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5 min read

The healing touch in an era of personalised medicine

As data powers a revolution in personalised medicine, surgeon David Cranston asks if we are risk of dehumanising medicine?

David Cranston is emeritus Professor of Surgery at Oxford University. As well as publishing academically, he has has also authored books on John Radcliffe, and mentoring.

A doctor looks thoughtful will holding a stethoscope to their ears.
Photo by Nappy on Unsplash.

In 1877 Arthur Conan Doyle was sitting in one of Dr Joseph Bell’s outpatient clinics in Edinburgh as a medical student, when a lady came in with a child, carrying a small coat. Dr Bell asked her how the crossing of the Firth of Forth had been on the ferry that morning. Looking sightly askance she replied;  

 “Fine thank you sir.”  

 He then went on to ask what she had done with her younger child who came with her.  

Looking more astonished she said:   

“I left him with my aunt who lives in Edinburgh.   

Bell goes on to ask if she walked through the Botanic Gardens on the way to his clinic and if she still worked in the Linoleum factory and to both these questions she answered in the affirmative.  

Turning to the students he explained  

“I could tell from her accent that she came from across the Firth of Forth and the only way across is by the ferry. You noticed that she was carrying a coat which was obviously too small for the child she had with her, which suggested she had another younger child and had left him somewhere. The only place when you see the red mud that she has on her boots is in the Botanic Gardens  and the skin rash on her hands is typical of workers in the  Linoleum factory.   

It was this study of the diagnostic methods of Dr Joseph Bell led Conan Doyle to create the character of Sherlock Holmes.  

A hundred years later and I was young doctor. In 1977 there were no CT or MRI scanners. We were taught the importance of taking a detailed history and examination. Including the social history. We would recognise the RAF tie and the silver (silk producing) caterpillar badge on the lapel of a patient jacket.  We would ask him when he joined the caterpillar club and how many times he had had to bail out of his plane when he was shot down during the war – a life saved by a silk parachute. We would notice the North Devon accent in a lady and ask when she moved to Oxford.  

The patient’s history gave 70% of the diagnosis, examination another 20% and investigation the final 10%. Patients came with symptoms and the doctor made a presumptive diagnosis – often correct - which was confirmed by the investigations. Screening for disease in patients with no symptoms was in its infancy and diseases were diagnosed by talking to the patients and eliciting a clear history and doing a meticulous examination. No longer is that the case.     

At the close of my career, as a renal cancer surgeon, most people came in with a diagnosis already made on the basis of a CT scan, and often small kidney cancers were picked up incidentally with no symptoms. The time spent talking to patients was reduced. On one hand it means more patients can be seen but on the other the personal contact and empathy can be lost.  

Patients lying in in bed have sometimes been ignored. The consultant and the team standing around the foot of the patient’s bed discussing their cases amongst themselves. Or, once off the ward, speaking of the thyroid cancer in bed three or the colon cancer in bed two. Yet patients are people too with histories behind them and woe betide the medic, or indeed the government, who forgets that.  

With computer aided diagnosis, electronic patient records and more sophisticated investigation the patient can easily become even more remote. An object rather than a person.  

We speak today of more personalised medicine with every person having tailored treatment of the basis of whole genome sequencing and knowing each individual’s make up. But we need to be sure that this does not lead to less personalised medicine by forgetting the whole person, body mind and spirit.  

Post Covid, more consultations are done online or over the telephone -often with a doctor you do not know and have never met. Technology has tended to increase the distance between the doctor and patient. The mechanisation of scientific medicine is here to stay, but the patient may well feel that the doctor is more interested in her disease than in herself as a person. History taking and examination is less important in terms of diagnosis and remote medicine means that personal contact including examination and touch are removed.  

Touching has always been an important part of healing. Sir Peter Medawar, who won the Nobel prize for medicine sums it up well. He asks:  

‘What did doctors do with those many infections whose progress was rapid and whose outcome was usually lethal?   

He replies:  

'For one thing, they practised a little magic, dancing around the bedside, making smoke, chanting incomprehensibilities and touching the patient everywhere.? This touching was the real professional secret, never acknowledged as the central essential skill.'

Touch has been rated as the oldest and most effective act of healing.   

Touch can reduce pain, anxiety, and depression, and there are occasions when one can communicate far more through touch than in words, for there are times when no words are good enough or holy enough to minister to someone’s pain.   

Yet today touching any patient without clear permission can make people ill at ease and mistrustful and risk justified accusation. It is a tightrope many have to walk very carefully. In an age of whole-person care it is imperative that the right balance be struck. There’s an ancient story that illustrates the power of that human connection in the healing process. 

When a leper approached Jesus in desperation, Jesus did not simply offer a healing word from safe distance. he stretched out his hand and touched him. He felt deeply for lepers cut off from all human contact. He touched the untouchables.   

William Osler a Canadian physician who was one of the founding fathers of the Johns Hopkins Hospital in Baltimore, and ended up as Regius Professor of Medicine in Oxford,  said:  

“It is more important to know about the patient who has the disease than the disease that has the patient”.  

For all the advantages modern medicine has to offer, it is vital to find ways to retain that personal element of medicine. Patients are people too. 

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5 min read

What my noisy, messy crow neighbours have taught me about how to live

We can’t control nature; we just need to become more porous to it

Joel Pierce is the administrator of Christ's College, University of Aberdeen. He has recently published his first book.

