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The patient versus the medical evidence

Convincing your patients of the medical facts can be challenging, writes George Winter.

The consultation is going swimmingly when the dread words tumble out: 'Doctor, I was looking on the internet ...'

Sighing, you recall Lady Bracknell: 'I do not approve of anything that tampers with natural ignorance. Ignorance is like a delicate exotic fruit; touch it and the bloom is gone.'

You decide to assert the universal truth that patients are blank slates on which the ideology of medicine is written.

Ushering the patient behind the screen, you order them to remove emotionally charged concerns about their disease and unbuckle any ideas about the role of illness in life beyond the consulting room.

Their disease is a discrete, biological entity, and medicine's view of it, not the patient's, carries the weight of authority because medicine is scientifically grounded. To bolster your claim, you point to a tome, the International Classification of Diseases wherein their disease is sequestered.

Stick to the facts
Next, you brandish the patient's test results while issuing an instruction to ignore any nonsense about disease as a social construction. 'These,' you say, 'are facts. Medicine is evidence-based and is about Gray's Anatomy, not Foucault's clinical gaze anatomy.'

At their next consultation, the patient produces Medicine and Culture by Lynn Payer.

In the foreword to the 1988 edition Dr Kerr White wrote: '... only about 15 per cent of all contemporary medical interventions are supported by objective clinical evidence that they do more good than harm.'

Your patient has the 1995 edition, in the preface to which Payer concedes this may have risen to 25 per cent.

This 25 per cent might be nudging the 30 per cent mark now. Nevertheless the patient asks you not only to explain such a dismal performance, but why, if disease can be so easily abstracted from its social context, medical practice in the US and Britain is so different.

Browsing through your copy of the book later, you learn that the French incriminate their livers at the drop of a beret, whereas in Germany, cardiac takes precedence over hepatic, with Herzinsuffizienz (loosely translated as 'cardiac insufficiency') a popular invocation.

Darkness at noon
In the USA, an attitude of 'if in doubt, do a lot' abounds. In contrast, UK physicians 'do less of nearly everything', although concern with the intestines, as in the Great British Bowel Movement, flourishes.

So how can GPs reconcile medicine's evidence-based approach with a medical gazetteer replete with such bizarre cultural overtones? Arthur Koestler, the author of Darkness at Noon believed that the human mind is basically schizophrenic. 'The hot steam of belief and the ice block of reasoning are packed together inside our skulls, but as a rule they do not interact.' he said.

So which persona dominates in your consulting room? The steamy believer or icy rationalist?

George Winter is a columnist for the Irish Medical News.

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