In Praise of Medical Heretics & In Search of more

About this time last year I was in Evanston with John McKnight. One of the things we did while I was there was play poker with his poker group, a group that has been playing poker since before I was born. John joked before the game that these days they start every game with an ‘organ recital’: someone will report how their heart is following their operation, then someone else will share how their eyes are beginning to fail, but how they’ve discovered these great new lenses, and so on.

As the first hand was being dealt in the poker game, that’s exactly what happened. The organ recital played out before my very eyes, and I smiled to myself. But as the banter took hold and the game advanced, what became clear was that these wonderful men were not talking about their ill health any longer, if they ever had been, but in fact were being healthful. In between the chips, beer and banter, we were dealing out more than cards, we were in fact making each other better through conviviality and genuine care. That’s how we work as humans.

top_navThe day after the poker game, John and I had lunch with Marian Thompson, the founder of La Leche League International who I have previously written about here.

What is perhaps less well known these days is the story of the doctor who was Marian’s number one cheerleader and supporter, their medical authenticator if you like, and the person who described himself, among other things, as a medical heretic: Robert S. Mendelsohn. Dr. Mendelsohn -a highly qualified paediatrician- is the focus of this blog.

During the 60s and 70s, Dr. Mendelsohn began to consider himself a “medical heretic.” He later recalled the process in his book Dissent in Medicine:

a_Robert_S“In the late 1960s, my patients began to return to me with the diseases that I had previously created. The first group of patients were the ones with cancer of the thyroid gland, because, when I was trained at Michael Reese Hospital as a pediatric resident, I learned that the proper treatment for tonsillitis was X-ray therapy. Together with hundreds of other doctors, I prescribed X rays for the tonsils. This led to an epidemic of tens of thousands of cases of thyroid cancer. The second group of patients had permanently yellow-green stained teeth from tetracycline given for the treatment of acne. The third group were the DES sons and daughters. When I was a medical student at the University of Chicago, I participated in the DES experiments in which we gave women that female sex hormone diethylstilbestrol in a fruitless attempt to prevent miscarriages. It didn’t work, but it did leave us a generation of sons and daughters with tumors and malformations of the reproductive organs…

When I first recognized those events in the late 1960s, I thought that perhaps that was all past history in medicine. Doctors today must have learned from their mistakes…

But, when I look today at diagnostic ultrasound, immunizations, environmental pollution, amniocentesis, hospital deliveries, allergy treatment, and practically everything else in medicine, it is obvious that doctors haven’t changed at all. They are simply making a different, new set of mistakes.”

He practised medicine at a time when patients knew little about the side effects of medication or the risks associated with various treatments, and certainly had no access to their medical records. Those were matters for doctors and consultants and of no relevance to patients or the general public. At that time doctors knew best, and patients knew nothing. Throughout his writings (three books and hundred of syndicated articles) and television and radio appearances, he advocated on behalf of patients and citizens and spoke ardently against medical hegemony.

Speaking on popular daytime TV programmes like Oprah, he criticised popular drugs like Valium and Prozac and raised awareness of their harmful side effects. He highlighted the problem of the overuse of antibiotics, long before it was popular to do so.

He embodied one of the most important features of civic professionalism, in that he expressed public dissent against many of the practices of the medical system of which he was part, in defense of the freedoms and wellbeing of his patients and the public in general.

“Bob’s books should be read by every doctor who wants to know what they can do that’s respectful and not disabling of communities’ power to be healthful and family power to do healthful things.” John McKnight

As a paediatrician he saw first hand how the medical professions were inadvertently ‘medicalising’ people to such an extent that people were losing choice and control over their bodies, lives, health and wellbeing. And how in turn, people/patients were walking zombie-like into those psychological chains.

