#irishmed, Telemedicine and “Technodoctors”

This evening (all going well) I will participate in the Twitter #irishmed discussion, which is on telemedicine.

On one level, telemedicine does not apply all that much to me in the clinical area of psychiatry. It seems most appropriate for more data-driven specialties, or ones which have a much greater role for interpreting (and conveying the results of!) lab tests. Having said that, in the full sense of the term telemedicine does not just refer to video consultations but to any remote medical interaction. I spend a lot of time on the phone.

I do have a nagging worry about the loss of the richness of the clinical encounter in telemedicine. I am looking forward to having some interesting discussions on this this evening. I do worry that this is an area in which the technology can drive the process to a degree that may crowd out the clinical need.

The following quotes are ones I don’t necessarily agree with at all, but are worth pondering. The late GP/anthropologist Cecil Helman wrote quite scathingly of the “technodoctor.” In his posthumously published “An Amazing Murmur of the Heart”, he wrote:

 

Young Dr A, keen and intelligent, is an example of a new breed of doctor – the ones I call ‘techno-doctors’. He is an avid computer fan, as well as a physician. He likes nothing better than to sit in front of his computer screen, hour after hour, peering at it through his horn-rimmed spectacles, tap-tapping away at his keyboard. It’s a magic machine, for it contains within itself its own small, finite, rectangular world, a brightly coloured abstract landscape of signs and symbols. It seems to be a world that is much easier for Dr A to understand , and much easier for him to control, than the real world –  one largely without ambiguity and emotion.

Later in the same chapter he writes:

 

Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

Now, as I have previously written:

One suspects that Dr A is something of a straw man, and by putting listening to the patient in opposition to other aspects of practice, I fear that Dr Helman may have been stretching things to make a rhetorical point (surely one can make use of technology in practice, even be something of a “techno-doctor”, and nevertheless put the patient’s story at the heart of practice?) Furthermore, in its own way a recourse to anthropology or literature to “explain” a patient’s story can be as distancing, as intellectualizing, as invoking physiology, biochemistry or the genome. At times the anthropological explanations seem pat, all too convenient – even reductionist.

… and re-reading this passage from Helman today, involved as I am with the CCIO , Dr A seems even more of a straw man (“horned rimmed spectacles” indeed!) – I haven’t seen much evidence that the CCIO, which is fair to say includes a fair few “technodoctors” as well as technonurses, technophysios and technoAHPs in general, is devoted to reducing the human to pure information. Indeed, the aim is to put the person at the centre of care.

 

And yet… Helman’s critique is an important one. The essential point he makes is valid and reminds us of a besetting temptation when it comes to introducing technology into care. It is very easy for the technology to drive the process, rather than clinical need. Building robust ways of preventing this is one of the challenges of the eHealth agenda. And at the core, keeping the richness of human experience at the centre of the interaction is key. Telemedicine is a tool which has some fairly strong advantages, especially in bringing specialty expertise to remoter areas. However there would be a considerable loss if it became the dominant mode of clinical interaction.  Again from my review of An Amazing Murmur of the Heart:

 

In increasingly overloaded medical curricula, where an ever-expanding amount of physiological knowledge vies for attention with fields such as health economics and statistics, the fact that medicine is ultimately an enterprise about a single relationship with one other person – the patient – can get lost. Helman discusses the wounded healer archetype, relating it to the shamanic tradition. He is eloquent on the accumulated impact of so many experiences, even at a professional remove, of disease and death: “as a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.

DUBLIN 1745-1922. Hospitals, spectacle and vice. By Gary A. Boyd. TLS, 30th June 2006

Thanks to Maren Meinhardt of the TLS, I have been getting the published text of pieces I have written for the TLS over the years. As it happens, a lot of these are from 2006, so a decade on, how do they stand up?

As a piece of prose, this is a rather sturdy, workmanlike review, with some clunky phrasing (“will find much of interest”)

The book deploys theory, as they say, in a way I was probably not all that familiar with at the time. It isn’t as effective as Susan Mat’s Homesickness: An American History in marrying a strong theoretical discussion with a readable, engaging narrative. Theory is often alienating, ironically since so much of it seems to be about power differentials and so forth.