Crows caw and strut.
Meet the neighbours.
Townsend Walton on Unsplash.

Our neighbours hate our crows. I can’t blame them. The hundreds of crows that occupy the tops of the ancient pines which surround our rural manse are the noisiest and messiest residents I have ever lived near. They greet each sunrise with a din of caws and counter-caws, as if they are deeply concerned that anyone might miss this momentous daily event or the fact that it’s now happening before 5:30a.m. In nesting season, which lasts most of April and May, our car is easily identifiable in any carpark by the crusted grey spots with which the crows see fit to adorn it. Within a week of moving in, we gave up on the washing line so invitingly strung between two of the pines. Our pristine whites were too tempting a target for our crows. 

I do not attend the meetings of our local community council, but I hear whispers of what transpires there. Our crows, evidently, have been a regular topic of conversation. Multiple solutions have been proffered for driving them away. All have been tried and all have failed. Our crows cling fiercely to their homes and their determination is more than a match for any human efforts. If I have the vibe of my community right, at least some of its members feel that there’s something perverse, obscene even, about a flock of birds being allowed to upset our human right to create a serene, comfortable, and convenient habitation. Our clump of houses is surrounded by a visually stunning landscape; shouldn’t the aural landscape be equally beautiful?  

If my family does not mind our crows, it is because the treetop drama is just one more example of many natural encroachments on the house, some more welcome than others.  

Every year we celebrate the miraculous return to our eaves of house martins, home from their intercontinental peregrinations. We look forward to another summer spent watching their acrobatics and listening to their chicks in the nests an arm’s length from our windows.  

Clearing up the mess of our attic’s bats is an annual chore, one thankfully performed stoically by our church’s property convener, but there are compensations - such as the twilight shows they put on outside our living room window, performing impossible turns and reversals midair in their search for prey.  

Less welcome are the massive spiders, which are a perennial presence; the slugs, which seemed to apparate onto the hall carpet all through winter, the mice, two of whom sacrificed themselves to knock our dishwasher out of action by chewing through its hose; and the wasps who built a nest the size of a telephone box in the roof space above our back bathroom.  

Least fun of all has been what we call the Great Earwig Migrations, which have happened twice in our half-decade in the manse and which involve weeks of finding the little bugs under, seemingly, every object and on every surface.  

When we moved into the manse, we expected challenges, the high heating bills, the leaking roof, and the isolation of the countryside. What we did not expect was the experience of porousness; the shock of realising that we had so little control over what other forms of life saw fit to share our habitation with us.  

At first it felt to me perverse, obscene even, that a house, even a 120-year-old house, should be so vulnerable to incursions by animal creation. Shouldn’t our home, our space, be a haven where we can control who or what enters, who or what we feel comfortable with, and who or what we can exclude?  

If I had to give a name to this expectation, maybe it would be that of the buffered home, a play on philosopher Charles Taylor’s description of the modern self as buffered. Taylor contrasts the selves we aspire to be in modernity, ones able to control and order our bodies, our space, our lives, and our relationships so that they accord with our autonomous desires and actions, with those of our premodern ancestors. Medievals and ancients assumed porosity. Bodies were subject not just to biological infection, but spiritual infections too. Projects and plans were frustrated not just by mistakes or personal failings, but by the ever-fickle whims of the goddess Fortuna. Their lives, their bodies, their homes, existed in a perpetual state of vulnerability. The threat of everything falling apart was always on the horizon. 

We want nature to survive, flourish even, but not at the cost of our comforts or our sense of autonomy and security.

Modern technology has helped us tame the more unwelcome of these forces, but it has also given us an overly naive expectation that all that is inconvenient about nature can and should be gradually eliminated. This expectation frames the way we respond to worries about climate change and other creeping environmental crises. We want nature to survive, flourish even, but not at the cost of our comforts or our sense of autonomy and security. But as our ancestors might remind us, we are part of nature too, and, just as in any relationship, mutual vulnerability and sacrifice are needed if we are all going to survive. This is scary, but there are resources within Christianity - within other faiths too - to help us understand that there are benefits to affirming our vulnerability, our porosity. 

My daughters love our crows. They point in wonder as the crows flood into the sky at dusk, hundreds of them making a giant circle once, then twice round the garden, before settling down for the night. When, in late May, grounded fledgings appear, bundles of feathers shocked at the sudden inhospitality of the nest, too stunned to realise they can fly home, my daughters watch over them, anxious lest the local cats take advantage of their bewilderment.  

A few Sundays ago, my youngest, who struggles to stay quiet and well-behaved in Sunday School, pulled me out of church early. We sat on the church lawn staring up at the crows and soon were adapting the andante melodies of that Sunday’s hymns into imagined songs of praise that crows might sing. “No,” my youngest said, simpatico with the crows as she is, “I think they’d want something more upbeat.” And so we tried setting our own corvid-themed praise lyrics to Rosé and Bruno Mars’ song APT, while listening to the caw and counter-caw above. “Dad, how do you think God sees the world?” she asked me when we finished. I stumbled through my best theologically informed explanation of how God could be in every part of creation without being of it, before she stopped me. “I think it’s like a giant snow globe that he holds in his hands.” Watching the birds swirl around us, two stationary figures caught by the same currents of air that were sweeping them aloft, what could I do but agree? 

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