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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. 

Explainer
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5 min read

When someone makes a claim, ask yourself these questions

How stories, statistics, and studies exploit our biases.

Alex is a professor of finance, and an expert in the use and misuse of data and evidence.

A member of an audience makes a point while gesturing.
On the other hand...
Antenna on Unsplash.

“Check the facts.”  

“Examine the evidence.”  

“Correlation is not causation.”  

We’ve heard these phrases enough times that they should be in our DNA. If true, misinformation would never get out of the starting block. But countless examples abound of misinformation spreading like wildfire. 

This is because our internal, often subconscious, biases cause us to accept incorrect statements at face value. Nobel Laureate Daniel Kahneman refers to our rational, slow thought process – which has mastered the above three phrases – as System 2, and our impulsive, fast thought process – distorted by our biases – as System 1. In the cold light of day, we know that we shouldn’t take claims at face value, but when our System 1 is in overdrive, the red mist of anger clouds our vision. 

Confirmation bias 

One culprit is confirmation bias – the temptation to accept evidence uncritically if it confirms what we’d like to be true, and to reject a claim out of hand if it clashes with our worldview. Importantly, these biases can be subtle; they’re not limited to topics such as immigration or gun control where emotions run high. It’s widely claimed that breastfeeding increases child IQ, even though correlation is not causation because parental factors drive both. But, because many of us would trust natural breastmilk over the artificial formula of a giant corporation, we lap this claim up. 

Confirmation bias is hard to shake. In a study, three neuroscientists took students with liberal political views and hooked them up to a functional magnetic resonance imaging scanner. The researchers read out statements the participants previously said they agreed with, then gave contradictory evidence and measured the students’ brain activity. There was no effect when non-political claims were challenged, but countering political positions triggered their amygdala. That’s the same part of the brain that’s activated when a tiger attacks you, inducing a ‘fight-or-flight’ response. The amygdala drives our System 1, and drowns out the prefrontal cortex which operates our System 2. 

Confirmation bias looms large for issues where we have a pre-existing opinion. But for many topics, we have no prior view. If there’s nothing to confirm, there’s no confirmation bias, so we’d hope we can approach these issues with a clear head. 

Black-and-white thinking 

Unfortunately, another bias can kick in: black-and-white thinking. This bias means that we view the world in binary terms. Something is either always good or always bad, with no shades of grey. 

To pen a bestseller, Atkins didn’t need to be right. He just needed to be extreme. 

The bestselling weight-loss book in history, Dr Atkins’ New Diet Revolution, benefited from this bias. Before Atkins, people may not have had strong views on whether carbs were good or bad. But as long as they think it has to be one or the other, with no middle ground, they’ll latch onto a one-way recommendation. That’s what the Atkins diet did. It had one rule: Avoid all carbs. Not just refined sugar, not just simple carbs, but all carbs. You can decide whether to eat something by looking at the “Carbohydrate” line on the nutrition label, without worrying whether the carbs are complex or simple, natural or processed. This simple rule played into black-and-white thinking and made it easy to follow. 

To pen a bestseller, Atkins didn’t need to be right. He just needed to be extreme. 

Overcoming Our biases 

So, what do we do about it? The first step is to recognize our own biases. If a statement sparks our emotions and we’re raring to share or trash it, or if it’s extreme and gives a one-size-fit-all prescription, we need to proceed with caution. 

The second step is to ask questions, particularly if it’s a claim we’re eager to accept. One is to “consider the opposite”. If a study had reached the opposite conclusion, what holes would you poke in it? Then, ask yourself whether these concerns still apply even though it gives you the results you want. 

Take the plethora of studies claiming that sustainability improves company performance. What if a paper had found that sustainability worsens performance? Sustainability supporters would throw up a host of objections. First, how did the researchers actually measure sustainability? Was it a company’s sustainability claims rather than its actual delivery? Second, how large a sample did they analyse? If it was a handful of firms over just one year, the underperformance could be due to randomness; there’s not enough data to draw strong conclusions. Third, is it causation or just correlation? Perhaps high sustainability doesn’t cause low performance, but something else, such as heavy regulation, drives both. Now that you’ve opened your eyes to potential problems, ask yourselves if they plague the study you’re eager to trumpet. 

A second question is to “consider the authors”. Think about who wrote the study and what their incentives are to make the claim that they did. Many reports are produced by organizations whose goal is advocacy rather than scientific inquiry. Ask “would the authors have published the paper if it had found the opposite result?” — if not, they may have cherry-picked their data or methodology. 

In addition to bias, another key attribute is the authors’ expertise in conducting scientific research. Leading CEOs and investors have substantial experience, and there’s nobody more qualified to write an account of the companies they’ve run or the investments they’ve made. However, some move beyond telling war stories to proclaiming a universal set of rules for success – but without scientific research we don’t know whether these principles work in general. A simple question is “If the same study was written by the same authors, with the same credentials, but found the opposite results, would you still believe it?” 

Today, anyone can make a claim, start a conspiracy theory or post a statistic. If people want it to be true it will go viral. But we have the tools to combat it. We know how to show discernment, ask questions and conduct due diligence if we don’t like a finding. The trick is to tame our biases and exercise the same scrutiny when we see something we’re raring to accept. 

 

This article is adapted from May Contain Lies: How Stories, Statistics, and Studies Exploit Our Biases – and What We Can Do About It
(Penguin Random House, 2024)
Reproduced by kind permission of the author.

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