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Volume 1, Number 2

RICHARD ASHER AND THE SEVEN SINS OF MEDICINE

BRUCE M.T. ROWAT, MD, FRCP

This paper was written to introduce the student and recent graduate to Richard Asher - a colleague well worth knowing. His essays are refreshing and thought provoking - they will reward both student and seasoned practitioner.

Richard Asher, who was born in 1912, qualified in medicine in 1934. He spent the most important part of his career at the Central Middlesex Hospital in London. Although Asher's specific clinical interests were endocrinology and clinical hematology, they ranged more widely than these subspecialties. In his capacity as Chief of the Mental Observation Ward at the Central Middlesex Hospital, he described several new syndromes including myxedema madness, and Munchausen's syndrome.

Describing the modern hematologist in 1959, Asher refers to him in a somewhat Chestersonian statement as an individual who "instead of describing in English what he can see, prefers to describe in Greek what he can't." (5)

His terse, crisp language and his humour are seen not only in clinical writing but in special articles dealing with general medical and philosophical issues. Papers such as "Why are medical journals so dull?" (4), "Straight and crooked thinking in medicine" (2), "Talk, tact and treatment" (3), "Clinical sense: the use of the five senses" (7), "The dangers of going to bed" (1), "Six honest serving men for medical writers" (9) are examples of this exceptional talent. A decade after Asher's death, Beaven wrote that the man's "immense vitality, energy and dramatic flair made him a legend in his own lifetime" (12).

Richard Asher married an accomplished professional musician and they had two children; Jane, friend in the 1960's to Paul McCartney of The Beatles, and Peter, formerly of the singing duo Peter and Gordon, ("Lady Godiva", "World Without Love"), who is now a record producer (e.g., albums by Linda Rondstadt).

Asher suffered a great disappointment when his Mental Observation Service was re-assigned to the new specialty of Psychiatry. This, and his failing health contributed to a serious depression in his later years, and in 1969 this gifted man and devoted physician took his own life. There is a cruel irony and, perhaps, something prophetic of Asher's 1959 paper on suicide: in the closing paragraph, he wrote -"Misjudgments by the patient or doctor may have fatal results especially as many doctors tend to underestimate the degree of the patient's depression". (6)

Many of Asher's papers have a timeless quality - and, like some of our medical classics, deserve rereading from time to time. His lecture "The Seven Sins of Medicine" is as instructive as it is entertaining. First published in The Lancet, on 27 August 1949 and re-published in a collection of his essays (10), his comments are directed to seven sins although he asserts that there are "an unlimited number." His lecture, he said, was given in the hope that "those students who wish to avoid them (the sins) may do so, and those who wish to indulge in them may enlarge their repertoire or refine their technique." The seven sins of medicine are identified as obscurity, cruelty, bad manners, over-specialization, love of the rare, common stupidity and sloth. The lecture, as topical today as it was some 35 years ago, serves as a gentle and humorous reminder of the pitfalls of medical practice.

In citing obscurity Asher encourages clarity in communication, whether in writing or speaking. Some obscurity is deliberate and may represent an attempt to hide one's ignorance in a specific area. "If you don't know, don't admit it. Instead, try to confuse your listeners." In 'medspeak', one such smokescreen, the physician abandons plain English in an attempt to appear learned, 'upbeat' or succinct and, in the process, to hide (15,16). In these circumstances, one's "communication" consists of long words, jargon, abbreviations, equivocations, and other vagaries. The end result, for both speaker and listener, is uncertainty and confusion.

However, not all obscurity in medical communication is deliberate. Crichton, Inglefinger and others have drawn attention to the defects in medical education, which produce practitioners (and teachers of medicine) who seem unable to present their ideas clearly. This state, which they term "obfustication," seems to continue unchecked (14). Having examined and found wanting a number of possible remedies to this problem -Franz Inglefinger's solution was to "encourage the student and graduate in medicine to take up serious non-professional reading" (21). Finally, these observers note with regret that the introduction to clinical studies of more sophisticated design and statistical methods has not increased the clarity of our expression.

Dr. Asher's second 'sin' is cruelty, both mental and physical. Of the seven sins he believed this was the most important and the most prevalent, and noted how often we make our patients unduly anxious by saying either too much or too little, by 'words said or words not said.' Recent articles in The New England Journal of Medicine's Sounding Board: "Healing by the fundamental" (13) and an editorial in the Canadian Medical Association Journal (23) have reminded us that, even in the midst of powerful technological resources, our words and hands have the power either to heal or to wound and that poor communication may leave the patient in an agony of uncertainty and fear.

