Public Expectations and Physicians' Responsibilities

Voices of Medical Humanities

John K Crellin

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315358383
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This guide for practice managers, in a question-and-answer format, explains accounting procedures and describes GMS, health authority and other sources of income. The book covers payroll, pension, personnel and complaints matters and advises on optimizing income for the practice.

CHAPTER 1

Voices from medical humanities: an introduction

The last decades of the twentieth century witnessed a striking outpouring of public concerns about healthcare. Many of these are noticed in Public Expectations and Physicians’ Responsibilities as it considers the qualities that the public hopes to find in physicians, indeed in all healthcare practitioners. In so doing, the book draws on medical humanities. Emerging in the 1970s, this field of study explores observations, other than from the sciences, on the human condition, especially on its illnesses, suffering and values.

Medical humanities

Readers of this volume - physicians, other healthcare practitioners and administrators, patients and everyone interested in healthcare - will see at least six broad, albeit overlapping, roles for medical humanities that can contribute to quality care:

1. providing practitioners with insights into the values of patients and practitioners as well as their attitudes toward health and illness
2. prompting practitioners to reflect on the diverse needs of patients, and on practitioner-patient relationships
3. alerting practitioners to what is needed in order to provide humane care to patients
4. prompting patients to consider their own role in healthcare
5. examining the nature of medicine, and the reciprocal influences between medicine and society
6. contributing specifically to patient care settings as therapy or as healing for physical ailments, the mind and the spirit.¹

The various roles are not mutually exclusive. Britain’s National Co-ordinating Council and Centre for Integrating the Arts and Humanities into the National Health Service, for instance, believes that an ‘arts on prescription’ philosophy will lead to doctors having more depth and breadth in their education and to patients achieving mental well-being through creative expression.²

The field of medical humanities is broad, almost catch-all. Areas of popular culture, ranging from movies to ‘medical thrillers’ and romance novels, add to insights from such established disciplines of the humanities as literature (including the now popular genre of patients’ narratives), history, ethics, philosophy and the visual and performing arts.³ Each subject area offers particular perspectives into the human condition as it relates to health and disease.⁴ Contributions also come from anthropology, folklore and sociology insofar as they draw attention to, for instance, lay beliefs and social values about healthcare.

Some people might be tempted to argue that all the necessary perspectives on lay beliefs, values and expectations can be gained from social science and historical studies alone. This, however, ignores a key role of medical humanities, namely that, unlike the emphasis in the social sciences on understanding groups, cultures and populations, it is about appreciating the diversity and individualism of patients.⁵ Medical humanities questions whether a ‘standard’ patient exists. It has been said that literature, through focusing on particular characters and situations, reveals more fully than the trends identified by historians how changes in medical practice impact on individual lives; it reveals, too, ‘the social realities in the dilemmas that physicians and patients alike faced in the wake of new discoveries and technologies.’⁶ As an instance, John Bayley’s moving account of a railway journey with his wife, a sufferer from Alzheimer’s disease, reveals a pattern of difficulties familiar to all in similar circumstances. Yet, at the same time, unique to Bayley’s situation was the international fame of his wife Dame Iris Murdoch, one of the influential novelists and philosophers of the twentieth century.⁷ It has, too, to be appreciated that the writer, the artist, whatever form of expression he or she uses, is generally a practised observer able to look from the outside, from the margins so to speak, and to offer carefully considered perspectives.

Although this volume is not a history, the interpretations of historians about trends are included, for an important part of medical humanities is to provide context and an understanding of constant and changing lay attitudes. For this reason, although the timeframe in this book mostly covers recent decades, it forays into the first half of the 1900s and even earlier, not only to make comparisons, but also to illuminate persistent public concerns as well as to comment on, for example, current nostalgia for the old ‘country doc’.

This volume introduces readers to many resources, some well known, others less so. A few lengthy quotes are included to show how the humanities illuminate individual perceptions, e.g. the happenings in a physician’s waiting room or a physician agonising over his or her detachment from patients. However, this is not an anthology. The book relies mainly on references and short quotes to document a point as it recommends and invites a reading or a viewing of an entire story, a painting, or other resource.

Many public concerns about medicine spotlight ethical issues; indeed, ethicists have been conspicuous in challenging medicine since the 1960s. However, ethical analyses are not included in the following chapters because of both lack of space and the availability of innumerable ethics/bioethics texts. Nevertheless the value of medical humanities for studying ethical dilemmas becomes clear. As stressed by others, the social context commonly provided by, for instance, fictional stories underscores that, in real life, clear-cut decisions to ethical dilemmas rarely exist, only best answers.⁸ Additionally, medical humanities commonly raises everyday ethical dilemmas that are given little or no attention in ethics textbooks - for instance, whether it is a physician’s responsibility to provide spiritual care if so requested by a patient.

