweeney. First, a greater role is proposed for subjectivity than Balint's behavioural, but nevertheless scientific, approach. Second, there is a review of evidence that a good, personal doctor-patient relationship has a therapeutic effect. In the absence of clear direct evidence, however, the review deals with the effect of social wellbeing and lack of stress on disease experience and studies which largely demonstrate the benefits of effective communication and consultation on “compliance”.
The second section of the book focuses on research, particularly into the efficiency of placebos. It argues that if placebo medicines or healers who are not medically trained can produce 50% improvement rates in a wide range of conditions, how much more effective could an experienced doctor be? As elsewhere in the book, the text is well referenced and here includes a review of the types of patients, placebos and doctors most likely to be successful. It is surely unlikely, as patients and doctors relate on increasingly equal terms, and as open information and disclosure become the expectation and right of all patients, that the therapeutic use of placebos without patients' knowledge, will ever again be acceptable. Accepting that placebos or faith healing can trigger the body to heal itself or to override symptoms is not the same as saying that placebos labelled as such will be similarly effective. Explanations arising from the study of conditioned response and the developing field of psycho-neuro-immunology both confirm that the patient has to expect an effect for there to be a chance of the effect taking place.
From the discussion of placebo, Michael Dixon develops the concept of the physician-healer: “primary care . . .. What we are offering is more than a soup kitchen for evidence-based medicine”. This is a self-healing process generated by the efforts of the physician-healer. Three theories are then offered to develop an explanation of this role and how it works. They deal with the effect of consultations in altering patients' perception with an improved physical state; the roles which can be adopted by the physician to encourage independence and passive or active healing, and finally the potential for economic efficiency if health services can supplement the increasing dependency on drugs and technology with effective use of the physician-healer–the therapeutic effect of the doctor.
In the third section, the focus is on turning theory into practice. In considering the doctor-patient relationship, the first model proposed is largely dominated by the doctor. It considers the authority of the doctor and the roles of magic or mystery. “If a therapeutic process is beyond a patient's comprehension, there is a tendency in some to lend it a degree of credibility that is out of all proportion to its actual effectiveness.” Whilst these issues are seen as inevitable parts of a consultation, the review moves to therapeutic effects which might be included: empathy, reassurance and so on. Finally, the end point of any ongoing doctor-patient relationship is described as putting the patient in the driving seat through information, self-help groups, relaxation and positive thinking.
At its conclusion, the book makes the case for empowering patients and provides a review of techniques which can be employed by doctors to make this a reality, particularly through the development of relationship. As such, it is indeed a counterbalance to the growing one-stop-shop, access-driven culture of the NHS. The evidence-base for this conclusion is strong and much of it provided as references. Therefore, the championing of subjectivity and attacks on the evidence-based-medicine culture appear gratuitous. They may lead critics to suggest that the book is a defence of, rather than a dissection of, doctor dominance and of doctor- rather than patient-led, variations in practice.