Healthcare or medicine: which is more important?
It’s December 1995. A chubby four year-old boy in a Thomas the Tank Engine woolly hat is crying.
He’s suffering from a very common ear infection that almost all children have experienced, ‘otitis media’. He’s crying because it’s painful.
His parents have tried for a couple of days to soothe him but it’s not helping. So now he’s sitting with Mum in a warmly lit, magical place, about to see a magical person. It’s not Santa’s grotto, it’s better than that. He’s going to see The Doctor (capitalised for effect, not the time-travelley one).
The Doctor is a jolly, overweight man. Like Santa, without the red costume or the beard, but with the same reassuring smile and the same aura of magic. The boy is me.
The Doctor is a stranger but Mum trusts him, so I trust him too. My tears have dried up as he approaches me calmly, softly, confidently. He listens as Mum tells him what the problem is and he seems to understand. And somehow — though I can’t remember what he said or did — I can tell that he cares.
The way I remember it, going to see The Doctor made me feel better almost immediately.
He carefully examines me. He looks at my throat and my ears, takes my temperature and feels my neck, very gently. He sits back and assertively names my affliction, ‘a nasty ear infection’. So my pain is real and it has a cause.
When we leave The Doctor, Mum has a piece of paper that we swap for a bottle of fluorescent liquid called ‘Antibiotics’. It’s yellow and is supposed to taste like bananas. I don’t like it as much as Calpol, which is delicious. Fortunately The Doctor said I could have both, so that’s ok.
Memory is a funny thing and our early memories are not the most reliable. But the way I remember it, going to see The Doctor made me feel better almost immediately and long before those antibiotics could have had any effect on my symptoms.
Why?
In my first year studying medicine, we had a minor but mandatory course called SCHI (pronounced ‘ski’). The Social Context of Health and Illness.
A lecturer had the audacity to tell us that healthcare wasn’t about biochemistry, anatomy and physiology (which were the major themes of our first year of study), that our traditional curriculum might be missing something.
A lot of people stopped showing up to lectures.
What? The course we’ve all just worked our butts off to get onto, at the great Cambridge University, might not be teaching us what it’s all about? Yeah, ok. Pull the other one. I’m a medic not a sociologist!
We had to pass SCHI to pass the year. But a lot of people stopped showing up to lectures. Each in our own way, I believe we were all very diligent in making sure that we learned enough to pass the exam, without letting any of the material affect our understanding of the world and our place in it.
Skip ahead to 2016. I’m working in my first job as a medical doctor in West London. I’m used to being a man with side-projects (voluntary work, teaching, writing — my friends describe me as ‘busy’).
Being an actual full-time doctor seems to leave far less time for that sort of thing. So when I finally get some time off to go to my parents’ for Christmas, I dive into the first thing I can find which is completely different from my day job.
My Mum has a degree in history and still has most of her university reading list on the bookshelf. I grab a couple of the more accessible-looking books and settle down to read about late medieval Britain.
My favourite book is by historian Keith Thomas. It’s called ‘Religion and the Decline of Magic’, and it has a long chapter on health and healing in the 16th Century. I’ll come back to this book in a future story because it’s very important to my understanding of healthcare. Suffice it to say this book was a revelation in my understanding of healthcare vs medicine.
I reflect on two ways to retell the story of the chubby boy with an ear infection. I can tell is as a healthcare story, or I can tell it as a medical story.
Medically, this was a fairly ‘low value’ consultation.
My preferred version is the one I already told you. The story of a boy with a problem, a trusted helper who analyses the problem, and a reassuring solution. That’s the healthcare story.
Here’s the medical story:
A concerned parent phones up her GP practice to book an appointment for her four year-old son, with one of the GPs. They’re lucky to get a same-day appointment (the waiting list is normally at least a week).
In the consulting room, the doctor takes a history. The symptoms are pain affecting the right ear, swollen lymph nodes and a sore throat.
An examination probably isn’t necessary. The child is alert, a good colour, doesn’t have any breathing difficulties, and even managed half a smile at a lolly-pop. The doctor knows the diagnosis based on the symptoms. Really, this could have been done over the phone but since they’re here…
The diagnosis is otitis media. It’s probably a viral illness. In the vast majority of cases, the body gets better by itself after three or four days. If it’s viral, antibiotics won’t help. In fact this parent and her child probably should have stayed at home and practised ‘self-care’. But since they’re here…
So they get a prescription of antibiotics and advice to continue using Calpol. As predicted, the boy makes a full recovery.
Healthcare is about witnessing human experience, building trusting relationships and providing reassurance.
Medically, this was a fairly ‘low value’ consultation. If anything, it could have had a net negative impact, exposing a child who would otherwise have been fine, to the potential side-effects of an antibiotic. As well as unnecessarily taking up a doctor’s time, contributing to antibiotic resistance, etc…
But the first version of the story was heart-warming, wasn’t it? It felt like a wonderful example of the value of healthcare.
And that’s because healthcare, unlike medicine, isn’t rooted in biochemistry, anatomy and physiology. Healthcare is about witnessing human experience, building trusting relationships and providing reassurance.
It’s at that point I realise what SCHI had been about. It’s a shame the timing and delivery of that course could have been chosen deliberately for us to completely ignore it.
The more stories I write, the more I want to understand the differences between concepts of ‘medicine’ and ‘healthcare’ further. I want to think about how the two can be reconciled, to do both better.
In the example above, the antibiotics in themselves weren’t necessary. The value was in the reassurance they brought. If the doctor had provided reassurance through other means, I think it would have been just as valuable. It would also have been better medicine.
At a time of rapid change in the way healthcare is provided, I think it’s more important than ever to ask what healthcare is, what it does and what we might be missing with new innovations.
Time and again, when I hear calls in the UK to ‘save the NHS’, they’re made without a meaningful expression of what it is that should be saved.
What are we defending? What does the system actually provide us with? Is it the medicine that’s more important, or the healthcare? Do we want more medicine or more healthcare?
Change is inevitable, not negotiable. And that’s a good thing, because change allows us to learn, grow and improve. But if we can’t clearly answer these fundamental questions, we can’t build a better system for the future.
I’m writing these stories, because these questions are urgent but seem to be largely un-asked by entrepreneurs, politicians and even medical professionals driving innovations in digital health and medical technology.
As I ask these questions, I’ll share my perspective as a human, a doctor, and a story-teller. I’ll also be asking other humans, doctors and innovators in healthcare to share their perspectives.
Together, I hope we can open up a debate. If you want to get involved in the conversation, leave me a comment or email me at dpneal91@gmail.com.
And watch this space!