Many physicians have voiced the same concerns as the public, often resting on results from social science investigations. Although medical voices commonly stem from professional dilemmas, even disillusionment with much medical practice, they do reassure the public that some physicians are listening to their disquiet. Physicians’ voices in this volume are, for the most part, taken from those expressed through medical humanities’ resources, especially from novels, short stories and essays. Widespread public acclaim has come to some physicians. The renowned American poet, essayist, short story writer and physician William Carlos Williams, who continued medical practice alongside international success as a writer, said: ‘I have never felt that medicine interfered with me but rather it was my very food and drink, the very thing that made it possible for me to write.’ Williams’ interest in people was ‘right in front of me. I could touch it, smell it. It was myself, naked, just as it was.’⁹ In fact, physicians have often found that creative expression, rather than writing ‘standard’ case histories, is needed to illuminate suffering and responses to it. Writings directed primarily to the medical profession are also culled, in part because they not only offer the public further insights into the minds of physicians, but also because they, too, indicate physicians’ efforts to find words and analogies that express the complexities of suffering amid shifting values within society and medicine.

It is appropriate to notice again that the book is intended for a broad readership. The field of medical humanities has developed rapidly in recent years not only in medical schools, but also as undergraduate and graduate level courses in general university studies. The subject area and the issues raised by medical humanities are relevant to everyone concerned about healthcare, not just the professionals involved. Lay readers can, for instance, analyse and compare their own responses to illness and expectations of medicine, consider the roles they expect of their physicians, look at their own responsibilities in healthcare, gain an appreciation of the concerns and tensions facing physicians, and, more narrowly, wonder how medical humanities can contribute to the moral order of a medical school and the development of the ‘good’ physican.¹⁰

Physician roles and the organisation of this book

It is not easy to organise the wide range of material offered by the humanities. One obvious challenge is to show how the attitudes and opinions of individuals resonate with, help to shape, or conflict with public opinion. In this book, the qualities and roles that the public expects or hopes for in its physicians offer a focal theme. Moreover, the expectations give a pragmatic focus by pinpointing issues on which the medical profession needs to respond, and certainly not to push aside as being too vague or philosophically abstract.

In developing the theme of roles, the book draws on an influential project that emerged in Canada in 1990. Following a doctors’ strike in Ontario during 1986, which raised questions about whether doctors were losing traditional values and ‘abandoning the covenant of service to society’, Associated Medical Services established a programme called Educating the Future Physicians of Ontario (EFPO).¹¹ In developing the EFPO project, extensive consultations with the public and groups of health professionals were used to identify what roles the public expected of its physicians.

The roles were identified by the following descriptive names: medical expert/clinical decision maker, collaborator, health advocate, manager (’gatekeeper’), learner, scientist-scholar, and lastly, with the input of consultations with physicians, a person.¹² These roles have, in part, been relabelled or reorganised by medical schools and organisations; for instance, at one medical school students need to be familiar with the role of ‘communicator/educator/humanist/healer’.¹³ Such adaptations, however, are in keeping with the spirit of the original data as is the case in this volume where being a professional is viewed as the overarching or umbrella role, as it were, to which all the other roles contribute.¹⁴ In fact, examining public expectations as a whole spotlights the need for society and physicians to examine closely the nature of professionalism and its current - i.e. early twenty-first century - role in quality care.¹⁵

EFPO has gained national and international influence beyond Ontario medical schools through such medical bodies as the Royal College of Physicians and Surgeons of Canada, which developed, for example, the concept of roles in its CanMEDS 2000 programme for residents in specialty training.¹⁶ An important issue is whether or not the Royal College’s efforts to evaluate the ‘skills’ and ‘competencies’ of residents in fulfilling the roles - using agreed-upon criteria - captures the values that are part of the public’s expectations of the roles.¹⁷ It must be said that of the triptych of educational goals in medical schools - ‘knowledge, skills and attitudes’ - it is attitudes that are commonly glossed over, largely because of the difficulty of measuring them.¹⁸ This volume supports the view that medical humanities offers physicians-in-training, indeed all practitioners (especially those with limited clinical experience), a sharper sense of public expectations than guidelines to issues found in such documents as the American Board of Internal Medicine’s ‘Project Professionalism’ (discussed in Chapter 2), or from the ‘attitudinal objectives’ for medical students and physicians adopted in the United Kingdom.¹⁹ Furthermore, medical humanities helps to explore the many issues raised in discussions on developing a more formal social contract between the medical profession and society than presently exists.²⁰

In this volume, the roles have been divided into two parts. Part I, ‘Foundation Roles’, looks at public expectations that challenge individual physicians to consider their values and responsibilities to patients. Part II deals with factors that more directly shape the physician’s role as medical expert and clinical decision maker. Although the latter role acknowledges public expectations of sound and up-to-date knowledge, we look particularly at how metaphors and stereotypes - disseminated widely throughout the voices of the humanities - may affect decision making. In both parts, some ‘byways’ are included; they serve not only to illustrate a particular theme, but also the broad scope of medical humanities and how, by illuminating the complex relationships between medicine and society, this can encourage physicians to look broadly at the society in which they work. Lastly, a short Epilogue raises questions about responsibilities and roles for pat...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface and acknowledgements
• 1 Voices from medical humanities: an introduction
• Part 1: Foundation roles
• Part 2 Physician as clinical decision maker: public voices, metaphors and stereotypes
• Epilogue: Physician and patient responsibilities
• Index