In discussing mental cruelty, Asher reminds us that, in bedside teaching and discussion, we may seem to forget the patients and behave as if they were not there or were unconscious. Recently I spoke to a Japanese physician visiting our hospital and asked him what struck him most about the North American medical teaching environment. Without hesitation he replied that we seemed so casual when we discussed differential diagnoses, prognoses, etc. at the bedside, treating the patient not as an important and respected person but as a bystander. This is particularly noticeable in the environment of the emergency department where the very familiarity of our daily routine may lead us unwittingly to treat the patient and his problems with "contempt." As Richard Bates (11) pointed out, "every day in your hospital and mine, patients are required to give their whole medical history with a stranger in the next bed and sometimes with that stranger's visitors listening-in. If his room-mate happens to miss out on the history-taking, he can get the whole thing repeated on teaching rounds the next morning." Another form of physical cruelty which Asher names if only to condemn it is over investigation. In a patient dying of widespread metastatic carcinoma, is it still necessary to "hunt the primary"?

Public and professional concern about such behaviour seems to be increasing. Two years ago less than one per cent of American hospitals had ethics committees but in 1984, 5 to 10% had organized such bodies. As it always has been, medicine today is 'more than medicine' - and these committees find it necessary to point out that sometimes "less treatment is better treatment". The revolution in devices and techniques has made diagnosis much easier and more accurate and has extended our powers to help patients. However, we must learn to use these tools intelligently and with discretion and learn to temper our enthusiasm and refuse ever to investigate for "completeness sake" or merely to satisfy intellectual curiosity.

In his useful paper, "Second thoughts", Robert Moser (24) notes that scientists and clinicians can be trapped in the "golden grasp of the intellectual imperative" and in such a state wear blinders; they press forward to the final diagnosis - an achievement that may do more to buttress the physician's ego than to improve the management of the patient. This obsession which is reflected in the cynical expression "if you have a hammer, everything looks like a nail" offers an insidious but powerful temptation in medical investigation. It is as if we said to ourselves: "If we can do it, then we should do it." We need to discipline ourselves to temper technical zeal in favour of therapeutic purpose - choosing to focus our full attention on the patient rather than seeking a technological "fix" for the physician.

Bad Manners - discourtesy towards patients, nurses, or medical colleagues is Asher's third sin. At one time or another, all have been guilty of this whether in our impatience in taking a history from a less than articulate patient, or at times indulging in "gallows humor" behind a patient's back. Shem's book, House of God, (26) gives a vivid picture of this and of medicine's many other sins and a good portion of Hillman's recent paper (19), "Doctor and Patient", deals at length with this concern.

As the fourth sin of commission, Asher cites overspecialization. His remarks on this point are worth repeating. "It is right that a doctor should have a special interest and knowledge about one subject. It is wrong for him to show special indifference and ignorance about all other subjects. Perhaps the worst feature of specialization is that it makes doctors feel they are doing wrong to deal with even the simplest case if it lies within the protected area of somebody else's specialty". This shortcoming probably is more noticeable in teaching centres where "more and more about less and less" is both encouraged and rewarded. The advice of consultants is easily available and, on the teaching wards, the inexperienced or the over conscientious may tend to consult excessively, driven by the thought that someone may know more about a specific subject than he does and by the fear of "missing something." Paradoxically, instead of generating a greater appreciation of the subtleties of individual illness, this approach leads to an erosion of physician confidence in their own abilities. Simply because there is more to be learned about a specific case may not justify the involvement of another consultant. "Over consultation" adds to the cost of health care and leaves less money for other areas of medicine. As well, this trend had steadily undermined the position of the generalist in teaching centres. Without the presence of generalists as role models in tertiary health sciences centres, many of the brightest students who start off in general programs subsequently seek further training in those specialties where the "more interesting patients" are to be found. Yet, despite this trend the past three decades have seen the emergence of two new "general" specialties - those of emergency medicine and critical care. This trend seen elsewhere in society (18,25) represents a response to society's need for the individual who has a "horizontal" overview of the patient's needs rather than the traditional sub-specialist's "vertical," organ-specific perspective. In a country as vast as Canada, with its relatively small population, it makes particularly good sense to train individuals to care for a wide range of medical problems, rather than limit physicians to a narrow spectrum of disease.

Next on Asher's list is love of the rare, spanophilia. The medical student is tempted to this indulgence by the researcher-teacher, who often has little to say about the wide spectrum of illness, but a great deal to say about his specific, and at times, limited area of interest. As long as medical schools emphasize in-depth, post-fellowship training in highly specialized areas as a requirement for faculty appointments, medical students will be exposed to teachers who have a significant bias towards their own areas of research, and therefore have a significant clinical handicap.

