Sir Miles Irving, August 2008

White Coat Lecture The not so quiet art: Medicine in the 21st Century

Provost Macpherson,Vice Chancellor ,Dr Roa, Distinguished Guests, Students, Ladies and Gentlemen.

It is indeed an honour to be asked to deliver this keynote address at your white coat ceremony here in this magnificent Arts Centre in Gateshead on the banks of the River Tyne next to the ancient city of Newcastle.

Enoch Powell, a famous British politician of former years, once advised me “always lecture with a full bladder, then you will not go on too long”. I want to add my own variant of this advice “lecturing five weeks after a knee replacement produces exactly the same benefits without the risk of any embarrassing accidents”.

Newcastle has a long history of the teaching and practise of medicine as– evidenced by the ancient company of barber surgeons that existed in the seventeenth century and their beautiful surgeon’s hall, now sadly long demolished. In my own specialty of surgery the names of the Newcastle surgeons Rutherford Morison and Grey Turner stand out in the fields of abdominal and oesophageal surgery whilst Rowbotham was one of the world’s pioneers in the scientific approach to the management of head injuries. In paediatric medicine the famous, and still ongoing ,“Thousand Families Survey” was initiated in this city by Sir James Spence and in the field of maternity care Newcastle was the first to establish flying squads for women who developed complications whilst giving birth in their own homes.

This fine tradition of scientific medicine continues to this day with Newcastle playing a leading role in many areas particularly genetics and stem cell research and the problems of ageing.

May I say at this stage how impressed I am at what St Georges University School of Medicine is doing to help tackle the massive shortage of doctors in this world of ours. I have long been aware of your existence and the work you are undertaking not least because one of the key individuals in your foundation, Paddy Ross was a colleague and friend of mine when we were training in surgery at St Bartholomew’s Hospital in London many years ago.

It is now some fifty years since I qualified in medicine from the University of Liverpool and over that time I have seen miracles in the practice of medicine that almost defy belief. Not a week goes by without some new advance in medicine being reported and indeed, though now retired from clinical medical practice I still experience new facets of my profession through its Research and Development activities, and not least today when for the first time I am taking part in a white coat ceremony, which is not a tradition in British medical training. But more of that later.

So what of my title today? It is taken from Virgil’s book the Aeniad which contains the following phrase;

Scire postetates herbarum usumque medendi Maluit et mutas agitare inglorious artes.

Translated into English this reads;

it was his part to learn the powers of medicines and the practice of healing ,and careless of fame, to exercise that quiet art.

From the time of Virgil to this present day I believe the core of our profession remains this combination of the powers of medicine with the practice of healing implemented within a framework which incorporates the features of the Quiet Art , and which distinguishes the whole from a mere technical exercise.

I first heard of this term when I was given a book compiled by a great Liverpool Physician called Robert Cooke who brought together an anthology of sayings about doctors. This book was given to me by the author in my first year after qualification following my looking after him for several weeks. Here it is, and it has remained a constant support to me throughout the fifty years since I qualified. How so ?

I want you now to picture a famous painting, currently in the Tate Gallery, called “The Doctor”. . It is by the famous painter Sir Luke Fildes, also from Liverpool, who has portrayed a bearded doctor of the 19th century sitting by the bedside of a dying child throughout the night whilst her parents look on anxiously. The doctor almost certainly did not know what was wrong with the child and even if he did he equally certainly was not able to do anything about it, but he was there bringing comfort at the time of greatest need of the child and her parents.

It was undoubtedly stimulated by the fact that Fildes had himself suffered the death of a son and indeed it is said that the picture is a tribute to the doctor that looked after his son.

I always thought that this painting portrayed the final moments of the child as shown by the obvious distress of the parents but in reading further about it I understand that the glimmer of light from the approaching dawn is meant to show that in fact the child was getting past the crisis and was to recover.

What did the public of that time think of such doctors who had little to offer but kindness and compassion. Robert Louis Stevenson the famous author of the book Treasure Island wrote the following:

There are men and classes of men that stand above the common herd: the soldier ,the sailor, and the shepherd not infrequently ,the artist rarely, rarelier still the clergyman; the physician almost as a rule. He is the flower(such as it is) of our civilisation; and when that stage is done with, and only to be marvelled at in history, he will be thought to have shared as little as any in the defects of the period, and most notably exhibited the virtues of the race. Generosity he has ,such is possible to those who practise an art, never to those who drive a trade; discretion tested by a hundred secrets; tact tried in a thousand embarrassments ;and what are more important, Heraclean cheerfulness and courage . So that he brings air and cheer into the sickroom, and often enough ,though not as often as he wishes, brings healing.

