Crusoe and Hans grew up together. Crusoe’s father encouraged her to believe she could do anything she put her mind to. Han’s father, Peter, was a story-teller who delighted both children with his stories, especially during the long evenings at the onset of Winter. He told them about the Microbe Hunters who discovered the causes of diseases and laid the basis for new cures.
But their favourite was the story of the Snow Queen. So scarily did Peter tell this that both children were certain that some Winter, the Snow Queen would sweep down and take one of them away leaving the other behind with a Mission to save whichever of them now had a sliver of ice in their heart.
But fairy tales are just that after all. Both went to University, and became doctors.
Medicine had just passed through a glorious Summer that had led to the greatest harvesting of the benefits of new treatments ever recorded in human history. Life expectancies increased dramatically. Where once almost every family was blighted by the death of a child, now almost no family had a child who died. In some countries the treatments conferred such obvious benefits that governments made them available for free. A tyranny of fear had been lifted.
After qualifying their paths diverged. Crusoe immersed herself in the problems patients brought to her. For her every patient was different.
Evidence Based Medicine
Hans gravitated toward the most exciting new discipline – evidence based medicine. What could be better than ensuring doctors stuck to treatments that had been proven to work and stopped doing things for which there was no evidence. Patients’ stories might be interesting, but the evidence allowed you to pull back the veil of stories and glimpse reality. Patient improvement might be only a placebo response. They and their doctors might think they knew what was happening but be wrong.
Even when there seemed to be cast iron proof that a drug did something useful in a laboratory or at a bedside, Hans insisted on the need to test it out in hundreds of patients. He was adept at reeling off instances when laboratory breakthroughs have proven to be a mirage. Hard-hearted though it might seem to dying patients, he insisted on a proper demonstration that treatments worked.
The Snow Queen
Unlike some of his colleagues, Hans was not a fundamentalist. There was a passion behind his approach born of a recognition that Medicine was up against the wiliest of adversaries – the pharmaceutical industry – who thought nothing of the deaths of children in pursuit of profits unless those deaths compromised a profit line.
Industry was truly villainous, and in an effort to contain its capacity to injure people Hans was to the forefront of ensuring that the latest evidence was built into guidelines to which doctors would have to adhere. Frustrated at the slow rate of progress, he was of the view this could only be explained by the fact that some doctors even those who were involved in writing the guidelines were on the take. He became a crusader for Sunlight – bringing all and any payments to doctors from industry into the chilly light of day.
His career took off. He moved to Boston. He hadn’t seen or heard from Crusoe for years. There was an ocean between them. He became dimly aware that she had become critical of guidelines. She seemed to have drifted into a position close to homeopathy quoting obscurantist nineteenth century philosophy about there being an Art to medicine in knowing when to give a drug but an even greater Art in knowing when not to treat.
Medicine clearly had to be one thing or the other – an Art or a Science. The idea that modern medicine could be an art he thought belonged to an era that believed in fairy tales.
Not having heard from Hans for over a decade, when she found a trip took her through Boston, Crusoe decided to surprise him. She found from his secretary that he had a clinic on Tuesday afternoons and joined the queue in the waiting room planning to walk in as his last patient.
She was early but had her iPad. The string of patients ahead of her after their appointments came back to the room to pick up waiting relatives, friends and belongings. She registered the low muttering of these returns. She could only catch snatches of the stories but there was no missing the disappointment.
“He told me there is no evidence that there is a dependence on these drugs – that my difficulties must just be the illness coming back”.
“He said I should stop worrying about the drugs. If I stopped the treatment and the illness came back that would be much more likely to cause harm to any baby we might have. If he had his way, pills would come stamped with an image of a pregnant mother precisely to stop people like me from misinterpreting what we find on the internet”.
“He told me that my hunch that my pills were causing me to drink were typical alcoholic denial and unless I got to grips with my alcoholism there was nothing he could do for me”.
“He told me that my idea that the medication he put me on to stop me smoking had caused me to have epilepsy was bizarre. Epilepsy is genetic not drug induced”.
“He told me that my conviction that the drugs had caused Shane to commit suicide was becoming close to delusional. I think we should leave before he detains me in a psychiatric unit”.
Crusoe walked in less jauntily than she had planned. Had she not known it was Hans she might not have recognized him. Flinty was the word that came to mind.
For a moment he had no idea who she was. Once he recognized her, he greeted her teasingly:
“What’s this I hear about you having gone over to the Dark Side?”
“Come out for a drink and a meal and I’ll tell you all about it”, she said.
He had a series of committee meetings he said but he could skip one and give her an hour – it was so good to see her. She really should have told him she was coming.
To Win Some, You Have to Lose Some
Quizzing him over a drink on how his patients responded to him, he told her that he suspected that time would show he was wrong in some cases but even on cases that once worried him he’d stopped feeling a long time ago. If the patients had been injured by treatment they would suffer less if he denied a link to treatment.
If someone who had been injured came to doubt the system and think that their injury could have been avoided, or that the system was going to acknowledge the injustice, it might lead to despair and who knows even suicide.
If patients on treatment or still to enter treatment came to doubt the system it would be too appalling a vista to contemplate.
Better leave it to people like him to negotiate with regulators and drug companies dispassionately. He was now in a position to do just this – a position he would never have been appointed to had he been too outspoken. And the companies were slowly coming round – they are registering their trials and making more data than ever before available.
Through the Looking Glass
There was even talk of nominating Andrew Witty for a special award – Nobel Prize might be a step too far for some people to take but even that artificial barrier would have to fall sometime.
“You do know that you’re killing more people than you’re saving”, she said.
“Don’t be silly”, he responded.
“Well life expectancies are falling, and drug induced death might even the leading cause of death now. That’s not because of the chemicals – the chemicals have always been risky. It’s because the information that makes it possible to use a chemical as a medicine has never been so toxic.
“Sorry”, she said, “that I didn’t get to Peter’s funeral. He was so pleased when you brought him over here to Boston.
“He got the best possible treatment,” he said.
“Oh I’m sure, given the treating team knew who you are, that he was being treated perfectly according to every guideline for diabetes and hypertension. But you know if you wrote a guideline for treating a Peter the first thing you’d have to put in is to half the number of whatever medicines he is on. I hear he was on twenty-one when he died”.
“So what do we do – do we go back to the day when some doctor arbitrarily decides what to keep in and what to leave out?”, he asked.
“Well when it all comes down to dust, you believe in placebos. You call them RCTs but they are really placebos – mumbo-jumbo. You force people to believe in a system rather than to question it and make it better”.
said Crusoe’s partner afterwards.
“The Snow Queen is far more formidable and wilier than I ever suspected”,she said. “Maybe I should have dropped some anti-freeze in his glass of wine”.
Illustration: The Heart of Medicine, © 2013 created by Billiam James