{"id":49727,"date":"2021-03-04T09:20:16","date_gmt":"2021-03-04T08:20:16","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=49727"},"modified":"2021-03-08T08:51:21","modified_gmt":"2021-03-08T07:51:21","slug":"richard-smith-the-medical-apostates-tale","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2021\/03\/04\/richard-smith-the-medical-apostates-tale\/","title":{"rendered":"Richard Smith: The medical apostate\u2019s tale"},"content":{"rendered":"

The Ministry of Bodies<\/span> by Seamus O\u2019Mahony is published today by Apollo. It has many acute observations on the practice of medicine in the 21st century, finds Richard Smith<\/span><\/i><\/p>\n

In his disturbing, funny, enjoyable, and beautifully written account of his last months as a doctor, <\/span>The Ministry of Bodies<\/span><\/i>, Seamus O\u2019Mahony tells us much about himself. He made a mistake in becoming a doctor: \u201cmy personality would have been better suited to a more contemplative life.\u201d In Julian Barnes\u2019s \u201cbipartite division of people\u201d he is an episodicist not a narrativist, and for the episodicist \u201cthe defining characteristic of human life is absurdity.\u201d O\u2019Mahony has a novelist\u2019s 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 \u201cthis apostasy was now making my job increasingly untenable.\u201d Some pundits reading his book might also describe him as \u201cburnt out,\u201d but he remains until the end the sort of doctor I hope to encounter when my time comes.<\/span><\/p>\n

O\u2019Mahony trained in Cork, moved to Britain, and returned as a consultant gastroenterologist to Cork\u2014to the hospital he calls the Ministry\u2014some 20 years ago. A great reader and lover of books, his name for the hospital must be inspired by George Orwell\u2019s <\/span>1984<\/span><\/i>, which has four ministries\u2014of love, peace, plenty, and truth. The change in the hospital building symbolises the decline that O\u2019Mahony sees: from a brand new building that would, according to the <\/span>Cork Examiner<\/span><\/i>, \u201cembarrass any top class hotel\u201d and where patients will be treated by \u201cmachines that make Star Wars look like a scrapyard\u201d to something that \u201cnow looks like a neglected apartment block in some remote post-Soviet city.\u201d<\/span><\/p>\n

When he arrived O\u2019Mahony was a gastroenterologist ready to bring the latest endoscopic techniques to the people of Cork, but the people needed more a general physician. \u201cThere are two kinds of doctor,\u201d writes O\u2019Mahony, \u201cicians 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\u2014supposedly\u2014adhere to the Hygieian tradition, which regards health as being in harmony with oneself and one\u2019s environment. The real difference, if I am to be truthful, is that icians are low status and ologists are high status.\u201d<\/span><\/p>\n

The general physicians \u201con take\u201d 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.<\/span> 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 \u201c<\/span>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\u2026The acute physicians cherry-picked those patients likely to be \u2018turned around\u2019 and discharged quickly, leaving all the other patients\u2014the majority\u2014with messier, less easily soluble problems to \u2018general medicine\u2019.\u201d<\/span><\/p>\n

O\u2019Mahony 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: \u201cIt\u2019s as if your social worker called round to fix your central heating or to do the conveyancing on the sale of your house.\u201d Something that he hates about being an ologist is putting PEG tubes into patients who would suffer less without them,<\/span> observing that in many cases, it \u201cwas more about fulfilling the complex emotional needs of relatives and staff than providing comfort for patients.\u201d<\/span><\/p>\n

Doctors do what they can to avoid being \u201con take,\u201d and O\u2019Mahony observes that \u201cthe ministry was a market where the major commodity being traded was responsibility; I was currently overinvested in this negative currency.\u201d 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.<\/span> O\u2019Mahony wrote an influential, prize winning book called <\/span>The Way We Die Now<\/span><\/i> (badly and overmedicalised, in short) and followed it up with <\/span>Can Medicine Be Cured? The Corruption of a Profession<\/span><\/i>, 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 \u201cYou\u2019ve got it right, <\/span>boy! <\/span><\/i>[the author\u2019s italic]\u201d<\/span><\/p>\n

Two of the great strengths of O\u2019Mahony are telling stories and drawing unlikely but funny parallels. The physician \u201con take\u201d needs the skills, he suggests, of Winston Wolfe, the character in the film <\/span>Pulp Fiction<\/span><\/i> who knows how to efficiently, quickly, and unfussily dispose of a headless corpse. These skills are:\u00a0<\/span><\/p>\n

    \n
  1. Be 100% reliable;\u00a0<\/span><\/li>\n
  2. Prioritise;\u00a0<\/span><\/li>\n
  3. Bad news first;\u00a0<\/span><\/li>\n
  4. Take things off your manager\u2019s plate\u2014then own it;\u00a0<\/span><\/li>\n
  5. Write things down;\u00a0<\/span><\/li>\n
  6. Strategy is for amateurs, tactics are for professionals;\u00a0<\/span><\/li>\n
  7. You can\u2019t manage what you don\u2019t understand;\u00a0<\/span><\/li>\n
  8. Start tough, then soften up;\u00a0<\/span><\/li>\n
  9. If it\u2019s not working, end it.<\/span><\/li>\n<\/ol>\n

    O\u2019Mahony 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. \u201cNot 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 \u2018difficult\u2019 families.\u201d<\/span><\/p>\n

    Working in outpatients and the wards is little better than being \u201con take.\u201d 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\u2019Mahony assures us that he is not writing about individual patients and pleads \u201cthe usual weaselly disclaimer\u201d that every patient is a composite of several people, so bear that in mind when reading his account of this patient: \u201c<\/span>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.\u201d<\/span><\/p>\n

    The 300 page book has many acute observations on the practice of medicine in the 21<\/span>st<\/span> century, and I\u2019ve selected just a few of my favourites:<\/span><\/p>\n

    \u201cThe worst thing about being a doctor is other doctors.\u201d\u00a0<\/span><\/p>\n

    \u201cThe 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.\u201d<\/span><\/p>\n

    \u201c[Richard] Asher wrote an essay for the <\/span>Lancet<\/span><\/i> in 1949 called \u2018The seven sins of medicine\u2019, 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.<\/span><\/p>\n

    \u201cTo practise medicine is to have a permanent feeling that you\u2019ve forgotten something.\u201d<\/span><\/p>\n

    \u201cIs there anything more useless than good intentions?\u201d<\/span><\/p>\n

    \u201cMedicine has yet to come up with a more useful drug than morphine; without it, few would have the heart to practise the profession.\u201d<\/span><\/p>\n

    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\u2019s 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\u2014<\/span>Radical Help<\/span><\/i> by Hilary Cottam. There are no jokes in Cottam\u2019s book, but its core argument is that the welfare state, including the NHS, is no longer fit for purpose and doesn\u2019t meet the current needs of the population. O\u2019Mahony\u2019s book illustrates her argument and entertains at the same time.<\/span><\/p>\n

    Richard Smith<\/strong>\u00a0was the editor of\u00a0<\/em>The BMJ\u00a0until 2004.<\/em><\/p>\n

    Competing interest:<\/strong> RS and Seamus O\u2019Mahony work together on the Lancet Commission on the Value of Death.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

    The Ministry of Bodies by Seamus O\u2019Mahony is published today by Apollo. It has many acute observations on the practice of medicine in the 21st century, finds Richard Smith In […]<\/p>\n

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