Boyd’s work on Dublin reminds me of the previously-linked to posts by Philip Lawton at Ireland After Nama – as the review suggests the book goes well beyond 1922 until the present day – with the construction of a new Chidren’s Hospital and the ongoing closure of city centre hospitals this analysis is ripe for revisiting.

Medicine at the margins
Seamus Sweeney
Published: 30 June 2006
DUBLIN 1745-1922. Hospitals, spectacle and vice. By Gary A. Boyd. 224pp.

Dublin: Four Courts. Pounds 45 (paperback, Pounds 19.95). – 1 85182 960 1.

Georgian Dublin, to most Dubliners and tourists, evokes architectural splendour, an age of elegance and grace. It is often held up as a contrast to architectural and social developments in Dublin since, as an era of enlightenment and progress. Hospitals from the era such as the Rotunda, the first dedicated, purpose-built maternity hospital in the British Isles, and St Patrick’s, the “house for fools and mad”, founded with Jonathan Swift’s bequest, still retain their original function, or rather, still function as hospitals in today’s sense.

For this was an age in which the meaning of “hospital” underwent a change. Its derivation rooted in the Latin hospes, from which also come hospice, hostel and hotel; “hospital” in the medieval sense was not necessarily a place of cure or anything much by way of medical activity. It denoted a place that offered a wide range of possible services, from lodging and victuals to basic forms of care. They usually had an overtly religious mission. Dublin hospitals founded before the period covered by this book, such as the Foundling Hospital and the Royal Hospital Kilmainham, exemplified this older function.

It was also an age when “man midwives”, by stressing the dangers of parturition and the possibilities of a medical approach, were beginning to acquire respectability.
Nevertheless, obstetrics still stood in some disrepute. John Blunt’s evocatively titled treatise Man Midwifery Dissected; or the Obstetric Family Instructor, Containing A Display of the Management of Every Class of Labours by Men and Boy Midwives; also of their cunning, indecent and cruel Practices, proving that Man-Midwifery is a personal, a domestic and a national Evil typified this anxiety.

Homesickness: An American HistoryThis is the background to Gary A. Boyd’s architectural history -part of the Making of Dublin City series -which focuses on the Rotunda, or Lying-in Hospital, but is far from solely concerned with it. The book originated as an investigation of the relationship in the Dublin of today between the “official city” of civic buildings, monuments, museums, shops and galleries and an “unofficial city” of marginalized spaces; “alleyways, vacated buildings, empty lots” and the like. In the course of this, Boyd discovered that in any CCTV network, such as that which monitors the “cultural quarter” Temple Bar, whose culture now largely consists of stag and hen weekends and Sunday morning piles of vomitus, there are “shadow” zones which evade surveillance, due to various features of urban topography. Thus, “even in one of the most tightly controlled public areas of the city, therefore, certain uncontrollable and unpredictable activities existed”.

Boyd was moved to consider the lacunae in architectural histories of Dublin’s more famous and historic public spaces and buildings regarding the “uncontrollable and unpredictable” activities of those marginalized in traditional architectural historiography. This volume is an attempt to reclaim that human element. Boyd begins on June 4, 1751, with the Lord Mayor of Dublin and other dignitaries processing in state to the New Pleasure Gardens in what is now Parnell Street.

There Bartholomew Mosse, founder of the Lying-In Hospital, a man equal parts impresario and medic, supervised the laying of the foundation stone for what would become the Rotunda. Mosse threw an elaborate breakfast and “genteel and liberal entertainments” for the Lord Mayor and assembled gentry. This spectacle masked Mosse’s, and the hospital’s, precarious financial situation, and the New Pleasure Gardens would play an important role in hospital fundraising.

