Ben Hoban is a GP in Exeter
For as long as there have been people, there have been those who needed looking after, whether due to frailty, poverty, injury or sickness, and those who looked after them. Disease has been one misfortune among many, all with the same general remedy: call what help you can and await events. Where societies have had the benefit of healers of one sort or another, the healers have certainly done their best to improve their patients’ outlook. However a larger part of healers’ function has been interpretive: to provide context and direct expectations during this wait, often with a kind of medical theatre, “amusing the patient while nature cures the disease.”1
…a larger part of healers’ function has been interpretive: to provide context and direct expectations during this wait, often with a kind of medical theatre..
.Doctors have always played their part in this, largely because for most of our history there hasn’t been much else that we could do. Despite its shortcomings, however, this kind of medicine is inherently patient-centred, springing from an individual’s worldview, values and concerns, and addressing the unique experience of their illness, and it is still the foundation for much of what we do.
If this First Age of medicine was concerned with interpreting illness, the Second Age was all about treating it and grew out of the scientific revolution, leading over time to hygiene, antibiotics, organ transplants and gene therapy. This is the medicine we learned as undergraduates, based on recognizing the symptoms and signs of disease and applying the appropriate treatment. The second age concerns itself with pathology more than people, who are seen as cases of a condition rather than individuals with their own story. It can at times be frightening and dehumanizing, but is also highly effective: think of all the medical and surgical advances of the last century and imagine what life would be like without them.
In the First and Second Ages, medicine was transacted between individual patients and doctors at times of illness. The Third Age, in which we find ourselves currently, is associated with the development of a much bigger picture in which this is no longer the case. Instead, healthcare systems interact continuously with whole populations, blurring the boundary between health and illness.
This process is analogous to the idea in business of vertical integration.2 A company manufacturing a product is part of a supply chain, in which it depends on others both further back in the chain, and further forward. In order to have something to sell, it first needs investment, raw materials, tools, premises and a trained workforce. In order to sell, it needs marketing, distribution, retail and customer support. As a company grows, it can become more efficient by taking on these roles itself, integrating forwards or backwards with its supply chain.
In the United Kingdom, we see the National Health Service simply as a provider of healthcare, but it already shows a high degree of vertical integration. Inasmuch as the NHS is a part of the state apparatus, it is already integrated with its finance through taxation, its workforce through government involvement in training, and its research and development through public funding of academia. Although at the retail end GP partnerships are technically independent contractors, they are in effect franchise-holders, and some are already employed directly. None of this is controversial, but it has profound implications for patients.
Patients are generally considered either beneficiaries or consumers of healthcare. Gradually and without realising it, however, they have also become a part of the supply chain. Their role has become to behave in such a way that the health service functions smoothly. In practical terms, this means accepting an emphasis on preventive care, screening and early proactive management of non-specific presentations to avoid their costly escalation.3 We go along with this every time we initiate primary cardiovascular prevention or refer a patient for investigation because of a combination of demographics and everyday symptoms which may be associated with cancer. In this situation, we are no longer acting to cure a sick patient or to help them make sense of their experience; we are risk-managing them based on health-economic considerations.
Naturally, patients don’t want to have strokes or cancer, but most of those who take cholesterol-lowering tablets or attend fast-track clinics do not benefit, and some come to harm. This kind of medicine places on both doctors and patients a heavy burden of responsibility for preventing sickness and death, while at the same time minimizing any real sense of agency. The population may have better measurable outcomes, but neither the doctor nor the patient is likely to notice the difference. Furthermore, if the only reason I am recommending statins this year is that they are cheaper than last year, the implication is that everyone ought to be on them if we could afford it, and that no one is healthy really.
Patients connected to a healthcare system generate demographic, physiological and disease-related data which contribute to a dynamic picture of the health of the whole population.
Health is being redefined neither as a state of maximum wellbeing nor the absence of disease, but as the lowest point on a curve representing the risk of any sort of adverse outcome. Most of these outcomes are clinical, but others, like unplanned hospitalization or litigation, are not in principle bad for patients, but put an additional strain on the system. It is significant that since the COVID-19 pandemic it has become normal to talk about the need to prevent the NHS from becoming overwhelmed, as if the survival of the system were the main aim.4 Granted, the health service can only benefit patients if it is functioning, and it is inevitable that an overstretched service will do this less well, but the change in emphasis suggests that we are now thinking in terms of managing a supply chain in which patients are just a part, and perhaps not the part they thought.
Patients connected to a healthcare system generate demographic, physiological and disease-related data which contribute to a dynamic picture of the health of the whole population. Analysis of these data can be used to plan services and conduct research, to fine-tune the system. Useful though this is, there is something disconcerting about the idea of people becoming not just patients, but mere data points, the end result of this particular supply chain, in the same way that we become the digital product whenever we use an internet search engine.5
The third age of medicine is at once the most benign and the most unsettling. We now have the organisational, medical and informatic tools to mitigate the effects of disease to an extraordinary degree. In order to use these tools to their full effect, however, we must submit to being constantly monitored and managed, and do more and more to safeguard our health despite knowing that we are unlikely to benefit directly, lest by getting it wrong we somehow break the machinery intended to care for us. Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive.6
Perhaps my reservations are not so much to do with practicalities, but with the principle. Given the choice, would we rather do our best to get on with life and not worry about our health, or do whatever it takes to avoid serious illness? As doctors, we can help our patients regardless of how they answer this question, but we must at least ensure that they understand it.
1. “The art of medicine consists in amusing the patient while nature cures the disease,” attributed to Voltaire from the end of the 19th century, but probably apocryphal; earlier versions are generally anonymous, as in The Quarterly Journal of Science, Literature, and the Arts 1823: ‘“Physic,” says a foreign writer, “is the art of amusing…”’ oxfordreference.com
2. From General Practice to Primary Care: The Industrialization of Family Medicine, Steve Iliffe, OUP 2008
3. The Patient Paradox: Why sexed-up medicine is bad for your health, Margaret McCartney, Pinter & Martin 2012
4. For a recent example, see NHS crisis: Health leaders raise alarm over ‘overwhelmed’ hospitals at No 10 summit with Rishi Sunak (inews.co.uk)
5. The idea that the consumer becomes the product can be traced to a 1973 video by Richard Serra and Carlota Fay Schoolman, which included the statement in relation to TV advertising, ”It is the consumer who is consumed. You are the product of t.v.” quoteinvestigator.com
6. God in the Dock: Essays on Theology and Ethics, CS Lewis, first published 1970