Can Medicine Be Cured

by Seamus O'Mahony

  NHS consultants are familiar with stories of patients having major operations cancelled so the target for elective surgery for patients with minor ailments can be met. Most will be familiar, too, with the cynical, and sometimes bizarre, ruses employed by managers to meet the four-hour emergency department target. The Academy of Medical Royal Colleges and Faculties in Scotland spoke for many in the NHS with their 2015 document Building a More Sustainable NHS in Scotland: ‘The current approach to setting and reporting on national targets and measures, while having initially delivered some real improvements, is now creating an unsustainable culture that pervades the NHS. It is often skewing clinical priorities, wasting resources and focusing energy on too many of the wrong things.’ Even the politicians – traditionally the great supporters of NHS targets – are beginning to have reservations. The Scottish Conservatives expressed these doubts in their manifesto for the 2016 general election (‘A world-class health-care system for your loved ones’): ‘We want our doctors making the best medical decision for a successful outcome, rather than feeling they have to service the input targets.’ Less than a year later, however, in February 2017, the same Scottish Conservatives attacked the Scottish National Party government for its failure to reach outpatient waiting list targets.

  In 2015, Dr Foster Intelligence published a report called Uses and Abuses of Performance Data in Healthcare. Roger Taylor, co-founder of DFI, was one of three authors, none of whom has a professional qualification in statistics or epidemiology. When a body such as Dr Foster, whose entire raison d’être is health-care metrics, publishes a paper detailing the limitations of such metrics, one should sit up and take notice. They clearly saw no irony in producing a document criticizing the metrics obsession that was directly behind their own foundation. The document listed the unintended adverse consequences of targets as: (1) tunnel vision: focusing on aspects of clinical performance that are measured and neglecting unmeasured areas; (2) inequity – for example, surgeons may avoid operating on the most seriously ill patients because they fear a ‘poor outcome’ with such patients may drive up their individual mortality rates; (3) bullying; (4) erosion – diminution of professional motivation; (5) ceiling effect – removing incentives for further improvement; (6) gaming; and (7) distraction – challenging, obfuscating or denying data which suggest underperformance. DFI suggested several steps to ‘reduce data abuse’, such as improving the quality of data and considering the potential for gaming. The heart surgeon Professor Stephen Westaby wrote a piece for the Spectator which showed how publishing cardiac surgeons’ death rates led to ‘adverse selection’:

  Mortality rates were published hastily. Surgeons were ‘named and shamed’ – a phrase destined to become enshrined in NHS folklore. Very rapidly the emphasis shifted from patient care to self-preservation. So many people contribute to the recovery of a heart surgery patient that the simplest way to stay under the radar is to avoid the sickest patients. Low risk translates into low mortality.

  Why do such ‘pseudoprofessionals’ as Roger Taylor, Joanne Shaw and Katy Dix wield more influence over health policy than the likes of Stephen Westaby? The contemporary distrust of ‘experts’ is partly to blame. Since the Thatcher reforms in the late 1980s, the NHS has provided rich pickings for management consultants and other opportunists keen to ‘exploit the commercial potential’ of whatever fad is grabbing the politicians’ attention. Modern politicians are more comfortable in the company of businessmen, management consultants and journalists than they are with professors of surgery and fellows of the Royal Society. They know that after leaving office, they may well be working with these same businessmen, journalists and management consultants. The phenomenon of the ‘revolving door’ between ministerial office and the private sector is now accepted as the way of the world: after Alan Milburn (so keen on Dr Foster Intelligence) resigned as health secretary in 2003, he took up a consultancy post with Bridgepoint Capital, a venture capital firm which funds private finance initiatives for the NHS. The politicians and journalists who expressed their shock and outrage over Stafford have moved on, as they always do, and Stafford Hospital must somehow keep going, its name forever sullied and tainted, bound for eternity to the corpses of the zombie stories and the zombie statistics.