This incident typifies the close relation between spectacle and buildings with a public, ostensibly altruistic function. The new hospital did not simply serve a function as a maternity hospital, but acted as Palladian backdrop to the promenades in the New Pleasure Gardens. These Gardens were not just the site of elegant strolling, but of illicit assignations, what a later age would call “cruising”.

Thus begins a wide-ranging exploration of the tensions within Dublin, and within medicine, between medical function and issues of desire and social control. The dates given in the subtitle are somewhat misleading. The emphasis is very much on the early stages of the chronology. The book ends with a survey of the development of the red light area, Monto -which takes us to the 1940s rather than 1922, with Monto’s demise hastened by the work of Frank Duff’s Legion Of Mary.

Over the course of the book Boyd covers an impressively wide range of ground, from the work of the Wide Streets Commission, the Leeson Street Magdalen Asylum, the Lying-In Hospital’s admission certificate (reproduced in the book, with its rules including “That no Woman great with Child is to be received into the Hospital, if she hath any Contagious Distemper, or the Venereal Disorder”), the memoirs of the demi-mondaine Peg Plunkett aka Mrs Leeson, developments in hospital planning and management, the relationship between the military presence in Dublin and prostitution and many other topics.

Boyd’s analysis is influenced by Foucault’s conception of medicine as a locus of social control of deviancy, and by Murray Fraser’s work on the administration of late eighteenth-century Dublin. Fraser suggests that, rather than a simple expression of the power and pride of an Anglo-Irish elite, many developments in Dublin at the time resulted from the work of three powerful but conflicting bodies: the “Ascendancy” parliamentarians, the mercantile class, and the British administration in Dublin Castle. Fraser suggests that the work of the Wide Streets Commission, for instance, reflected a realignment of Irish interests with those of Britain.

Dublin 1745-1922 is lively and accessible -largely because Boyd quotes contemporary voices at length. His own prose style has enough wit and evident suspicion of the pieties of other ages and our own to keep the reader’s interest.

It is refreshing to read of issues that are often treated as purely medical or sociological from an architectural history perspective, albeit an architectural historiography strongly informed by social and political considerations. Some readers may find the influence of Foucault overbearing, and the occasional lapses into theoretical jargon somewhat off-putting (things are constantly “subverting” other things). Nevertheless, any Dubliner, anyone with an interest in the city’s history and development, or with an interest in the history of medical and obstetric practice, will find much of interest and find their impression of Georgian elegance modified.

Review of “Take Me To The Source: In Search of Water” and “The Blue Death” – TLS, 2008

Apologies for the hiatus. This is my submitted copy rather than the review as it appeared in the TLS. I re read most of Rupert Wright’s book a few years ago. This was the first time I came across the concept of water charges, which seemed to strike everyone else in Ireland as something completely out of this world in late 2013. I greatly preferred Wright to Morris and found his debunking of the “the world’s next war will be over” idea (I nearly typed meme!) convincing.

Take me to the source: In search of water. Rupert Wright

The Blue Death: Disease, Disaster and the Water We Drink. Dr Robert D Morris

Thales of Miletus, the earliest identifiable philosopher and scientist (in a fairly loose sense of both terms) held that “everything is water.” That this is the first philosophical and first scientific statement is no accident; water is central to human existence. In the West, however, the words of Jake Gittes in “Chinatown” are apt – “I turned on the faucet, it came out hot and cold, I didn’t think there was a thing to it. “Rupert Wright, who has previously written books about life in the Languedoc region, begins his discursive, digressive, suitably elusive book with the sudden cessation of water supply in his French home. When he bought the place, the fact that it came with its own water supply was another romantic touch. Only when it stopped did he realise that there was indeed “a thing to it.”

Wright has written an entertaining tour of the world of water, if such a tautology is possible in a world that is mainly water. From the gigantic excavation of a third water supply tunnel for New York, happening almost invisibly to passers-by in Midtown Manhattan, to asommelier instructing bored Parisians in the appreciation of spring and mineral water, to the hunger-striking Bishop of Barra in Brazil trying to stop the damming of the São Francisco River, humanity’s relationship with water is by turns inspiring, absurd, and tragic.

