The Physician’s Tale

BEDSIDE MANNERS:
The Troubled History of Doctors and Patients
By Edward Shorter
Simon and Schuster; 316 pp.

Consider the paradox of the latter-day physician. On the one hand (and with the clear exception of law enforcement) no subject so consistently fascinates prime-time audiences as medicine. From Kildare and Casey, through Quincy and Hawkeye, to Mark Craig and Victor Erlich, we feel compelled to celebrate a profession whose members one normally meets only in moments of risk or distress.

On the other hand, there is the troubling suspicion, felt by doctors and patients alike, that something is seriously amiss with late-20th-century medicine. Its powers are breathtaking, but in practice encounters with doctors are often cold and abrupt, dealings with hospitals are formal and regimented, and even though recovery may be a direct result of the doctor’s talents, one may be left with the sense that a disease has been treated, not a person.

And yet this, Edward Shorter argues in Bedside Manners, is what medicine has become: in fiction, a ready source of drama and heroism, but in fact a practice whose drama springs primarily from crisis management, and whose heroism rests on skills that are ultimately technical.

Medicine, he contends, has undergone a decisive transformation over the past 40 years, in which enormous curative advances and the current deterioration of patient-doctor relations are part and parcel of the same process. Bedside Manners is an attempt to make sense of the present situation by examining the circumstances which brought it about.

It is a valuable contribution in that Shorter, a historian at the University of Toronto, has written, not a history of a profession or of illness and its treatment, but a history of a relationship – of the changing encounter between patients and physicians over the past 200 years. His point, distilled to its essentials, is that the powers of contemporary medicine have been won only by recasting the healing arts in the guise of the natural sciences.

In a world of dialysis and defibrillation machines, of insulin injections and intravenous drips, it is perhaps difficult to remember that medicine has only recently acquired its scientific gloss. But just as our relations with doctors today are marked by a confidence in their technical capacities (a confidence so firm that patients have come to expect a level of exactitude and reproducibility from their hospitals unmatched even by NASA, and rush to litigate when they are disappointed), so the doctor-patient relationship of the 18th century and much of the 19th was colored by the reality that the physician could do virtually nothing to alter the course of an injury or illness that was physical in origin.

There were no X-rays, no catscans, no antiseptics, no anesthetics, no antibiotics, no vaccines. Most of the doctor’s arsenal of purgatives and emetics was worthless, if not actually harmful. A small infection could have fatal consequences; surgery was limited largely to the hurried amputation; and if patients recovered from severe illnesses, it was most likely the result of the body’s immunological defence, not of the doctor’s labor.

It was not until the period 1880-1950 that what Shorter calls the “modern” physician appeared, and along with him (he was usually male) the “modern” patient. It was then that medicine came to acquire a sense of the physiology and biochemistry of the body, and therefore an understanding of disease founded in testable terms. Caught up in the zealous empiricism that stamped 19th-century industrialism, medicine probed the workings of health and illness with new tools and in new ways: the stethoscope, the microscope, the clinical autopsy, bacteriology, pathology, epidemiology. The result was that the physician could speak with conviction about what was causing a patient’s complaints, although he could still do little either to arrest or correct a disease.

Nonetheless, the new scientific footing acquired by medicine produced a physician confident about his own esteem and a patient duly impressed by the learning and the authority of the doctor. It is this, Shorter argues, that legislated the real curative power of early 20th-century medicine, and it is this that has been steadily lost in the post-war years.

In the absence of sophisticated means of peering inside live bodies (blood and urine analyses, barium enemas, spinal taps), the diagnosis of the modern doctor had to be based on lengthy consultations with his patient. Armed with a new diagnostic competence, he could distinguish between pathological maladies and those that were mere symptoms of psychological disturbances. And although his paternal authority might be useless against a carcinoma, it could certainly be used to soothe the psychic pains of his clientele. Still unable to cure, the modern physician in his capacity as analyst, confidant and confessor could nonetheless heal.

It has been the triumph of what Shorter calls “postmodern” medicine that the scientific understanding which allowed the modern doctor to make reliable diagnoses has given rise to a host of drugs, treatments and surgical techniques that actually work. In the process, however, something of worth has been lost.

The signs are everywhere. As in any profession, there is a hierarchy of pay and prestige among doctors. Rural general practitioners, who may deliver and care for an entire generation of a community, rank toward the bottom. Cardiac surgeons, who spend most of their time with patients who are unconscious, rank toward the top.

There are no tests of compassion or social grace administered in medical schools; doctors in training are measured instead by their abilities to recall the Krebbs cycle and to spot a benzene ring. In place of bedside manner, we now have the laboratory bench. In place of the frequent consultation, we now have the clinical interrogation (no questions about the family or how’s the job; instead: “Any dizzyness? Vomiting? Allergies?”).

In short, the doctors can keep uncle Harry alive, his arteries clogged by a lifetime of Labatt and duMaurier and camembert, but only by treating him as an organic mechanism in which a key element is about to malfunction, and by understanding their own task as interceding to prevent the whole organism from failing. Uncle Harry, the postmodern patient, has become little more than a problem to be solved. His postmodern doctors begin to bear more of a resemblance to high-tech plumbers, mechanics or engineers than to the learned, genial humanists of popular memory.

If the only byproduct of this realignment in medical training and practice were a strain on doctor-patient relations, the triumphs of the profession would more than offset its maddening impersonality. But the real danger, Shorter argues, is that the galloping success of technically minded medicine has undermined the physician’s ability to treat anything not curable through pharmaceutics, regimen or surgery. Uncle Harry’s psychic contentment simply isn’t on the agenda anymore.

One should stress that this is not a book for professional historians. (Critical teeth cut on, say, Michel Foucault’s Birth of the Clinic will be as appropriate to Bedside Manners as incisors are to chocolate mousse.) Instead, soundly documented and chattily written, it is offered to those whom it will do the most good: doctors and their patients. And although Shorter is not a practising physician, his wife is, and he himself spent four years as a part-time medical student while researching the book. Uncle Harry would do well to hear his argument out.

• Montreal Gazette June 14, 1986