  It would be foolish to argue that metrics have no place in medicine, but over-emphasis on such metrics has distracted contemporary medicine from its true purpose. Numbers should be our tool, not our tyrant. Society’s main concern about medicine is lack of compassion. This concern, as the Stafford scandal showed, is justified, and many doctors and nurses see this as the greatest challenge for contemporary health care. The components of compassion – kindness, courage, competence, bottom – are unquantifiable. The ‘invisible glue’ − the goodwill which once held together organizations like the NHS − has vanished.

  13

  The Mendacity of Empathy

  The mortality figures at Stafford distracted attention from what was most shocking about the story: the culture of neglect and cruelty at the hospital. The witness statements to the first Francis Inquiry described an institution bereft of common human decency, where sick elderly people were left to lie in their own excrement. The scandal led to a predictable reaction from the medical establishment, with a slew of statements from the royal colleges asking what could be learned from Stafford? Many – especially those positioned well away from the wards and the emergency departments – declared that the real problem was a lack of empathy. There are currently over 1,500 books listed on Amazon with ‘empathy’ in the title. From government to health care to education, empathy is the putative fix for all our societal woes. Some commentators, such as Peter Bazalgette, author of The Empathy Instinct (2017), proposed that NHS doctors and nurses should undergo formal empathy training. Such training is now embedded in US medical training, because empathy is now one of the accredited skills required by the American Council for Graduate Education in Medicine. Empathy is thus doing a brisk trade in the big business (and new member of the medical–industrial complex) that is medical education, and the journals regularly feature earnest articles on how to teach it. A systematic review published in 2014 in the journal BMC Medical Education identified over 1,400 papers on empathy. One study ‘sought to build medical student empathy for patients receiving injections by asking medical students to take turns injecting each other with saline solution’. Others used ‘role playing’ and ‘reflective writing’. Although the authors of this review were keen to promote these toe-curling endeavours, they conceded that ‘the majority of studies lacked highly rigorous designs’.

  Big Science is muscling in, too. Empathy is the latest target of the neuroscience based on functional magnetic resonance imaging (fMRI) of the brain. ‘Functional’ MRI differs from standard MRI scanning by mapping the differential rate of oxygen consumption in specific parts of the brain; this is thought to measure metabolic, and hence neuronal, activity. Functional MRI scans display impressive colour changes which reflect these differences in oxygen consumption: if an area of the brain ‘lights up’ during a specific activity, it is assumed that this activity ‘takes place’ in that location. The sociologist Scott Vrecko listed fMRI-based neurobiological accounts of altruism, borderline personality disorder, criminal behaviour, decision-making, fear, gut feelings, hope, impulsivity, judgement, love, motivation, neuroticism, problem gambling, racial bias, suicide, trust, violence, wisdom and zeal. Many commentators have called this branch of neuroscience the contemporary equivalent of phrenology, the bizarre belief – which had a remarkable hold on the public imagination in the nineteenth century – that personality and intellectual ability could be determined by examination of the contours of the skull. Phrenology eventually died out, mainly because it had no plausible scientific basis, and because it was used to give a bogus scientific credibility to racism. The neo-phrenology based on fMRI has been called ‘neurobollocks’ by its detractors. It has infiltrated economics, criminology, theology, literary criticism, education, s
ociology and politics; the American writer Matthew Crawford described fMRI as ‘a fast-acting solvent of critical faculties’. Some more cautious scientists, however, are painfully aware of its limitations; the neuroscientist David Poeppel observed that ‘we still don’t understand how the brain recognizes something as basic as a straight line’. Functional MRI scanning is also a contributor to the Replication Crisis in Big Science, as exemplified by the notorious ‘dead salmon’ study. The academic psychologist Craig Bennett of the University of California Santa Barbara was concerned about ‘random noise’ causing spurious false-positive results from fMRI scanning. To investigate this ‘random noise’, he purchased a (dead) salmon from a fishmonger and carried out a series of fMRI scans. Having been placed in the scanner, ‘the salmon was shown a series of photographs depicting human individuals in social situations with a specific emotional valence’. The salmon was scanned and ‘several active voxels were discovered in a cluster located within the salmon’s brain cavity’. (The three-dimensional image produced by fMRI is built up in units called ‘voxels’: each voxel represents a tiny cube of brain tissue.)

