Richard Smith: The medical apostate’s tale

The Ministry of Bodies by Seamus O’Mahony is published today by Apollo. It has many acute observations on the practice of medicine in the 21st century, finds Richard Smith

In his disturbing, funny, enjoyable, and beautifully written account of his last months as a doctor, The Ministry of Bodies, Seamus O’Mahony tells us much about himself. He made a mistake in becoming a doctor: “my personality would have been better suited to a more contemplative life.” In Julian Barnes’s “bipartite division of people” he is an episodicist not a narrativist, and for the episodicist “the defining characteristic of human life is absurdity.” O’Mahony has a novelist’s eye for the absurd, and absurdity fills his book as it does medical practice. He confesses as well that he is a medical apostate and that “this apostasy was now making my job increasingly untenable.” Some pundits reading his book might also describe him as “burnt out,” but he remains until the end the sort of doctor I hope to encounter when my time comes.

O’Mahony trained in Cork, moved to Britain, and returned as a consultant gastroenterologist to Cork—to the hospital he calls the Ministry—some 20 years ago. A great reader and lover of books, his name for the hospital must be inspired by George Orwell’s 1984, which has four ministries—of love, peace, plenty, and truth. The change in the hospital building symbolises the decline that O’Mahony sees: from a brand new building that would, according to the Cork Examiner, “embarrass any top class hotel” and where patients will be treated by “machines that make Star Wars look like a scrapyard” to something that “now looks like a neglected apartment block in some remote post-Soviet city.”

When he arrived O’Mahony was a gastroenterologist ready to bring the latest endoscopic techniques to the people of Cork, but the people needed more a general physician. “There are two kinds of doctor,” writes O’Mahony, “icians and ologists, such as geriatr-icians and ophthalm-ologists. Ologists belong to the Asclepian tradition, which focuses on the specific causes of disease, while icians—supposedly—adhere to the Hygieian tradition, which regards health as being in harmony with oneself and one’s environment. The real difference, if I am to be truthful, is that icians are low status and ologists are high status.”

The general physicians “on take” must move around the hospital in the morning, seeing about 20 patients scattered across multiple wards, with many of them left on trolleys for hours. Age may bring experience, but it makes these rounds ever more exhausting. The general physician was once the king in the medical court, but now “General medicine was the dustbin of the ministry; a professional cul-de-sac, drained of interest, resource, and prestige. This was the one clinical activity my colleagues immediately abandoned if the opportunity arose for them to do so…The acute physicians cherry-picked those patients likely to be ‘turned around’ and discharged quickly, leaving all the other patients—the majority—with messier, less easily soluble problems to ‘general medicine’.”

O’Mahony still practices as an ologist and creates a wonderful metaphor for how as an ician he removes bile duct stones from a man with a fractured pelvis: “It’s as if your social worker called round to fix your central heating or to do the conveyancing on the sale of your house.” Something that he hates about being an ologist is putting PEG tubes into patients who would suffer less without them, observing that in many cases, it “was more about fulfilling the complex emotional needs of relatives and staff than providing comfort for patients.”

Doctors do what they can to avoid being “on take,” and O’Mahony observes that “the ministry was a market where the major commodity being traded was responsibility; I was currently overinvested in this negative currency.” Nobody is keen to take the patients with multiple problems often including dementia, alcohol addiction, and severe social problems or to tell the patients or their families that the patients are dying. O’Mahony wrote an influential, prize winning book called The Way We Die Now (badly and overmedicalised, in short) and followed it up with Can Medicine Be Cured? The Corruption of a Profession, a stinging critique of modern medicine. I see him as the Fyodor Dostoevsky of a plethora of doctors writing about their practice. At least one of his patients had read his book on death and told him “You’ve got it right, boy! [the author’s italic]”

Two of the great strengths of O’Mahony are telling stories and drawing unlikely but funny parallels. The physician “on take” needs the skills, he suggests, of Winston Wolfe, the character in the film Pulp Fiction who knows how to efficiently, quickly, and unfussily dispose of a headless corpse. These skills are: 

  1. Be 100% reliable; 
  2. Prioritise; 
  3. Bad news first; 
  4. Take things off your manager’s plate—then own it; 
  5. Write things down; 
  6. Strategy is for amateurs, tactics are for professionals; 
  7. You can’t manage what you don’t understand; 
  8. Start tough, then soften up; 
  9. If it’s not working, end it.

O’Mahony reflects as well that to prepare for his job he would have been better employed as a young doctor shadowing a nightclub bouncer or warder in a high security prison than pointlessly counting lymphocytes in a research project. “Not once have I ever thought, yes, the three years I spent in an Edinburgh laboratory researching mucosal immunology really helped on the wards today, yet every day I was talking down angry drunks, calming delirious old folk, defusing the wrath of ‘difficult’ families.”

Working in outpatients and the wards is little better than being “on take.” The wards are filled with people, many of them young, with terminal liver failure, while outpatients features many patients with somatic problems and those for whom patienthood is their career. O’Mahony assures us that he is not writing about individual patients and pleads “the usual weaselly disclaimer” that every patient is a composite of several people, so bear that in mind when reading his account of this patient: “She had already seen a rheumatologist, a chest physician, a neurologist, a pain specialist and a psychiatrist. She was now on fifteen medications, including two opiates. I asked if she was taking a legal case against this factory: she was. Her patienthood was now so all-consuming that not even a huge financial settlement would cure her.”

The 300 page book has many acute observations on the practice of medicine in the 21st century, and I’ve selected just a few of my favourites:

“The worst thing about being a doctor is other doctors.” 

“The protocols governing colonoscopy mandate the removal of all colonic polyps in all patients. These protocols were based on three delusions: that resources are limitless, that complications never occur, and that people live forever.”

“[Richard] Asher wrote an essay for the Lancet in 1949 called ‘The seven sins of medicine’, which he listed as: obscurity, cruelty, bad manners, over-specialisation, love of the rare, common stupidity, and sloth. I whiled away the wait at the eye clinic by coming up with my own seven deadly sins: venality, humbug, cowardice, neophilia (love of the new or the novel), Phariseeism, boosterism, and sentimentality.

“To practise medicine is to have a permanent feeling that you’ve forgotten something.”

“Is there anything more useless than good intentions?”

“Medicine has yet to come up with a more useful drug than morphine; without it, few would have the heart to practise the profession.”

As I read the book, I found myself hoping that my daughter, who is halfway through her first year as a doctor, would not read it. It’s a book that will appeal most to the battle weary and is ideal for those who would like a deeper understanding than most books and television programes offer of what goes on in hospitals. I also thought about another excellent book that I have recently finished—Radical Help by Hilary Cottam. There are no jokes in Cottam’s book, but its core argument is that the welfare state, including the NHS, is no longer fit for purpose and doesn’t meet the current needs of the population. O’Mahony’s book illustrates her argument and entertains at the same time.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS and Seamus O’Mahony work together on the Lancet Commission on the Value of Death.