‘The Doctor’ by Fildes. Part 2: Poverty and propaganda

Ring, my friend, I said you’d call
Doctor Robert
Day or night he’ll be there any time at all
Doctor Robert

 

Doctor Robert, The Beatles


Learning objectives

1. Continue our exploration of ‘The Doctor’.

2. Reflect on how images and their use shape societal expectations.

3. Think about how the medical profession will manage to navigate the now traditional role of a doctor in a modern world.


Previously we examined the painting The Doctor’, a composite of several Victorian era physicians intended by Fildes ‘to put on record the status of the doctor of our time’. We explored the doctor in the image who was extremely ‘low-tech’ even by the standards of the time. The painting itself used a specially created studio and models. Perhaps today, the painting would be considered ‘fake’ or the equivalent of a photoshop that’s so bad that it’s good.

However, to simply pigeonhole the picture as fantasy would be unjust. It was inspired by a personal loss and the image wasn’t designed to showcase the advances of medical science. It does however impress upon us many of the qualities of a good doctor from the perspective of a layman. In many respects, it epitomises the doctor-patient relationship. At the time, doctors themselves were keen to highlight this new positive image:

A library of books written in your honour would not do what this picture has done and will do for the medical profession in making the hearts of our fellow men warm to us with confidence and affection.

W. Mitchell Banks FRCS, British Medical Journal (1892)

Even if the medical profession wanted to, it is unlikely that it could have created such a powerful piece of propaganda. Verghese proposes that the iconic image was exploited by the medical profession to misinform the public. The poverty stricken family would not have been able to afford such a well dressed GP to have visited them at home.


Questions

Why did Fildes use a family that were visibly poor rather than a wealthy one (his own) in his painting?


The painting is a classic example of social realism. Fildes may have been trying to draw attention to the conditions of the working class and social disparities in access to healthcare. Some of his other paintings had this theme of social realism. Indeed the poorly child in The Widower looks remarkably similar to the poorly child in The Doctor.

the_widower

The Widower
Image from https://commons.wikimedia.org/wiki/File:Sir_Luke_Fildes_-_The_widower_-_Google_Art_Project.jpg

Milligan points out that there were a number of contemporary paintings from various artists with a similar theme to The Doctor but were nowhere near as popular. Many of these other paintings had no obvious doctor portrayed in them or highlighted that rural communities did not (or would not) allow doctors to visit.

Fildes see[s] the nursing of children through illness as the exclusive province of parents in poor rural families, who either cannot afford professional medical care or choose, for some other reason not clearly indicated in the pictures, to eschew it.

Disease was a great social egalitarian. Rich or poor, historically the medical community were impotent to the point they often accelerated pathological processes instead of reversing them. With scientific method, enlightenment and rationality the Victorian doctor was at last empowered. The Doctor helps convey this change. Yet, this process came simultaneously with the industrial revolution. The health effects of pollution and population movements disproportionately targeted the poor. Despite the considerable advances in medical science at the time, the doctor was still not able to fight the effects of poverty on health.

Going back to The Doctor, Douglas writes of the painting:

The doctor broods, and in truth there was very little more he could do; he was almost as helpless as the parent only six feet and three or four social classes away.


Questions

How does poverty influence the health of your patient population today?

Should more effort be made to encourage those from working class background to become doctors?


Fast forward to 1949 where the advent of the National Health Service (NHS) in the UK provided universal access to GP services including home visits (or house calls) regardless of ability to pay. With this, an element of Fildes aspirational painting came to fruition.

At the same time the American Medical Association (AMA) used the image in a successful campaign to minimise political interference in the profession and promote voluntary medical insurance. They used the slogan “keep politics out of this picture”. Helpfully for the AMA, Fildes’ wholesome image had already entered the minds of Americans a few years earlier when it appeared on a postage stamp.

Voluntary Health Insurance – The American Way will KEEP POLITICS OUT OF THIS PICTURE

stampDoctors AMA Centennial 3-cent 1947 issue U.S. stamp, commemorating the 100th anniversary of the founding of the American Medical Association (AMA)
Image from https://commons.wikimedia.org/wiki/File:Doctors_AMA_Centennial_3c_1947_issue_U.S._stamp.jpg

Today the concept of a home visit is commonplace to UK GPs yet has become to be seen as antiquated for many in America. In 1930, about 40% of American doctor-patient interactions were home visits, but by 1980, the rate had reduced to 1%. In 2010, 19% of American family physicians said they made at least one home visit a week and by 2013, the number had fallen to 13% with only 3% reporting making more than two home visits a week. Even in the UK, the notion of home visits is increasingly being questioned. Reimbursement and time management are inevitably significant factors. Compare this with what Milligan describes as the ‘The Doctor’s ideal of selfless, unpaid service’.