Heady stuff, but only one example of many similar pieces written around this time. Nowadays he would of course have included women doctors in his description. It is interesting to note that of all the attributes that Stevenson values in the physician the one he mentions last of all is healing. That’s not to say he does not value healing; the parents in Fildes’ painting want healing of their child more than anything else, but Fildes, who you recall had himself suffered a death of a child was depicting all those other attributes mentioned by Stevenson. I consider that these are the Quiet aspects of the Quiet Art. I hope that what follows will persuade you that these Quiet aspects of medical practise are as important today, in this era of high technology medicine, as they have ever been.

Even as Stevenson and Fildes were writing and painting ,the effects of the scientific enlightenment were beginning to bear fruit and allowing our profession to emerge from what Sir Frederick Treves the famous London surgeon described as the medical dark ages.

Treves was an exemplar of that combination of medical science and the Quiet Art for not only did he have the skill and knowledge to save the life of the king by draining an appendix abscess on the eve of his coronation, but also in a truly humanitarian act rescued the Elephant man from poverty and captivity in circus shows and looked after by giving him accommodation in the Royal London Hospital.

So is it different today when we have the most powerful array of effective treatments that has ever existed and which backed by sound evidence expands at an almost exponential rate?

Our 21st Century patients have high expectations of what we have to offer and expect the highest standards of care.

However there is a paradox at the present time in that whilst we deliver increasingly effective medical care , in the Western World there is an unprecedented interest in, and use of complementary therapies ,for which there is no scientific evidence.

Does this represent a reaction to the fact that in delivering our successful high technology treatments the medical profession of today may be tending to ignore the Quiet aspects of our practice with the result that, as suggested by the title of my talk today, Medicine in the 21st Century is not as Quiet an Art as it should be.

If this is the case then we, as a profession, will be missing out on just those aspects of our work that make our occupation so enjoyable and memorable.

Every experienced doctor will tell you when he or she looks back on their professional lives that the rare moments of triumph of diagnosis and treatment are always recalled with pride and relish as great occasions, whilst those terrible cases that go badly wrong are remembered with sadness and often guilt. However, the vast majority of routine cases that go well are rarely remembered.

However , the really memorable moments one recalls are often those when one is using the attributes common to all good doctors when practising the Quiet side of our art. For example when one is alone with a patient at a time of difficulty, bringing reassurance through the holding of a hand and patiently listening or alternatively joining in the moments of fun, laughter, and at times hilarity.

Careers in medicine are gilded by such memories of patients and events. I once recall sitting with an elderly nun who was accepting with amazing calm and equanimity the fact that she had an inoperable malignant disease and that her life was coming to its end.. As our conversation drew to a close I commented that I knew that nuns took their religious name from that of a saint yet I had not heard of a saint Thecla which was her professed name .Sister Thecla looked at me, smiled sweetly and said “no, not yet, but soon”.

Even awful times can have their lighter moments and episodes of bravery . Some thirty five years ago when terrorists were regularly bombing London the criminal high court of London ,known as the Old Bailey was attacked and some 160 people were injured. I was the duty surgeon at St Bartholomew’s Hospital ,Britain’s oldest hospital now approaching its 900th anniversary , which was situated very near to the Court. Amongst the injured was Judge Caesar Crespi, a rather large man who was heavily overweight and who was caught in the blast just as he was being evacuated from the building. He was brought to the hospital still in his gown and legal dress ,bloodstained and awry. As I triaged him at the hospital entrance he greeted me with a booming voice saying, doctor, I tried to save the Old Bailey by putting myself between the bomb and it.

A few weeks later the hospital was full of the victims of the Tower of London bomb explosion and I recall the singular horror of a young visitor from New Zealand with his leg blown off by a terrorist bomb pleading with me not to cut off his new shirt which” daddy has just bought me”. Years later this memory was lightened when on a visit to New Zealand I discovered the boy had turned into an adult who was a skilful football player.

That the quiet art is relevant across the whole spectrum of medical practise including research is shown by Sir David Weatherall, Regius Professor of Medicine at the university of Oxford and a Fellow of the Royal Society, the highest accolade in the scientific world this country can offer, and a medical scientist of the world rank. His book about science and research in medicine is titled Science and The Quiet Art and has on its front page the picture by Fildes to remind us that medical progress through research and its high technology outcomes needs to be combined with what he calls the importance of the pastoral role of doctors in patient care to counter the dehumanising effects of purely technological approaches to ill health.

So what has all this to do with your white coat ceremony today?

