November 30, 2004

Patients’ Viewpoint Gives Book Its Humanity

Medical Correspondent Dr Muiris Houston looks at the changing face of Irish medicine

"The medical profession did not want any state control of medical services because it felt that it would destroy the doctor - patient relationship."

- Dr Leonard Abrahamson, president of the Royal College of Physicians.

"The extraordinary animus against the Custom House (the Department of Local Government and Health) and the people in it - everything we did or tried to do was met with suspicion and resistance (by the medical profession)."

- Dr James Deeny, chief medical advisor, Department of Local Government and Health.

Although these quotations are from the 1950s, it is interesting to reflect on the sentiments and suspicions they encapsulate against the background of the biggest single change currently taking place in the health system in over 30 years.

The setting up of the Health Service Executive(HSE) and the decision to give it responsibility for the day to day running of the health service from January 1st represents massive change. The Department of Health will now focus on planning and policy; the health boards will be no more; and the 120,000 or so people working in the health system are understandably anxious about their future.

The quotes are from Patients, Potions & Physicians - A Social History of Medicine in Ireland, by Tony Farmar, a fascinating description of sickness, disease and treatment from the 17th century to the present. Unlike other books on the history of Irish medicine, Farmar looks at the issues from the patients' perspective as much as that of the physician. He was commissioned by the Royal College of Physicians to write the book to celebrate its 350th anniversary.

The book details the disease and unscientific remedies of the 18th and 19th centuries through the "golden age" of antibiotics and steroids to the present day emphasis on technological medicine. Despite these advances it shows how the impact of poverty on health is still profound; death from cancer is four times greater and that from stroke three times greater for people of the lowest socioeconomic status in the State. Farmar recounts how the information super highway has altered the balance of the doctor- patient relationship.

"In 1974 The Irish Medical Times looked back nostalgically at the era when 'the doctor's opinion, advice and indeed decisions' were rarely questioned. By 2004, that era was long over. Patients increasingly see themselves as consumers, more or less aggressively evaluating treatments, picking and choosing services, informing themselves. In the course of this process there has been mounted a fundamental challenge to the hegemony of orthodox biomedicine," he writes.

Even this august supplement, despite its relative youth, is included in Farmar's analysis. The media in general is credited with stimulating an aggressive approach to medical negligence litigation and to "doctor-bashing".

Back at the coalface of change, Pat McLoughlin, the newly- appointed director of the National Hospitals Office in the HSE, might find a section on reforming the health system salutary reading. In 1936, the Hospital Commission recommended that Dublin's 12 general hospitals be rationalised. A proposal to merge the Richmond and the Mater hospitals floundered; the Commission obliquely referred to "difficulties inherent in the position" which it could not overcome.

For the next 40 years, these and similar "difficulties" - involving a failure of political will to confront the entrenched positions of hospital boards and consultants - meant nothing happened. The 1968 Fitzgerald report proposed that the number of Dublin hospitals be reduced to five or six. It took almost 30 years for this to actually happen.

As Farmar notes, there was more than just a human unwillingness to address change. He summarises the tensions as follows: "the key to a consultants' power was access to beds and therefore the ability to admit patients; at the same time there was strong pressure to establish consultants on a salaried basis and to minimise lucrative private practice."

The ultimate success of the book is due to the authors device of using "the medical encounter" as the basis for a series of snapshots of Irish medicine.

By doing so it remains firmly rooted in the patients experience through the ages. It is to the credit of the present officers of the Royal College of Physicians and to the author that the book is written in such a relevant and accessible way.