Michel Foucault (1926–1984) was a professor of the history of ideas in Paris. And what a time to be in Paris! A time to upend convention. A time to overturn authority and to remodel knowledge. Foucault was particularly concerned with the exercise of power within social systems. He explored the ways in which social control is constructed and maintained. He saw history as a series of changing thought systems that determine social activity and that are constructed to serve the ends of those in power. He developed this theme through his definitive historical studies of human sexuality, of crime and punishment, and of medicine.
Foucault’s The Birth of the Clinic should be read by all reflective doctors. Foucault develops the concept of ‘the medical gaze’, describing how doctors modify the patient’s story, fitting it into a biomedical paradigm, filtering out non-biomedical material. A ‘gaze’ is an act of selecting what we consider to be the relevant elements of the total data stream available to our senses. Doctors tend to select out the biomedical bits of the patients’ problems and ignore the rest because it suits us best that way.
Foucault’s charge is that doctors are doctor-oriented, not patient-oriented, and thus medicine creates an abusive power structure. Medical school has taught us more about biomedicine than about patients. The medical tribe tends to dominate rather than share. We control, stick people into appointment slots, strand them in waiting rooms, QOF them, and talk above their heads.
While Foucault trashed medicine’s reputation with sociologists, Ian Kennedy then brought medicine’s faults into the UK public spotlight. Although Kennedy is best known for his Chairmanship of the Bristol Inquiry, published in 2001 and relating to tertiary care, he first voiced his deep scepticism of the UK system of medicine in his 1980 Reith Lecture Unmasking Medicine.
The opening of Kennedy’s synopsis of the Bristol Inquiry Report is pointed: ‘The story of the paediatric cardiac surgical service in Bristol is not an account of bad people. Nor is it an account of people who did not care, nor of people who wilfully harmed patients. It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. Many failed to communicate with each other, and to work together effectively for the interests of their patients’.
Kennedy’s synopsis continues with prophetic words ‘... For the future, it must be part of all healthcare professionals’ contracts with a trust (and part of a GP’s terms of service) that they undergo appraisal, continuing professional development and revalidation to ensure that all healthcare professionals remain competent to do their job ... there must be agreed and published standards of clinical care for healthcare professionals to follow, so that patients and the public know what to expect’. So the philosopher bred a prophet and the pen is mightier than the syringe. In modern medicine Foucault rules UK?
CPD further study and reflective notes
The notes in Boxes 1 and 2 will help you to read and reflect further on any of the brief articles in this series. If this learning relates to your professional development then you should put it in your annual PDP and claim self-certified CPD points within the RCGP guidelines set out at http://bit.ly/UT5Z3V.
Box 1. Reflective notes
Motherhood, apple pie, patient centeredness — no one is going to oppose such wonderful icons. What do we actually mean by being patient centred?
Could the way we run our GP surgeries be described as patient centred?
If not then what are the obstacles in the system to becoming more patient centred?
What obstacles do we find in ourselves to becoming more patient centred?
Box 2. Further reading
Primary source
Foucault M. The birth of the clinic. London: Routledge, 1989: Ch 6. (First published as ‘Naisssance de la Clinique’. France: Presses Universitaires de France, 1963).
Further study
Misselbrook D. Thinking about patients. Newbury: Petroc Press, 2001 (now Oxford: Radcliffe Press). Chapters 2 and 3.
If your reading and reflection is occasional and opportunistic, claims in this one area should not exceed 10 CPD credits per year. However if you decide to use this material to develop your understanding of medical philosophy and ethics as a significant part of a PDP, say over 2 years, then a larger number of credits can be claimed so long as there is evidence of balance over a 5-year cycle. These credits should demonstrate the impact of your reflection on your practice (for example, by way of case studies or other evidence), and must be validated by your appraiser.
- © British Journal of General Practice 2013