Article
Care
Comment
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. 

Article
Biology
Comment
Wildness
5 min read

There’s a sting in the tail if we construct lessons from nature

Don’t be like the bees

Juila is a writer and social justice advocate. 

A bee keeper hold honeycomb to the light
HiveBoxx on Unsplash.

‘Be like the bees’ we hear not infrequently. These furry hive dwellers have been coopted by many, from socialists to capitalists, to put a point across. One party draws on their social structure as an inspiration, another their worker bee ethic. They are indeed an example to us. And yet at the same time, bee communities do things that we would find reprehensible in fellow humans. Male bees are expelled from the hive when they are no longer considered reproductively useful. The bees we see out and about this summer are often the oldest, sent to do the dangerous foraging work because they are considered the most expendable. This was a jarring discovery for me, reading it in Katherine May’s timely book, Wintering, during the first COVID-19 lockdown. I was one of the millions shielding and being protected by the ways that society shifted to serve the most vulnerable to the virus; bees, I had just learned, would not behave like this. There are some limits, it seems, to the lessons we construct from nature.  

For we do love to construct them. Spend a moment on LinkedIn or Substack, and there are a multitude of articles drawing lessons from the world around us and the creatures we share it with.  

This impulse is not new; throughout history, people and communities have done this. People’s relationship with nature is not static or homogenous. The wilderness has been variously a place of fear to be avoided, of growing wonder as described by the Romantic Poets, a site of knowledge neglected by those in power but maintained by others, often women and indigenous communities.  

What strikes me about the current trend is that it seems to push to an extreme of unquestioning veneration: nature is perfect and our whole teacher. There are posts about perfect harmony we should emulate, or a call to copy an endless adaptability. These are the things that we might long for – but do not seem to be borne out in ecosystems where sea urchins demolish kelp forests, and the climate crisis reveals the limits of species to adjust. We are being called to see what we want (or feel we need) rather than what actually exists in the world around us.  

This instinct to carve lessons from creation extends beyond the natural world to the work of human hands. The Japanese art of kintsugi, repairing broken pottery with gold, has become increasingly prevalent as a metaphor for healing; a beautiful idea but one that risks being stripped of its culture, and that has both limitations and dangers. In Sarah Perry’s novel, The Essex Serpent, Cora’s husband Michael masks his abuse by speaking in a romantic metaphor of his intention to break her down and mend her with gold, like the Japanese art in their hallway. But Cora is not a vase; she is woman. Michael’s breaking harms her. She only begins to repair after he is gone; it is messy, some parts seem irrevocably changed. I think of my own losses, and how healing is indeed available, but rarely as straightforward as putting the same pieces back together. To think it is so can hinder our restoration, and miss out on the transformation that may be possible. As the journalist Poorna Bell wrote after her husband’s death by suicide: “I was in some ways sadder, wiser, but also my existence was much bigger, more honest.” 

We have a great capacity to learn – and we need it to survive. As writer Andy Crouch put it in his book, Culture Making: “a human baby is the strangest and most wonderful creature this world can offer. No other mammal emerges so helpless from the womb, utterly unable to cope with the opportunity and adversity of nature. Yet no other creature holds such limitless possibility… We are hard-wired for nothing but learning. All we begin with are possibilities.” 

This ability to grow and understand and change is essential if we are to navigate the world. And in our encounters with this place, with brokenness and confusion, the instinct to make meaning, to tidy, to be able to point to something and say 'this is how we should be’ is a form of comfort. Maybe even control it. We are grappling with not just how to understand the world, but how to be in it.  

If we are always looking for the lesson, we devalue nature by prizing it just for what it can give us. 

Creation and creativity have much to teach us – they’re a testament to and the fruit of the imagination of God. But to prize them just for their lessons seems to fall into another form of extraction and to miss out on something else, something that may be a greater gift in this messy world: wonder.  

Bees moving from flower to flower are not setting out on their mission with a side hustle of education for the human race. They are being their full bee selves. Nectar is necessary; this is how it is collected. Bees share knowledge about the good plants via a ‘waggle dance’. This is how the colony persists. It is not for my benefit (though it may encourage me to a moment of playfulness).  

Writing this on my balcony, I pause when I see dozens of birds circling one thermal; a moving column of gulls and red kites that goes up and up and up. I could strive for a teachable moment (maybe something about co-existence?) but it feels not just unnecessary, but an interruption. In that moment, I was a human being in awe of birds riding the warm air; that feels like something full of beauty in itself. I worry that if we are always looking for the lesson, we devalue nature by prizing it just for what it can give us. And we miss out on the opportunities to marvel at creation itself.  

And, in calling each other to be like other creatures, we accidentally dehumanise other people and ourselves. In the face of conflict, polarisation and disconnection, to contend for each other’s humanity feels vital. And to recognise our own humanness is to acknowledge our limitations. There are parts of nature currently beyond our comprehension. Birdsong holds complexity heard by the intended audience but we can only guess at its meaning. There is something to accepting the edges of our own understanding. Sometimes we touch on truths that seem to contradict or be in tension. Perhaps they are layers that we cannot intellectually fit together but that build up a fuller, richer story that resonates in our souls. Glimpsing something of the multifaceted wisdom and wonder of God himself – and that helps us to remember who we are. A particular type of creature: a human. 

So, I won’t be a bee. I’ll keep trying to learn to be what I am: a particular human in a bigger community, world and story. Now, I’m off to admire the goldfinches, glinting in the sunshine. 

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