Well. let me start by saying that I realise that this is a significant and memorable day for you and your family and friends and one you should relish, enjoy and remember.

My introductory comments have been designed to show you that what you are committing yourselves to in today’s ceremony is not just about the practice of clinical science and advanced technology but also about the wider humanitarian side which is encompassed in the words Quiet Art and is almost certainly what Dr Gold was aspiring towards when he introduced the White Coat Ceremony.

So, let us for a moment briefly look at the origins of the White Coat Ceremony.

I must say that I was intrigued when I first heard about it for in all my years in travelling to the USA I had not come across it until very recently.

You however will all know that it is a contemporary medical ritual devised by Dr Gold of the Robert Wood Johnson Foundation. It was introduced some 15 years ago in 1993 at the university of Columbia under the title humanism in medicine.

Then it consisted of symbolically putting on a white coat and receiving a book on doctoring and a pin for the coat saying Humanism in Medicine. Putting on the coat was regarded as a statement that the doctors to be are accepting the ideals of the Hippocratic Oath and those of a great profession. From its origin in the United States it has spread quite widely and involved other medicine related specialties.

I have no doubt that some public statement of what is expected of doctors, and the opportunity for them to acquiesce to the values extolled is necessary, be it at graduation or as today at the start of you careers.

One has to ask whether such a symbolic act in which you take part today would have prevented the darker side that has at times afflicted our great profession . History reveals that the medical profession during its existence has embraced some pretty disgraceful practitioners. For instance records show that the biggest professional group in the Nazi party of Germany was made up of doctors. Many terrorist leaders have been doctors, and in Russia psychiatrists were involved in the imprisonment of political dissenters. In recent times in my own country Dr Shipman, a general practitioner deliberately killed a huge number of elderly patients. Within the last few weeks Radovan Karadzic from Serbia has been arrested and is to be tried before the international court in the Hague for Genocide. He too is one of our profession who at the time of his arrest was practising medicine.

The University of Maryland justify their White Coat Ceremony by saying that it recognises the point of entry into the profession of medicine and is a vow to maintain professional attitudes and behaviours in work and relationships with classmates, teachers patients and the community at large.

I know that I am not alone in wondering whether this rationale presents too conventional a picture of medicine and its practitioners.

For instance the order in which the University of Maryland has stated the goals is not one that I would consider appropriate for the 21st century. Personally , I would have put them in the reverse order on the grounds that our first responsibility is to the community and patients we serve.

Additionally I believe that the profound changes that have occurred at an exponential rate in the practice of medicine within the last few decades require a radical alteration in the way we think about and manage the delivery of medical care.
Such challenges are not addressed by this conventional view of our profession nor ,I believe, are they represented by the conventional view of the white coated doctor a portrayal which reinforces the more technical side of the profession.

This leads me to explore the symbolism of the white coat, particularly here in the United Kingdom where as far as I am aware the White Coat Ceremony is unique to the University of Northumbria in its relationship with St Georges University.

The fact is, that in this country doctors have a uniquely British problem with white coats. Although many patients, particularly older ones, prefer to see doctors in white coats, doctors themselves are not keen on them .Indeed many abhor them, and they have long been banished from children’s hospitals and psychiatric institutions. A major blow to their use occurred last year when the Government’s Department of Health recommended that they should be forbidden on hospital ward rounds on the grounds of infection control.

To be frank, and to use modern parlance, in Britain White Coats are not regarded as ”cool”.

On the other hand the symbolism of the White Coat is not entirely without significant meaning in this country. Another book which has brought stimulation and pleasure into my life as a doctor mentions the white coat in its title. White Coat Purple Coat is written by a Welsh respiratory physician called Dannie Abse.
This physician poet talks about the white coat as the mark of the doctor and the purple coat as that of the poet

Song for Pythagoras

White Coat and Purple coat
A sleeve from both he sews
The white is always stained with blood,
That purple by the rose,

And phantom rose and blood most real
Compose a hybrid style
White coat and purple coat
Few men can reconcile

White coat and purple coat
Each can be worn in turn
But in the white a man will freeze
And in the purple burn

However, although I am sceptical about the symbolism of the white coats in today’s ceremony I believe that the ceremony has another outcome which will be of equal if not more importance to you in the professional life that lies ahead of you.

I know from reading commentaries on the White Coat ceremony on the web by some of your colleagues who have been through the ritual that they too have had doubts about its message and significance. Such doubts are important for they introduce you ,at the very start of your professional lives, to that essential requirement of a good doctor namely a high degree of scepticism and the associated ability to think laterally about your profession, its values and its teaching. This is in marked contrast to cynicism which is destructive because it almost invariably descends into inactivity rather than the creativeness which can be generated by scepticism.