As the proportion of the population considered old increases, chronic diseases and immobility become more common. Bearing this in mind, there would instinctively be a greater need for home visits as patients become more immobile. There is evidence that early interventions in the patient home can prevent costly hospital admissions and improve patient outcomes.

Yet, a trend away from home visits appears to be the trajectory for many healthcare systems. Primary care resources are increasingly stretched by the changing demographics of the population it serves.

But if you don’t want to blame limited resources, you could also highlight the lack of access to equipment, poor lighting and incomplete medical notes increasing the risk of medical errors when seeing a patient outside the normal office environment. Medical errors lead to litigation and therefore it’s dangerous for doctors to see patients at home (although not going on a home visit is a dangerous choice too…)


Questions

What is the system of daytime GP home visits in your working area?

How about evening and night GP home visits?


Getting back to Fildes’ painting, we can increasingly see the dichotomy it presents to us. It is perennially used as a paradigm of the doctor-patient relationship, yet the practicality of delivering this ideal in today’s world is increasingly challenging and risky. Doctors today may forget this is not a message by the medical profession to other doctors, but instead a message to the medical profession by a grieving parent. It highlights the humanity that can be achieved in the doctor-patient relationship if the circumstances and the healthcare system permit.

So what can this image convey to the doctors of today? I feel it can highlight to medical students and doctors that, as Brody points out, ‘character and virtue are as important as knowledge and skills.’ However, it should also be highlighted that it is indeed a manufactured image, one that may be used for propaganda purposes to benefit or harm doctors as well as their patients.

The Lancet reproduced the image in 1998 to celebrate 50 years of the NHS, extolling the virtues of nationalised medical health care. However, using Fildes image to bash doctors over the head and say this is what you doctors should be like! is counterproductive as it largely unachievable and may cause feelings of failure and alienation of doctors from the patients and each other. Using the painting in media campaigns can foster unrealistic expectations from patients. Yet the emanating character of the doctor in the painting could instead be used to encourage all of us to ask instead what are the obstacles preventing us from achieving Fildes’ ideal?


Questions

How do healthcare system failings affect your doctor-patient relationships?

How does politics interfere with achieving Fildes’ ideal?


Barrett concludes that ‘the high water mark of public perception represented by The Doctor has long passed.’ But perception this indeed was, as it did not represent the reality of medical care at the time. Moore summarises the predicament we find ourselves in well:

Fildes’ picture is far from being an accurate representation of historical reality. A fine example of Victorian spin produced to enhance the image of the Medical profession and that of the establishment as a whole, by suggesting they had the power to confront the difficulties encountered by society. The real irony of Fildes’ contrived and fictionalised image is that this deception persists to this day.

What do you think? Please consider commenting below.


Summary

The power of images such as The Doctor should not be underestimated. As medical technology advances and access to specialist knowledge increases, wisdom becomes increasingly important. With time, the image presented to us by Fildes will seem increasingly anachronistic while the nostalgia from doctors and patients alike will highlight the incongruous situation in which they find themselves.


Further resources

The family physician: what sort of person?
https://www.ncbi.nlm.nih.gov/pubmed/9773291

Luke Fildes’s The Doctor, Narrative painting, and the selfless professional ideal.
https://www.cambridge.org/core/journals/victorian-literature-and-culture/article/luke-fildess-the-doctor-narrative-painting-and-the-selfless-professional-ideal/1E22DA494165711967D825D475D21223/core-reader

The Gordon Wilson Lecture “The Doctor in Our Own Time”: Fildes’ Famous Painting and Perceptions of Physician Attentiveness.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2394702/

The Doctor in early Cold War America.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960915-0/fulltext?rss=yes

The Doctor.
https://www.bmj.com/content/340/bmj.b5660

The real irony of The Doctor.
https://www.bmj.com/content/340/bmj.c482

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