Another sin, common stupidity may present itself as medical automatism, either investigative or therapeutic. Automatism is the failure to recognize the necessity of tailoring, to the specific patient, one's approach, investigation and treatment and to go on without question following a flow chart. (Current term -algorithm!) This automatic behaviour results in inappropriate and poor medical care, and again generates unnecessary costs. An example of this nonsense is ordering a B12 and folate before starting a blood transfusion in an otherwise healthy young man with a significant upper GI 'bleed'.

Sloth completes Asher's list of medical sins. He reminds us of the necessity of complete and accurate history and physical examination before proceeding with ancillary investigations. However, the advance of technology with its many successes has encouraged many to neglect this foundation. This temptation and the indiscriminate use of laboratory and radiography fosters poor work habits and careless decision-making; it encourages intellectual sloth and wastes scarce resources. As Cuff puts it "overtesting's kickback is that you get patients in and out of your office faster" (17). Medical educators must encourage deliberateness of thought and intellectual rigour in decision-making if the student is to make his way successfully through the ever-proliferating medical literature. Recently, in an article entitled "Osler as visiting professor: house pupils plus six skills," J. Willis Hurst stresses the importance of intellectual discipline in modern clinical medicine (20). Dr. Hurst imagines Osler, speaking to house staff in 1984, and asking if they are able to read their journals intelligently, and pointing out that this activity calls for considerable sophistication. Canada's most distinguished physician asked: "Can you read your journals intelligently? Are the conclusions correct? Can you apply the conclusions reached in any given article to your own patient population, etc?" This analytical approach, which improves decision-making and sharpens clinical skills, is not an activity of the intellectually lazy.

The gifts of Richard Asher are impressive. From his clear, humorous and philosophical comments emerges a man who was "a giant in those days" (22) when medicine was advanced by careful clinical observation and painstaking correlation between findings during life and after death - rather than by a complex technology.

This paper was written to introduce the student and recent graduate to Richard Asher - a colleague well worth knowing. His other essays are equally rewarding (1-11). Refreshingly provoking, they will reward both student and seasoned practitioner.

Bruce M.T. Rowat MD, FRCP
Department of Medicine
University of Toronto, Toronto, Ontario, Canada


REFERENCES
  • Asher R. The Dangers of going to bed. Brit Med J 1947;ii:967-968.
  • Asher R. Straight and crooked thinking in medicine. Brit Med J 1954; ii:460-462.
  • Asher R. Talk, tact and treatment. The Lancet, 1955; 268: 758-760.
  • Asher R. Why are medical journals so dull? Brit Med J 1958;ii: 502-503.
  • Asher R. Making sense. The Lancet 1959;ii:359-365.
  • Asher R, Leonard-Jones J.E. Why do they do it? The Lancet, 1959;i: 1138-40.
  • Asher R. Clinical sense: the use of the five senses. Brit Med J 1960;i: 985-993.
  • Asher R. Apriority: thoughts on treatment. The Lancet 1961;ii:1403-1404.
  • Asher R. Six honest serving men for medical writers. JAMA 1969;208:83-87.
  • Asher R. Richard Asher talking sense. Pitman Medical 1982.
  • Bates R.C. The fine art of understanding patients. Medical Economics Book Division Inc., 1972.
  • Beaven D.W. Precordial catch. New Zeal Med J 1979;89:95.
  • Benjamin W.W. Sounding board: healing by the fundamentals. N Eng J Med 1984; 311:595-597.
  • Crichton M. Medical obfuscation: structure and function. New Engl Med 1975; 293:1257-1259 and 1979; 294:562-564.
  • Christy NP. English is our second language. N Eng! J Med 1979; 300: 979-981and 1979; 301:506-508.
  • Christy NP. Silence always sounds well. Am J Med 1979; 67:550-552.
  • Cuff JH. Questioning the tests. The Globe and Mail. Dec. 1, 1984.
  • DeBono E. Future positive. Middlesex: Penguin Books, 1980.
  • Hillman H. Doctor and patient. Resuscitation 1984; 11:127-130.
  • Hurst JW. Osler as visiting professor: house pupils plus six skills. Ann Intern Med 1984; 101:546-547.
  • Inglefinger FJ. "Obfuscation" in medical writing. N Engl J Med 1976; 294:546-547.
  • Lock S. Giants in those days. Ann Clin Res 1972;4:308-309.
  • Morgan PP. "Wounded healers" can help give hospital patients more humane care. CMAJ 1984; 131:1335-1336.
  • Moser RH. Second thoughts: the intellectual imperative (and its prodigenous progeny). J Chron Dis 1983;36:413-417.
  • Naisbitt J. Megatrends. Warner Books, 1982.
  • Shem S. House of God. Corgi Books Ltd., 1982.

ACKNOWLEDGEMENTS

The author thanks Irene Charles for typing the manuscript, and Peter Honor, Manager, Medical Photography, Toronto General Hospital for his cartoons.

*Richard Asher, MD, MRCP, 1912-1969