Why is scepticism so important at this early stage in your careers.? The answer is because at this stage of your training you are very susceptible to didacticism not least because of the many good personal attributes that have led to you wanting to enter medicine as your lifetime profession.

One of your medical student colleagues writing in a medical journal some 15 years ago summed up these attributes when he wrote this about being a medical student.

I am that most fragile of hobbledehoys, the doctor soon to be; infinitely malleable, ludicrously credulous, brazenly idealistic and just plain scared.

In such a state the acquisition of the art of being sceptical ,as opposed to cynical ,is one to be cultivated for the history of medicine repeatedly shows that ,in some areas, what one day is taught as infallibly correct, within a short time is shown to be of no value or even dangerous. One of the greatest realisations by our profession in recent years is that virtually everything we do is a balance between benefit and harm and it is in assessing this fact for each of our patients wherein lies the skill of modern medicine. Indeed to reinforce my scepticism I about white coats I have to remind you that they themselves can be pathogenic for there are a group of patients who exhibit the condition of white coat hypertension, a rise in blood pressure occasioned by the sight of a doctor in a white coat.

The Quiet aspects of our profession, including scepticism, are an integral component of good medical practice in the 21st century and can generate therapeutic benefits in their own right.

There is general agreement that doctors in addition to being clinically competent should be well rounded individuals with a range of outside interests. Sometimes these interests can overlap with ones professional practise and be of value to patients. There is sound evidence that music and art have valuable roles in treating certain medical conditions.

You may be surprised to know that a search of the literature shows that poetry too can have a significant place in medical practice. The medical journal the Lancet has recently had more than one article dealing with the role of Poetry on the Ward Round which, amongst other things, can certainly be used to address the most difficult and sensitive situations. Take this poem for instance which touches on the issues of racism, anti Semitism and that most difficult of all problems namely when a doctor develops a profound dislike for a patient and even momentarily may wish not to treat him or even to do him harm

Dannie Abse, CASE HISTORY

Most Welshmen are worthless ,
An inferior breed doctor,

He did not know I was Welsh.

Then he praised the architects of
The German Death Camps-
Did not know I was a Jew.
He called liberals “white blacks”,
And continued to invent curses.

When I palpated his liver
I felt the soft liver of Goering: when I lifted my stethoscope
I heard the heartbeats of Himmler;
When I read his encephalograph
I thought,”Sieg heil ,mein Furher”

In the clinic’s dispensary
Red berry of black bryony,
Cowbane, deadly nightshade,
deathcap.
Yet I prescribed for him as if he were my brother.

So the message for you, tomorrows generation of doctors who will be practising in the 21st century, is to be competent in embracing the powers of medicine and delivering healing but to be so within the framework of the quiet aspects of our profession.
I you can reach the standards laid down by Robert Louis Stevenson for a perfect doctor remember that they were reached by doctors who like Sir Luke Fildes portrayal showed devotion and a quiet heroism but who, incidentally, never wore white coats.

This, underlying timeless approach, whilst coping with all the excitement of the new technologies which will inevitably unfold, will ensure continuing public support (currently running at a level of around 95% trust for British doctors)for our profession in the 21st century.

Before I step down from this podium I want to give you something to raise your morale.
I am well aware that talks such as I have given today are very much ”old dog to young dog” activities and as such may soon be forgotten. The ideas and values that I have advocated are much more likely to be sustained if they arise, are developed, and are taken forward by people of your own generation.

I therefore have found it highly encouraging that what I have advocated today for your consideration is already being promulgated by your own generation.

When I had finished compiling this talk I turned to a literature search and to my amazement and alarm came across an article (from which I have already quoted earlier in this talk) written in 1993 and published in the Journal of the Royal Society of Medicine, by Jason Warren, a medical student from the university of Adelaide , under the title courage and the quiet art: night thoughts of a doctor to be.

It was a profound and challenging article, virtually identical in content and approach to, but far more eloquent than ,my talk today and also centred around Fildes painting , My reaction was that had the author heard what I have just said he would have had a claim against me for plagiarism.

This all goes to show that you like him , at the start of your careers ,possess in your minds all the potential to be just as radical and innovative as any else in our profession as long as you let your thoughts flower within an atmosphere of humility and skepticism

I wish all of you commencing your clinical careers a long and happy time in our wonderful profession and hope that this ceremony today will permanently foster within you the quiet aspects of our Quiet Art.