SECOND OPINION:Lessons of the past can open up path to the future, writes DES O'NEILL
ALTHOUGH MEDICINE is often referred to as both art and science, the lay public rarely appreciates how seriously medicine pursues the “art” aspects. All major medical journals devote significant space to the medical humanities – ethics, history of medicine, and the insights that the arts give to the experience of illness. For example, the Lancet recently reviewed Seamus Heaney’s Human Chain, while the British Medical Journal viewed ageing through the lens of Pixar’s wonderful animated movie, Up.
That the history of medicine is particularly relevant was underlined forcefully by a stimulating Lancet paper on Semmelweis. An important advocate for changing medical practice in the 19th century, he was also an early victim of urban myth, which suggests that he was run out of Vienna because he challenged the status quo.
As Oscar Wilde would say, the truth is rarely pure and never simple: there are lessons for us all from Semmelweis in how best to manage change and the addressing of unpalatable situations in clinical practice in a way which is effective and carries our colleagues with us.
Semmelweis, a Hungarian practising as a senior trainee in obstetrics in the Vienna of the Austro-Hungarian Empire, was horrified by the high level of mothers who died of infection after childbirth. After noticing that the rate was lower in the wards run by midwives compared with those run by doctors, he was sparked to action by the death of a friend from infection after an accidental cut at a post-mortem.
Semmelweis thought that the doctors, who frequently attended autopsies, brought some “cadaverous particles” with them, and advocated what in hindsight was an overvigorous hand-washing policy – lasting a full five minutes with a caustic and irritant solution of chlorinated lime. Although within two years he had reduced the death rate, his ideas were met with at best tolerance, at worst derision, and his contract was not renewed.
He moved to Budapest and wrote increasingly angry and open letters to European obstetricians, accusing them of murder. Even his wife began to feel that he had lost insight and committed him to an asylum where he died, ironically, of an infection.
The benefit of better-informed historical perspective is that it liberates us from a simplistic notion of noble hero shunned by an insensitive and arrogant profession holding on to the status quo. The leading Austrian medical journal supported his medical ideas, and the experience of his mentor Škoda is revealing: Škoda’s innovations were radical and temporarily sidelined his career, but he was eventually recognised as full professor of medicine in Vienna.
In truth, a number of factors contributed to his career check: without minimising the conservatism of many in the medical profession, it was compounded by his lack of seniority, his ethnic minority status and his over-radical and irritant hand-cleansing regime. In addition to his somewhat spiky personality, there was no theoretical support for his ideas. Not only would it would take almost another 30 years for Louis Pasteur and Robert Koch to discover that bacteria caused infections, but public health – which would have recognised the dramatic fall in maternal deaths – was not yet given due weight and credibility in this era.
So what lessons are there for those who wish to introduce change into inappropriate care situations for which there seems to be undue tolerance?
The first is not to lose hope, and to understand that change is an iterative and often gradual process after the first exposition of danger. The second is to have humility that one’s own solutions may need tempering, and the benefit of the wisdom of others, to be effective. The third is an open faith in present and future science, both of which supported most, but not all, of Semmelweis’s contentions.
The last, and most challenging, is to work out how to carry one’s own colleagues in as far as this is possible. If this had happened with Semmelweis, many tens of thousands of lives would have been saved: only those without a sense of proportion could fail to understand the irony implicit in Shaw’s contention that all change depends on the unreasonable man. The tempering of wisdom and humanity that successfully combine reason and unreasonableness is a gift that we all need to strive for, whatever our sphere of practice.
Prof Des O’Neill is a consultant in geriatric and stroke medicine