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Soundings: Medical heroes

2003; BMJ; Volume: 326; Issue: 7380 Linguagem: Inglês

0959-8138

Kevin Barraclough,

Health and Medical Research Impacts

I suppose that, in the age of evidence based medicine, it is somewhat passe to have heroes. Nowadays we believe things in medicine only when there is evidence to do so. Non-medical friends are a little incredulous when I explain the emergence of this startling idea 300 years after the Enlightenment. They presume that all we had before this was prejudice based medicine. And maybe they're right. I remember the culture shock of a London teaching hospital with its aloof oligarchy of consultants. From the slightly shabby world of scientists chatting over coffee I entered a miasma of Savile Row suits, anachronistic servility, and unforgiving clinical failures. A decade later I welcomed the idea that evidence should replace authority. But is “The Medical Authority” now extinct? I remember several types of this beast in the past. There was the bullying professor who would bellow at medical students about the critical importance of headache in people with acromegaly, or bark at the stupidity of the world at large in missing a case of Frohlich's syndrome. This would be the medical authority as bombast, and is not greatly mourned. It is nuclear physicist Edward Teller's definition of “expert”—someone who has made all possible errors in a very small field. They have lost touch with the world. But there was another altogether more sympathetic figure—the repository of a wide clinical wisdom not available in books. This is the experienced clinician as hero. Their authority derives from experience and clarity of both thought and exposition. I think anyone who has gasped for air in a darkened auditorium under the crushing weight of a mountain of PowerPoint bar charts will acknowledge that detail more often obscures truth than reveals it. The trouble with evidence based medicine is the sheer undigested bulk of it, and its relative crudity as an instrument for analysing something as complex as the practice of medicine. I still feel the need for medical heroes to guide me with simple conclusions, even though I know that that simplicity is the outcome of technical subtlety. But my heroes are active clinicians rather than experts on bar charts. For me, a single clinical aphorism is usually worth a thousand abstracts. It is summed up in a quotation I have always ascribed, somewhat implausibly, to Yogi Bear: in theory there is no difference between theory and practice; in practice there is.