Doctors are men who prescribe medicines, of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.
When we were at medical school way back in the darker ages, my colleagues and I were indoctrinated into a paternalistic mode of practice. The doctor knew best; he (there were less than ten per cent of women in our year) had gone through five years of training in anatomy, physiology, biochemistry, pathology, diagnosis and therapeutics. So unlike Voltaire’s severe castigation, we knew a lot about the science of medicine, but we still knew little about people. Our patients presented their symptoms, we asked the relevant questions and we formulated the diagnosis. For example, if a patient had abdominal pain, we would ask: where is the pain, what kind of pain is it (throbbing, colicky, boring or like a knife), does it radiate to the back, does eating bring it on, how long after a meal does it come on, does exercise or posture affect it, is it relieved by defaecation? Then we would confirm our suspicions by a careful physical examination to elicit tenderness or swelling and perhaps an X-ray or blood test and prescribe the appropriate treatment. We were trained to deliver a pill for every ill.
Medicine was a matter of logistics. We were discouraged from getting involved with our patient’s lives. We didn’t ask about what had happened before the illness started and we never enquired about the nature of any stress. We protected ourselves from all the messiness of life by our buttoned up white coats. Later, working as a registrar in gastroenterology in Sheffield, I once wrote an article for Northwing, the medical students’ magazine, entitled the White Coat Game, in which I questioned the purpose of the white coat, pointing out that it certainly wasn’t to protect our normal clothes from our patients bodily fluids, because when we did endoscopies, we had to remove our white coats and hang them up. The white coat had to remain spotless at all times.
Change rarely happens quickly. It can take years before sufficient pressure of opinion builds up to alter practice. Sometimes it doesn’t happen. Most medical and almost all surgical specialisms still adopt a paternalistic model. GPs have always known their patients better, but many now see their role as providing the appropriate information to allow their patients to decide what suits them best. This applies particularly to illnesses like IBS, where there is no agreed cause and no definite treatment. Management is more of a collaboration; a meeting of experts. The patient knows everything about their life and the doctor knows about the medical options which may help. The arrangement of the furniture may have changed; patients no longer sit in front of the doctor’s desk, they sit at the side while the doctor engages with their computer screen and relays the information. Eye contact can be minimal and with just about 10 minutes per appointment there is never enough time to gather exchange sufficient information.
With the wide availability of Google and Wikipedia, patients are far more informed than they ever have been. The danger is that people can be so influenced by propaganda, advertising and personal testimony that they struggle to know what information to rely on. As a result, some GPs adopt a more interpretive model, in which they help their patients understand the literature and facilitate a joint decision that feels right for them. But this still needs time.
Charities can play a vital role in all of this. The IBS Network functions not just as an information portal. ‘Your Questions’, the telephone helpline and the articles on this blog attempt to provide you with a resource for understanding your illness, interpreting your symptoms and guiding your treatment options. But it still may not be enough. My impression is that many people with IBS need the personal face to face engagement and mutual understanding to develop the confidence to manage and resolve their own symptoms. This is where IBS Self Help Groups play such an important role. Could you start a self help group near you? If so please sign up to our training day on October 22nd (see our advert on Facebook).
You need never be alone with your IBS.