He concluded that people were increasingly turning to professionals to deal with issues best addressed in community life or through family support, and he was passionate about bending this trend back on itself. Consequently, in an effort to be an effective doctor, when people brought their children to see him he’d ask ‘‘what would your grandmother have done about that?’‘

John McKnight in sharing his memories of Bob with me, noted: “I began to see that his assault on medicine as a practising doctor was what a responsible professional would do. Bob was a professional trying to answer the same question we are, but at the opposite end: what am I really needed for?”

Dr. Mendelsohn understood that community assets were decisive in determining our health and wellbeing, inclusive of mental health, and that there was no medical, scientific, or curative proxy for those assets. Accordingly he asked himself a lot of probing questions about the appropriate roles and functions of medical professionals, and in particular how he and his colleagues could ensure they did not do harm to the health producing capacities of their patients and the communities they served. In practice, he did this by conducting a very simple, organic but effective neighbourhood impact assessment. The answer to the question ‘what would your grandmother do?’ becomes revealing of what might be displaced if he, as a doctor, prescribes an inferior pharmacological alternative. Since the grandmother’s function is irreplaceable, there is no adequate proxy in the medical world; in much the same the way as formula is an inferior substitute for breast milk. So while it can’t adequately wholly replace breast milk, it can supplement, and sometimes displace it.

Of course there is a place for formula and there is an even more important and perennial place for experts and their expertise, but as with everything, the right balance is essential. So here are some lessons we can draw from Dr. Mendelsohn’s wisdom with regard to the right balance and apply to current circumstances. We might call them precepts for professionals and systems who wish to cultivate appropriate relationships that do not disable the people they serve:

  1. Start with the assumption that the primary assets for enduring personal, social, economic and environmental well being of people are already within communities and that the work of external agencies is to help to reveal those assets and support local people to link them up in a way that makes best sense to them.
  1. Recognise that external professional resources will largely be wasted if the internal health capacities and assets of people and their local community are not discovered, respected and then developed in a citizen-led way. This is a necessary prelude to effective relationships with outside resources, if unhealthy dependency and waste of resources is to be avoided.
  1. Therefore health professionals, within their Hippocratic oath, must articulate a precaution, a commitment to ‘do no harm’ to civic agency. Outside resources (even where they are less ample than before) that overwhelm, control or replace efforts of local citizens and their associations across the life course, will harm and undermine the necessary civic efforts of people and their neighbours. So conduct a neighbourhood impact assessment.
  1. Ultimately all enduring progress in the domain of health and wellbeing is contingent on understanding limits. What are you not going to do to be helpful?
  2. Citizenship does not cease when one dons a white coat and stethoscope. We need more medical heretics. Dissent among medical professionals is critical to democratising healthcare. As Peter Block reminds us: ‘If you can’t say no, your yes is meaningless’.

So what does this mean for Social Prescribing?

Social prescribing is a good faith attempt to get to the root of personal, social, economic and environmental issues that seemingly present as clinical symptoms when viewed through the sickness idiom. It’s an approach with some merits, but we need to be cautious. We need to take heed of what Dr. Mendelsohn teaches especially when it comes to power relations, not to mention Dr. Atul Gawande who delivered last year’s Reith Lectures

In Gawande’s final lecture {The Art of Wellbeing} he mentioned the issue of over medicalisation of health and and said he believes health systems are becoming a threat to societal and individual wellbeing. Before social prescribing can be effective, doctors must engage in social proscribing, being clear about what they can’t and won’t do. Equally they and their patients must be willing to become reacquainted with the health producing capacities of citizens and communities, which is tantamount to saying doctors and patients have to stop being doctors and patients and start being citizens together.

This cannot happen solely from a doctor’s surgery, it requires that we go hunting for health producing capacities at street level; that we actively support local residents to identify, connect and mobilise their own assets, and that professionals redouble their efforts to do nothing to overwhelm, control or undermine them.

With asset based community development and willing medical heretics, wellness will no longer need to be scripted by a doctor; from womb to tomb, we and our neighbours will become the primary authorative authors of our own and each other’s wellbeing.

Anyone for an organ recital…. and a game of poker? Your deal…no script I promise…

Cormac Russell

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