  As well as the obligatory fMRI-based neuroanatomy, all contemporary meditations on empathy contain earnest accounts of mirror neurons, described as ‘the most hyped concept in neuroscience’. These cells were first described in the 1990s by the Italian neuroscientist Giacomo Rizzolatti, who studied macaque monkeys, and noticed that the monkeys’ ‘pleasure centres’ were activated by the sight of seeing a human engaged in a pleasurable activity (eating peanuts). He also found that some motor cells (involved in the control of movement) are activated by the sight of the same movement in others (humans and monkeys). Since then, outlandish claims have been made for these neurons, particularly by the Indian-American neuroscientist V. S. Ramachandran, who believes these cells are responsible for empathy, language, even civilization. A sobering review of mirror neurons by the British neuroscientists James Kilner and Roger Lemon, published in Current Biology in 2013, concluded that we can’t extrapolate findings in monkeys to humans; we’re not absolutely sure if these cells exist in humans; and even if they do, we’re not sure what their function is. These doubts haven’t remotely impeded the establishment of the new popular science orthodoxy which holds that mirror neurons are what make us human and empathetic. Neurobollocks has escaped from the laboratory and is now the rickety foundation for popular, and populist, books by writers such as Jonah Lehrer, Malcolm Gladwell and many others. Writing in the New Statesman in 2012, Steven Poole described this phenomenon as ‘an intellectual pestilence’ and observed how putting the prefix ‘neuro’ to whatever you are talking about gives it a pseudo-scientific respectability.

  Several recent books give us breathless accounts of the neuroscience of empathy. Here is a passage from Peter Bazalgette’s The Empathy Instinct:

  In 1994, [Simon] Baron-Cohen identified another region of the empathy circuit – the orbitofrontal cortex… And in 2013, Tania Singer and colleagues at the Max Planck Institute in Germany hit on another piece of the jigsaw. The right supramarginal gyrus helps us to separate our own feelings about a situation from those of the subject of our empathy.

  Bazalgette’s sketchy understanding of how scientific inquiry works doesn’t inhibit him in the least, and he concludes that therapeutic applications of this neuroanatomical knowledge are just around the corner: ‘Routine fMRI scans will identify psychopaths and others with an empathy deficit as people requiring special attention. There will be programs to repair the parts of their brains which malfunction.’ He suggests that ‘there is an argument for the screening of all of those in the front line of patient care. This would require the development of new emotional intelligence and empathy tests.’ In the near future, he seems to suggest, would-be doctors will undergo fMRI scanning of their orbitofrontal cortex and right supramarginal gyrus.

  Dr Helen Riess is a psychiatrist at Harvard Medical School and is an expert in teaching empathy. Having first developed a shaky, unpersuasive scaffolding of neuroscience (the standard stuff about fMRI and mirror neurons) around empathy training, she then set up a for-profit company called Empathetics™ which offers empathy training for medical students, nurses and doctors. (The word ‘empathetics’ gives the impression that this is a new branch of medicine, sounding, as it does, vaguely like ‘anaesthetics’.) Riess has even produced a study showing that doctors who had been through her course were rated by patients as being ‘more empathetic’: a good example of the new trend for advertising disguising itself as ‘research’. ‘Empathetics’ is closely related to another American medical movement called ‘Narrative Medicine’, whose high priestess is Dr Rita Charon of Columbia University. It is no coincidence that both Narrative Medicine and Empathetics took root and flourished in the US, where the dominant ethos in medicine is consumerism. Doctors can indeed be trained to simulate the outward expressions of empathy – maintaining eye-contact, giving the ‘correct’ verbal prompts, and so on. This is similar to acting; indeed, out-of-work actors often find employment as ‘patients’ in such exercises. The title essay of Leslie Jamison’s 2014 collection The Empathy Exams recounts her experience as a medical actor, a ‘standardized patient’ for the training of medical students. These ‘patients’ have to give an evaluation of the students’ performance:

  Checklist item 31 is generally acknowledged as the most important category: ‘Voiced empathy for my situation/problem’. We are instructed about the importance of this first word, voiced. It’s not enough for someone to have a sympathetic manner or use a caring tone of voice. The students have to say the right words to get credit for compassion.

