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18 October 2011
In this year’s Harveian Oration, Dr Iona Heath, President of the Royal College of General Practitioners, explores the divisions within the medical profession, dualistic views of the human body, divisions within society and the implications of each for the future of medicine. In an Oration brought to life with illuminating quotations from writers, poets and scientists, Dr Heath argues that we need to bridge those divisions to improve care for patients and create a fairer society. Key excerpts below:
Dr Heath argues that the historic division between general practitioners and specialists has been beneficial for both patients and the health service as a whole. GPs see the patient in the context of their wider life, and the referral process ensures specialists can concentrate on patients’ specific diseases, ensuring a better outcome:
‘General practitioners have learnt from experience the benefits, to both the individual and to society, of holding the border between subjective illness and the disease categories recognised by biomedical science; of confining people within those categories only when such labelling will be positively useful to them; and of deliberately minimising exposure to the harms of medical technology. In this way, general practice attempts to direct both the power and the rising costs of biomedical science where it can help rather than where it harms. Holding the border between illness and disease underwrites the cost-effectiveness of the health service to a far greater extent than gatekeeping at the point of referral.’
Dr Heath is worried about the recent introduction of competition and the effect it will have on the GP/specialist relationship:
‘Medical specialists employed by acute hospital trusts are now working within a framework of incentives which provides ‘Payment by Results’ while medical generalists are being encouraged or coerced into undertaking commissioning, the intention of which is to keep patients away from costly hospital services. These policies are driving a wedge between specialists and generalists and making it more and more difficult for the two parts of the profession to work collaboratively in the interests of patients.’
All patients experience illness and disease in a particular way – their own, and not as a standardised object. While doctors increasingly recognise this, ‘the bureaucracy of healthcare seems more and more driven by the attractions of this (object) model and its attendant guidelines, quality indicators and payment for performance.’
Dr Heath argues that the biomechanical approach to illness must be supplemented by an understanding of the patient’s life and experiences, which are often key to the medical problems experienced:
‘And science is beginning to show that there is a also a medical relevance. Lives wound bodies and wounds leave deep bodily scars that never fully heal. They are caused by trauma including terrible accidents and injuries but they are also caused by abuse, misery, and humiliation, especially when these occur in early childhood. The patients we cannot cure, the ones who return again and again, have wounds and all too often we remain ignorant of their nature.’
Science is beginning to catch up with GPs’ experience in this area, by showing us how a difficult life and continuous stress can bring on premature ageing by shortening telomeres – the parts of the chromosome that protect it from damage. Adverse experiences, particularly in childhood, also predict premature mortality and adult autoimmune disease. Now that the science is helping to explain the observations, how should the medical profession respond?
Dr Heath explains how structural violence in society turns people into ‘objects and things’, and fosters social inequalities, exclusion, poverty, racism, and other situations that underpin health inequalities:
‘As society becomes evermore economically polarised, health is systematically damaged by the structural violence this entails and yet governments still appear to believe that health inequality can be tackled in isolation from the socioeconomic inequality that drives it.
‘The evidence suggests that society should invest much more heavily in the early years of childhood and in providing opportunities for families to thrive. The present situation should be considered completely unacceptable: society both neglects and demonises vulnerable families, ignores the continuous process of damage that is undermining the health of poor children and then blames, and again demonises, health and social care professionals when children die.’
Instead of taking refuge in biotechnology, Dr Heath argues that doctors should lobby more strenuously to protect the vulnerable, minimise violence and abuse and promote a more equitable distribution of wealth, hope and opportunity within society:
‘…medicine will never be a pure and simple place but its constant interplay of opposites make space for courage, joy, creativity and freedom and the possibility of making the world a better place. However, if beyond this, we cannot bring these opposites together into a more coherent, and in the case of society a fairer, whole, we will remain divided and we will fail.’
To arrange an interview with Dr Heath, please contact RCP PR Manager Linda Cuthbertson on 020 3075 1254, 07748 777919, or e-mail Linda.Cuthbertson@rcplondon.ac.uk.
The Harveian Oration
William Harvey, the eminent 17th Century physician who discovered the circulation of the blood, gave an indenture to the RCP in 1656 for an annual dinner to encourage friendship between Fellows and Members of the College at which there should be an oration 'with an exhortation to the Fellows and Members of the said College to search and study out the secret of Nature by way of experiment'. The College continues the tradition by inviting a leading doctor or scientist to give the Oration on issues relating to his or her own field of work.
Dr Iona Heath
Iona Heath worked as an inner city general practitioner at the Caversham Group Practice in Kentish Town in London from 1975 until 2010. She has been a nationally elected member of the Council of the Royal College of General Practitioners since 1989, and chaired the College’s Committee on Medical Ethics from 1998 to 2004 and the International Committee from 2006 to 2009. She is currently President of the Royal College of General Practitioners, having been elected for a three-year term from November 2009.
From 1993 to 2001, she was an editorial adviser for the BMJ and chaired the journal’s Ethics Committee from 2004 to 2009. She has been a member of the WONCA (the world organisation of family doctors) world executive since 2007.
She writes regularly for the BMJ and has contributed essays to many other medical journals across the world. She has been particularly interested to explore the nature of general practice, the importance of medical generalism, issues of justice and liberty in relation to healthcare, the corrosive influence of the medical industrial complex and the commercialisation of medicine, and the challenges posed by disease-mongering, the care of the dying, and violence within families.