Brimful of Asher
Seamus O’Mahony, Consultant Physician, Cork University Hospital
Richard Asher: Talking Sense. London: Pitman Medical, 1972.
A Sense of Asher. London: British Medical Association, 1984.
The Royal Society of Medicine recently (3 November 2014 – 24 January 2015) held an exhibition called “Richard Asher (1912-1969): A Celebration”. Asher, an English physician and writer, is mainly unknown to those under fifty. He was appointed as physician to the Central Middlesex Hospital in 1943, and worked there until his resignation in 1964. He was a general physician, with interests in haematology, endocrinology, hypnosis, and the physical basis of mental illness. He argued passionately in favour of generalism, and warned against what he saw as increasing over-specialisation. Asher had a unique, aphoristic, literary style: he wrote articles which were easy to read, witty, and which often challenged received opinion. He had a passion for clear, elegant English, but admitted that his prose style did not come easily. His essays ranged from the purely clinical to the speculative and philosophical; he wrote not only for the medical journals, but also the popular press. He was an inspirational clinical teacher, and an accomplished and much sought-after lecturer. He is probably best known for coining the term “Munchausen’s Syndrome”.
One of Asher’s clinical commitments was as consultant in charge of the mental observation unit at the Central Middlesex, where he saw an average of 700 patients a year. This experience provided him with the clinical material for such articles as “Myxoedematous Madness” (1949), “The Physical Basis of Mental Illness” (1954), and, of course, “Munchhausen’s Syndrome” (1951). In 1964, the hospital authorities decided to appoint a psychiatrist to take charge of this unit. Asher was deeply offended, and resigned his consultant post. His remaining years were plagued by ill-health and melancholy; he took his own life at the age of fifty-seven.
Asher described himself as “a physician more at home at the bedside than in the laboratory”, and wrote many articles on what he regarded as the heart and soul of clinical medicine: the history and physical examination. He advised his students and readers to ignore the textbooks and to think for themselves. Most of his essays were inspired by simple clinical observations, prompting the thought: “Nobody seems to have commented on the fact that …” He argued for the supremacy of experience and noticing. He inspired such famous protégés as Jonathan Miller and Oliver Sacks.
If Asher had a passion for detail in the history and physical examination, he had an even greater passion for clarity of expression, and the correct use of words. He was modest about his abilities as a writer, claiming that “the standard of medical writing is so low that a doctor literate enough to put on paper something that can be read and understood without much suffering is soon looked on as a literary giant of cultured scholarship.” He often pointed out that “style” in prose was the result of painstaking hard work and much re-writing. He was, observed the medical journalist Ruth Holland, proof of the truth of C.E. Montague’s maxim: Easy reading, hard writing.
Asher abhorred obscurity, slip-shod thinking, jargon and inelegant prose. Indeed, he listed obscurity as one of “The Seven Sins of Medicine” (1949), the other six being Cruelty, Bad Manners, Over-Specialization, Love of the Rare (Spanophilia), Common Stupidity, and Sloth. He noted how obscurity advanced academic careers: “Remember that the harder anything is to understand, the more readily will committees allocate money to it. Much sensible medicine is obvious, but the obvious does not impress.” He could have been accused of biting the hand that fed him when he wrote a piece for the BMJ called “Why are medical journals so dull?” (1958). He wrote that journal authors “clog their meaning with muddy words and pompous prolixity …”
He valued clarity in thought as much as plainness of expression and elegance of style. He was a student of formal logic, taking inspiration from such works as Rupert Crawshay-Williams The Comforts of Unreason (1947), Robert H. Thouless’s Straight and Crooked Thinking (1930), and Lewis Carroll’s Symbolic Logic (1896). He was aware of the discomfort caused by cognitive dissonance: “Some beliefs are cherished a long time before some pundit kills them for us, and the extraction of a firm rooted belief is as unpleasant as the removal of an impacted wisdom tooth.” He derived his own word – “apriority” – to describe a kind of lazy thinking, particularly the notion of treatments that had a theoretical reason for why they might work, but for which there was no evidence that they did work. He was pessimistic about changing doctors’ thinking: “It has been held by some teachers that rational thinking in medicine would be improved if doctors were taught logic. I rather doubt this. Most of our ideas are accepted because they are convenient or likely, and not because of logical reasoning.” Asher was friendly with Richard Doll and Archie Cochrane, and was a champion of the concept of Evidence-Based Medicine, decades before the phrase was coined.
Asher had an uncomfortable relationship with psychiatry, culminating in the disastrous termination of his duties as physician in charge of the mental observation unit at the Central Middlesex. He wrote that psychiatry is “regarded by other doctors with a mixture of suspicion, reverence, and ridicule”. He particularly disliked such phrases as “Psycho-dynamic” and “psycho-biological” relationships: “The use of those key words lends an impressive but nebulous air of humane profundity to your utterances and conveys that ordinary doctors are unsympathetic and remote beings with no interest in their patients’ feelings.”
He agreed, however, with the psychoanalyst Michael Balint that the most important therapy at the doctor’s disposal was the doctor himself. He doubted, however, that “communication skills” could be taught:
It can be learnt by experience and to some extent by watching great doctors handling their patients, but it cannot be taught like pharmacology. All the power of tongue and pen, and all the wisdom of textbook and lecture can never teach a doctor the knowledge of when to probe and when to leave alone, when to chide and when to reassure, when to speak and when to keep silent. They are private mysteries with a different solution for every one of the million permutations of personality involved between a doctor and his patient. (“Talk, Tact and Treatment” [1955]).
This passage encapsulates Asher’s enduring appeal. His assertion is clearly and elegantly expressed, it questions received opinion, and is based on decades of clinical experience.
Asher believed that medicine’s dominion was limited. He argued against screening, “fussing” over health, “vain strivings after longevity”, and aggressive interventions in patients with incurable cancer. He knew that medicine had little to offer for many patients, and admitted ruefully that “it is better to believe in therapeutic nonsense than openly to admit therapeutic bankruptcy.”
Two collections of his essays and articles (Talking Sense [1972], A Sense of Asher [1984]), are both long out of print. Asher’s students are either of advanced age or dead. Decades on, however, his prose still sparkles. He mocked what he saw as pompous, illogical and just plain wrong. His article on “The Dangers of Going to Bed” (1947) was hugely influential in ending the routine practice of prolonged bed-rest, with all the dangers listed listed by Asher. He had a sharp instinct for humbug. What windmills would he tilt at in 2015? He would have been pleased by the triumph of Evidence-Based Medicine, but would have rebelled against the tyranny of protocols and guidelines, and Evidence-Enforced Medicine. He would have been horrified by the growth of the pharmaceutical industry, and by how easily it has suborned academic medicine and the journals. He would be dismayed by the slow death of medicine as a profession, and its imperceptible transformation into a service industry. He would have witnessed how the sins which he enumerated culminated in the catastrophe at Stafford. He would have been gratified that the Royal College of Physicians has belatedly come around to his view that physicians should be generalists first.
Asher did not feel appreciated within his profession, perhaps because his wit was confused with frivolity, and his clarity of expression mistaken for a lack of depth. Sydney Smith responded to a similar accusation: “You must not think me necessarily foolish because I am facetious, nor will I consider you necessarily wise because you are grave.” Come on, BMJ publications: why not re-issue the books?