  Jamison observed that some students cynically game this po-faced charade: ‘I grow accustomed to comments that feel aggressive in their formulaic insistence.’ Although her writing is characterized by a relentless and wearisome solipsism, Jamison has a moment of insight when she began to obsessively check her face for weakness after her brother developed Bell’s palsy (facial paralysis): ‘I wonder if my empathy has always been this, in every case: just a bout of hypothetical self-pity projected onto someone else.’

  The new discipline of medical humanities also claims to develop empathy in medical students and doctors. It began in the 1970s with modest aims, covering such ground as ethics and the history of medicine. It turned its attention to great works of literature with the hope that these books could teach something about the experience of illness and the business of doctoring. So, for example, Tolstoy’s novella The Death of Ivan Ilyich is often used to teach students about what Dame Cicely Saunders called ‘total pain’, meaning the kind of extreme existential suffering experienced by some dying people. Some students thought it useful, others didn’t. In the early years, courses in medical humanities were generally taught by doctors who happened to have an interest in literature, history and ethics, but the discipline was gradually annexed by professional humanities academics, chiefly because it attracted significant funding from bodies like the Wellcome Trust. (Yet another example of how easily medicine is colonized by rival professions who have spotted an opportunity.) The medical schools weren’t aware of the seismic changes in the humanities that began in the 1960s. Doctors and medical students were mystified by post-modernist claims that there was no objective truth, that all written documents – including scientific papers – were ‘narratives’, informed by the cultural and economic milieu of the authors. Post-modernism’s high priests – such as Foucault and Derrida – were also aggressively anti-science. These academics brought to the subject this post-modernist world view, and an incomprehensible jargon. Here is a typical sentence from a 2011 article in the journal Medical Humanities entitled ‘Medical humanities as expressive of Western culture’: ‘The act of asserting disciplinarity, even interdisciplinarity, derives momentum from a certain teleological impetus to self-narrate, producing a coherent or centralizing version of self-hood in relations to one’s envisaged audience.’ This passage is reminiscent of the infamous 1996 Sokal hoax,
when the eminent physicist Alan Sokal submitted a paper to the American journal Social Text entitled ‘Transgressing the boundaries: towards a transformative hermeneutics of quantum gravity’. The paper, a deliberate parody of post-modernist gobbledygook, was accepted and published. The new journals devoted to the medical humanities can only be read – and are only meant to be read – by a small, highly specialized, academic audience. I looked through a recent issue of the journal BMJ Medical Humanities, and found words like assemblage, hybridity, concorporeality, durative, anthropogony, postconventional, embodied (selves and materialities), and, of course, ‘narrative’. The jargon of the medical humanities bears a striking resemblance to that of conceptual art, so mocked by the cultural critic Jonathan Meades: ‘It is the language of the trained liar, of the professionally mendacious… impenetrable to the uninitiated, a language of exclusion.’

  Narrative Medicine, with its glutinous mix of virtue signalling, pseudo-biblical language and social justice agenda, is the dominant and unchallenged orthodoxy within the medical humanities. Robin Downie lamented the obsession with ‘narrative’ and pointed out that doctors have always listened to the patient’s story – it was called taking a history. The Narrative Medicine lobby believes that patients are ill served by a medical establishment that is relentlessly mechanistic and dehumanizing. ‘Inevitably’, wrote the doctor and philosopher Raymond Tallis in Hippocratic Oaths (2004) ‘many commentators trained in the humanities, and remote from the responsibility for making and acting on correct diagnoses, see the tussle or tension between stories as a hermeneutic power struggle, with the omnipotent doctor crushing the powerless patient with his version of events.’ Some students question, not unreasonably, what these cloistered academics can possibly teach them about the challenges of medical life and dealing with the sick and dying. A group of students from four English medical schools wrote a short piece for the journal Clinical Teacher entitled ‘Hold my hand while you misdiagnose me’, arguing that the curriculum in medical schools had become over-concerned with ‘soft’ skills at the expense of medical knowledge.