THE DISEASE OF THE LEARNED
As a philosopher turned GP myself, David Hume has long been my favourite philosopher. He lived in 18th-century Scotland, with renowned Scottish physician William Cullen as his own doctor and friend. Hume attended university at age 12, early even in those days, pushing himself so far that he ended up developing the ‘Disease of the Learned’ — a malady that seems to have been a sort of depression or nervous breakdown. Philosophers can suffer from burnout too.
THE MOST ‘GP’ FIGURE OF THE ENLIGHTENMENT
In philosophical circles, Hume is considered to be ‘one of the most important philosophers to write in English’1 but his isn’t the name that springs to mind if the man on the street is asked to name a famous philosopher. In fact, there’s much to recommend Hume as the most ‘GP’ figure of the Enlightenment. In An Enquiry Concerning Human Understanding he sets out to apply the scientific method to the study of human nature. I can’t think of a more succinct way to describe the aims of modern general practice. A morning surgery can provide several patients with not much in the way of textbook pathology, but human nature is always on full display. If Hume himself was sitting in on my consultations, I imagine him suggesting that, because reason is ‘impotent’, I must ‘excite the moral passions’ of my patients. If smokers really wish to change their behaviour, Hume would think that it is not enough to print ‘SMOKING KILLS’ on the packet — you must also include a disgusting picture of a diseased lung. And he might have a point.
THE UNEXPLAINED
Hume teaches humility. A recent thoughtful editorial about medically unexplained symptoms2 drew a variety of responses. It is clear that, for some doctors, the idea that certain things might be ‘unexplained’ or even ‘unexplainable’ is anathema. Their message is clear: we must simply try harder.3
ARE WE TRULY RATIONAL?
But Hume spilt a lot of ink concerning the idea of cause and effect, and indeed expressed ‘sceptical doubts concerning the operations of the understanding’.4 He thought many of the beliefs we form seem to be the product of ‘some instinct or mechanical tendency’ rather than any truly rational process. We often have to remind ourselves that ‘correlation does not imply causation’ because human nature endows us with the folk psychology that if B follows A, then A probably caused B. Doctors have a habit of explaining symptoms using a biomedical model and this habit can lead us to look for physical disease in less-than-appropriate cases. This concept has again been recently discussed in the pages of this journal.5 How much testing must we do before we can stop? Reflection on the philosophical concepts underpinning our decisions can make a real difference to day-to-day practice.
EVIDENCE-BASED MEDICINE?
The whole enterprise of evidence-based medicine is founded on the assumption that the results of a randomised controlled trial are generalisable and applicable to the patient sitting in front of us. But often the participants in the trials were different from our patients in a variety of ways, not least with respect to comorbidities. This does not mean we should abandon our efforts to make practice more evidence based, but it does mean that when we consider the options we should take full account of messy reality.6 A healthy dose of Humean scepticism does not have to paralyse us in our decision making but it does counsel caution. ‘Will this tablet truly benefit this patient?’ is not a question that can be answered precisely. But Hume’s ideas save us from ‘philosophical’ fence-sitting about matters of practical importance — he confirms that our natural tendency is to make a judgement even in the absence of ironclad rational proof. And isn’t that what we pay our indemnity fees for?
CHANGE THE FOCUS OF TRAINING
To the extent that philosophy can be defined as ‘thinking about thinking’, it is a discipline that could not exist without reflection. To what extent current training fosters reflective GPs7 can be informed by philosophy. The deeper discontents with the structure of modern education generally — one does not fatten a pig by weighing it — suggest that we need to encourage the natural philosophical tendencies within all of us and change the focus of training from crude accountability to development.
The self-actualisation of true reflective practice is higher up Maslow’s hierarchy of needs than ‘passing my ARCP’.
- © British Journal of General Practice 2017