Diagnostic criteria, Rae Varcoe

Being a Doctor: Understanding Medical Practice
Hamish Wilson and Wayne Cunningham
Otago University Press, $35.00,
ISBN 9781877578366

I have been a doctor for 45 years. How I wish that this volume had been available 46 years ago. I emerged from medical school with a head overloaded with such information as the diagnostic criteria for Disseminated Lupus Erythematosis, the eight most common causes of hypercalcaemia and the presenting features of the numerous forms of syphilis along with their treatment options. I had had no education in how to discuss these diagnoses with the relevant people, let alone any permission or invitation to enter imaginatively into the lives of the sufferers and how these illnesses (and their treatments) might affect them or their families. This book goes a long way toward redressing that balance.

The authors are both academic GPs, teaching medical students at Otago University and graduate doctors (usually GPs). The book is a presentation of their own and others’ wisdom in regard to the human, rather than the biomedical, aspects of managing illness and to the skills involved in “being alongside the patient”. At no stage do they pretend it is easy, but they do indicate that examination and evaluation of the human interactions, and the acknowledgement of the difficulties inherent in them, are as worthy of study and reflection as are the intricacies of cardiac arrhythmias or of obstetric anaesthesia.

They are careful to distinguish between the two entities: resolution of disease and healing. They define the latter as “the resolution of suffering”. Such ideas have been actively examined since the early 1980s when Eric Cassells wrote “The Nature of Suffering and the Goals of Medicine” in the New England Journal, but the two authors take his concepts much further and add lots of their own. They begin their book with the question “What Makes a Person?” and end with “Patient Safety” and with “The Place of General Practice”.

Each chapter is enlivened by personal vignettes, extensive literature analysis, Venn diagrams and wise reflection. The material is very well organised with each chapter introduction setting out which issues the chapter will explore and ending with a final crisp, boxed summary. The longest chapters are on “The World of the Patient” and “The Assumptions of Modern Medicine”, both of which are well worth thoughtful reading, but the chapters on doctors’ health and wellness, the culture of medicine and reflective practice, are particularly useful.

The local colleges of medicine and surgery are now taking steps to alter the medical culture, reduce the impact of authoritarian hierarchies, and encourage reflection, compassion and self-analysis. This book takes those ambitions further and has additional emphasis on managing the health and well-being of the doctors themselves. It also examines the inherent “masculinity” of current medical culture where achievement, control and social power are considered more important than mutual cooperation, leading to the situation where junior staff members are unable to question the decisions and behaviour of their seniors. In this regard, medicine is slowly learning from other professional regulators, such as those of airline pilots. Anaesthetists, particularly, have been quick to modify practices and procedures and other disciplines are following. The authors note that “when the culture is supportive, medical work can be exhilarating and rewarding”, but Wilson and Cunningham are very able to examine the situations where that work can be extremely challenging.

An example is their discussion of the “heart sink patient”. That is, the sort of person who inspires apprehension and despair when their name appears on the patient list. With their usual sagacity, the authors invite the reader to consider the phenomenon as a “heart sink experience”, arising in the doctor and worthy of self-examination and scrutiny, rather than an exogenous, unchanging aspect of the relevant patient. The authors begin to explore the phenomenon from a psychoanalytic viewpoint, starting with the concepts of transference reactions and moving from there to suggestions as to how to make better use of our own negative reactions by acknowledging them, formulating a plan, setting limits and discussing difficulties with a trusted colleague in an appropriate setting. They are especially emphatic about the hazards of labelling people and the benefits of making better use of heart sink reactions: “Trying to reach an elusive moment of professional intimacy requires courage and a willingness to travel where the journey is unknown and where dangers certainly lurk. It is easier to avoid or even shut down such encounters”; “The more one critiques and examines one’s own reactions and responses to patients, the more one is able to sit with greater degrees of suffering.”

The authors outline methods of achieving and maintaining such compassionate equanimity. They give some details of those involving peer groups, writing, supervision or specific coaching and examine models of consultation which focus attention on the person of the patient as much as the management of disease. Each chapter is of great interest to the practising doctor and the areas of universal difficulty, such as the ill patient without evident disease, are examined in a thoughtful and illuminating manner.

Who else would enjoy this book? Certainly medical students and GPs should read it, as should clinical specialists. Paramedical clinicians are likely to find it valuable, and it would be particularly useful for those students still at school and deciding on whether a career in medicine might suit them. I am not sure that it would be of great interest to the lay public as its field of enquiry is necessarily narrow and specific.

Given what I now know, would I choose a life in medicine again? Yes, definitely. Would that life have been richer, fuller, more companionable and less stressful if the precepts in this book had been part of the medical ethos? Yes, definitely.


Rae Varcoe is a Nelson physician, poet and reviewer.


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