My recollections of Keith Macleod date back to the late 1970s when I was studying medicine at the University of Otago. Keith’s views regarding the role of clinical medicine in people’s lives, his focus on patient experience and his methods of teaching all had a major impact on me. All that I learned from Keith in my early medical education has stayed with me and remained relevant over the years.
This was an era in which most doctors and patients tended to view the doctor as the ‘expert’: the person with all of the knowledge about illnesses and how to treat them. The patient’s job was to provide a good history of the condition, make themselves available for examination and investigation, and then, once diagnosed, to follow their doctor’s instructions regarding treatment. As I recall it, the importance of the patients’ expertise, the meaning of their condition in the context of their lives and the limits to medical knowledge and practice were not acknowledged within the medical school curriculum at that time.
This was also an era in which teaching was largely didactic, with teachers sharing their expertise and knowledge with their students, whose responsibility was to learn from their teachers and texts and subsequently apply what they learned in their own practice.
During the third year of my medical school training, senior clinicians delivered lessons that revolved around illustrating the clinical and pathological findings that were associated with a particular condition. They would not only talk about the condition, its clinical course and any radiological or laboratory findings, but they would also bring someone experiencing the condition (usually in a hospital bed) into a lecture theatre full of medical students, to illustrate the signs and symptoms of the illness.
Over thirty years on, I remember clearly only one of these lessons, and it was Keith’s. Inevitably it was not like any other I had experienced and (clearly) it left a deep and enduring impression.
Keith did not spend any time on preamble or lecturing the class or giving any introduction to the condition he planned to present. He began by introducing a woman who could neither see nor hear anything at all and who had been born with this condition. As he interacted with her, it was clear that the experience of touch was the single most important modality if you wished to communicate with her, and Keith expanded on the importance of touch in her world. When she left the room, my mind was already busy with this information, thinking about its implications for her, and for her doctors. Keith did not move on to give any further details of the medical perspectives on her condition, which was unusual in such a lecture. It left me feeling fully engaged with the ‘patient experience’, with my mind racing to grasp this.
To my surprise, Keith then did something that no other similar presenter had done. He brought in a second person, again without the usual preamble. Keith simply invited this man to talk about the impact of his illness on his life. What emerged was that his condition was one that resulted in insensitivity to pain. During the conversation with Keith, the man described his life and the degree to which he had to constantly compensate for this lack of sensation. If he was not continually alert and checking for any harm to his skin, this man could severely burn his hand on a hot stove or dish, develop horrific blisters as a result of poorly fitting shoes, or come to harm in a multitude of other ways. So here we had a man for whom the sense of touch (at least that associated with pain) is completely missing, though vision and hearing were intact. Once again we were invited into this experience from the perspective of the patient.
This juxtaposition of one person reliant almost solely on touch with another in whom some sense of touch is missing was to me an incredibly powerful and thought-provoking experience. Over the years to come, as I was privy to Keith’s ideas, I was to see this juxtaposition of “opposites” as a tool Keith used to free up and expand our thinking.
This experience also introduced me to a second of Keith’s teaching “tools” which I experienced as opening me up to learning, and that is the element of surprise. I was continually surprised by Keith’s approach, as it broke with tradition on many levels. In this instance I was surprised when Keith started the lesson with the patient without introduction or preamble, and again by moving straight on to a second patient, and one whose condition so contrasted with the first.
Cleverly, by introducing us to the people with the condition first, and by having us hear about it from their perspectives, he also anchored us in the patient experience and called on our ability to empathise and imagine. These are abilities that are in my opinion essential in the practice of clinical medicine, and this ability to enter the patient’s world was a third and critical element of Keith’s effectiveness as a teacher.
He challenged us to expand our thinking, he surprised us and thereby anchored our learning at an emotional level and he endeavoured to take us inside the patient’s world to deepen our empathy and understanding.
I have no recollection of the rest of the content of this session, though I do know that Keith went on to talk more about these conditions (information I could readily retrieve now, should I so choose, from the medical literature). The experience Keith provided that day was, for me, unique and powerful. I am certain that what I learned from Keith about the importance of understanding the experience through the eyes of the patient, of understanding their world beyond their illness, has profoundly shaped my subsequent work. I remain grateful to Keith for the way he crafted this opportunity to learn and to the two people who gave up their time to come and talk with us and share their experience.
Sue Hallwright has worked for many years to change health systems so that they enable people seeking help for mental health challenges to take the lead in their own recovery and to support each other. Conversations with Keith McLeod about his ideas over many years have had a profound influence on her thinking and her work.
This is part one of an adapted extract from: The Next Patient in the Waiting Room: Essays on Edwin Keith Macleod. Physician, Poet, Thinker. Versal Press, 2016.
Read part two of Sue Hallwright’s article here.
Read more about Keith Macleod here.