Water policy is steadfastly unsexy. All over the world, Wright notices, oil ministers are Harvard-educated, Rolex-wearing, Armani-clad; water ministers wear cheap suits and use their mobile phones to tell the time. Wright is no reflex contrarian, but his scepticism about some of the received wisdom about water and water policy is bracing. One truism of bien pensant opinion he  seems wearied by is the wars of the coming century will be a fought over water, a notion he imagines Flaubert consigning to a contemporary Dictionnaire des Idées Reçues. Only one war, he writes, has ever definitively been fought over water – “more have been fought over salt.” Water has been a tool of war rather than a cause of war, and the need for water drives co-operation as much as competition (Europe’s oldest law court the Tribunal de las Aguas de la Vega de Valencia, consists of eight magistrates who have convened every Thursday at midday since the Tenth Century to ensure the fair distribution of Turia River water.)

Wright is much more interested in how writers and artists have described and depicted water. Poetry flows throughout. He is particularly enraptured by the single flowing sentence that is Bloom’s reflection on water in Ulysses. That dry systemiser Stephen Dedalus disliked bathing and suspects ‘aquacities of thought and language’; hydrophilic Bloom boils the kettle and embarks on an epic sentence of reverie and connection about water. Three other texts especially inspire Wright – John Cheever’s “The Swimmer”, Roger Deakin’s “Waterlog” and Charles Sprawson’s “Haunts of the Black Masseur: The Swimmer as Hero” and he has something of the ruminative charm of Deakin and the digressive erudition of Sprawson.

No mention of Ulysses in Dr Robert D. Morris’ “The Blue Death” (Morris, incidentally, uses his professional title on the book’s cover.) While Rupert Wright does not gloss over the lethality of water-borne infections and the mass misery and death that can be caused by consuming water, Morris, a public health physician and water researcher, focuses exclusively on water-borne threats. Water, as a substance itself, is not centre stage – indeed is hardly mentioned. An aside that “safe water is not an end, but a process, an ongoing struggle in which improvement is always possible and often necessary. Purity, it turns out, is fleeting” is the closest we come to the philosophical reflections of Wright.

He begins with the tale of John Snow and the Broad Street pump. Snow is to epidemiologists what Indiana Jones is to archaeologists, and Morris lays of the suspense a little thick: “Snow felt he was finally closing in on the proof that might muffle his critics. The ground itself would need to shake to divert his attention from the task at hand. He would soon discover that an epidemiological earthquake like no other had its epicenter on the north side of the Thames.” We move on to the battles over cholera of Robert Koch and Louis Pasteur (“like seasoned gunfighters, they would meet in the streets of Alexandria with test tubes blazing until only one man was standing.”)

The tone shifts suddenly halfway through. Morris is no longer describing the heroic age of epidemiology and public health, but is centre stage. A meta-analysis he performs linking  long-term consumption of chlorinated water with cancer earns him the suspicion of the water treatment industry and, it seems from his own account, the Environmental Protection Agency. Again we are reminded that water is “unsexy” – public attention, for Big Water, means bad news. Outbreaks of cryptosporidium in Milwaukee in 1993 and E. coli 0157:H7 in Canada in 2000 illustrate the weaknesses of water processing systems that have changed little in a hundred years. Morris is no neutral in these matters, and closes the book with an eight point plan for ensuring safe water (step 7, by the way, involves the universal use of point-of-use filtration for drinking water.)

Wright writes ruminatively, philosophically, sub specie aeternis,, while Morris is the researcher in the arena of current controversy and impatient with the slow pace of change. Wright is amusedly tolerant of bottled water and its attendant absurdities; Morris is angered by a fad whereby more water is used to produce the bottle than goes inside. Both aim to reveal the truth about the ubiquitous and invisible substance that we are learning not to take quite so much for granted – water is everywhere, water is eternal, water is indestructible, and water is scarce, fleeting, and fragile.