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A blast from the past: Learning to talk with patients over half a century

In July 1968 Newcastle University let me loose, very young, still a schoolboy really, with a head full of medical lore and a very limited concept of what being a doctor meant, despite my father being a battle-hardened GP in South Shields. Consulting in the modern sense had not been on the curriculum. A couple of half-remembered Oslerism’s such as ‘The good physician treats the disease; the great physician treats the patient who has the disease’ and ‘Listen to the patient – she is telling you the diagnosis’ had managed to impinge on my consciousness, but were only floating in the ‘not quite important’ part of my cortex. What after 5 years had been hammered into my midbrain was ‘taking a history’. The nature of the game was diagnosis, demonstrated by often theatrical professors with a flare and mystery reminiscent of the best magicians. As in a conjuring trick, the patient supplied a few choice words (the Prof made the choice) and Hey presto! A magical name was pronounced. The diagnosis and all that subsequently followed were cloaked in a mystical paternalistic obfuscation. Prescriptions were still written in Latin, and patients were not encouraged to explore the nature or the consequences of their illness too deeply. There was a long tradition behind this behaviour, dating back to Hippocrates. His famous, but rather weird, oath makes no reference at all to a doctor’s duty to converse with patients. In fact, in Decorum Hippocrates admonishes doctors to ‘perform their duties calmly and adroitly, concealing most things from the patient . . . revealing nothing of the patient’s future or present condition’. Plato, in several of his writings, stated categorically that doctors had a right to tell lies for good and noble purposes. This Greek ethic was rooted in the best of motives – it was believed that without respect for medical authority there could be no cure. The idea of the patient participating in decision-making was seen as counter-productive. The main tenets of Greco–Roman medicine were that patients must honour doctors, for the latter received their authority from the gods, and therefore patients must have faith in their doctors and promise obedience. In the 18th and 19th centuries, a few isolated luminaries suggested educating and involving patients. John Gregory, Professor of Medicine at Edinburgh, was a notable example. Benjamin Rush, a famous American contemporary of Gregory, held similar views, but, like Gregory, favoured deception whenever enlightenment was not equal to the task. They were both essentially pragmatists, seeking the most effective doctor–patient relationship for therapeutic ends. However, by the middle of the 19th century some patients were beginning to get a little restless. John Stuart Mill, the famous libertarian, put it quite succinctly in 1859: ‘Over himself, his own body and mind, the individual is sovereign’. However, even by 1968 this view had not made too much of a dent in the cast iron medical school curriculum.