I have been reading Archie Cochrane’s account of his life
and work (not in general print – but I got it from the Cardiff University
archives for £14.99 - http://www.cf.ac.uk/cochrane/index.html). It is not at all as I expected. Although there are elements of autobiography
in the classic, seminal monograph, `Effectiveness and Efficiency’, these are
anchored to the main, compelling argument for evidence-based medicine. So, famously, he recounts his experience as a
doctor in prison of war camps where, to his surprise, the lack of available
treatment did not equate to bad outcomes.
He concluded that not enough was known about what worked, leading to
`Archie’s law’ (as I have coined it) – “always assume that a treatment is
ineffective unless there is evidence to the contrary.” So much, so known (although the power of the
argument still has the capacity to stun even now).
What surprised me though in the memoir is the tone of it –
honest, to the point of painful, spiky and personal. There is the unvarnished account of
frustrations – taking six years longer than standard to qualify as a
doctor. This was not only the diversion
to join the international brigade in the Spanish civil war (what a generation),
but also an abandoned PhD and some years following his Jewish analyst in exile
across pre-war Europe. He is candid
about some of the personal problems which led him to seek this help and
thwarted, it appeared, his adult relations.
He attributes some of these difficulties to his early years with a
distant, Calvinist upper class family.
The frustrations were not only personal. This book also charts his work after the war
in running a pioneer epidemiology unit in Wales. In one of his chapters he talks about a
`decade of failures’ in his two valley research, which never quite achieved
what he imagined in understanding the aetiology of pneumoconosis. And he also expresses a feeling of shame in
his long stints as sole medical officer of a series of prisoner of war camps –
at having in some ways bypassed the `real war’ or the glittering medical career
of his contemporaries. Indeed, his
account of his wartime experiences focuses on sorting out food parcels and
digging latrines. Another kind of
heroism.
The tone throughout is humane, self-searching and
challenging – of himself as well as others.
He saw himself as outside the establishment. A brilliant story which gives you the measure
of the man is in his evaluation of the new coronary care units. A trial was set up comparing these with care
at home, although the cardiologists were loath to subject such self-evident
effective treatment to such scrutiny. As
Cochrane says (p211):
“The results at that stage showed
a slight numerical advantage for those who had been treated at home. It was of course completely insignificant
statistically. I rather wickedly
compiled two reports, one reversing the numbers of deaths on the two sides of
the trial. As we were going into
committee, in the anteroom, I showed some cardiologists the results. They were vociferous in their abuse:
`Archie’, they said, `we always thought you were unethical. You must stop the
trial at once…’ I let them have their
say for some time and then apologised and gave them the true results, challenging
them to say, as vehemently, that coronary care units should be stopped
immediately. There was dead silence and
I felt rather sick because they were, after all, my medical colleagues.`
So, no clubbable man he.
Even a colleague he respects is described as `overweight… rude, bad
tempered’. This impatience with
colleagues, combined with deep empathy for patients (from the Russian
tubercular prisoner dying in his arms in one camp to the rather cranky distant cousin
who he tenderly cares for at home) shines through on every page. Although never married, he created a
wonderful home and garden which became a refuge for many – including the rather
cranky distant cousin and companion who were cared for by him to the end. There is something about the unconventional
but far from solipsistic life. And an
unwavering commitment to scientific method (to the comic extent of tracking
down all family members at a funeral for faecal samples in tracing a hereditary
disease) and frustration with the
rituals and norms of medical practice. And
this is perhaps part of his greatness – his ability to shape medical
science. And perhaps be a disruptive
innovator, in Christensen’s terms [http://www.claytonchristensen.com/key-concepts/]. His struggles, his chequered life story had
as much a part to play as his undoubted intellectual vigour and vision.
This chimes with another `great life of medicine’ which I
was thinking about – Cicely Saunders. I
haven’t read her letters or biography, but from the BMJ short profile [http://www.bmj.com//content/suppl/2005/07/18/331.7509.DC1],
I was struck by parallels with Archie Cochrane.
Born to a privileged but cold and distant family, plagued by chronic
back pain, finding affinity with the marginalised (including the thread of
significant Polish men) and quietly defying convention by living in shared
housing with friends even after marriage.
Hers was a protracted path to
qualified doctor – via social work (hospital almoner) and nursing. She struggled for acceptance at a time where
social and professional expectations were narrow. And yet it is because, not despite, of these
tensions that her pioneering vision of palliative care – and her understanding
of `total pain’ - was born.
I was thinking of this as the pressure seems even greater
now for our teenage children to make directed choices and compile mini-dossiers
of activity and unblemished achievement even before they reach college. What place for those who need time to
stumble, and struggle, and try many paths before finding work where they can
make a difference?
