Adapted from the In Practice blog on Boston.com.
SPOILER ALERT! If you have not yet seen the fourth episode of the third season of “Downton Abbey’’ and wish to be surprised by it, read no further. This is about medicine, then vs. now. First, to recap the relevant aspects of the story: Lady Sybil, 24, daughter of Lord and Lady Grantham, is about to deliver her first baby, a little prematurely. It’s assumed that she’ll have the baby at home, but there’s some controversy about who should attend her. Her mother favors the family doctor, Richard Clarkson. while her father wants Sir Phillip Tapsell, obstetrician to the aristocracy.
Both doctors are summoned, and they argue about Sybil’s condition. Clarkson thinks that Sybil’s confusion and swollen legs are signs of eclampsia, also called toxemia, a potentially lethal condition in which a woman has seizures during pregnancy or soon after delivery. He feels her only hope of survival is to have a cesarean section at the hospital — a high risk procedure in the pre-antibiotic era. Sir Phillip thinks that Sybil is fine. She delivers a healthy baby girl, but the next day she begins having seizures and dies.
I got to thinking about how medicine has and hasn’t changed since 1920, as portrayed in this well-researched show.
What seems unfamiliar, at least in the developed world, is Lady Sybil’s fate. In the early 20th century it was not uncommon for women to die in childbirth (from infections, hemorrhage, and eclampsia). Today, pregnancy and delivery are much safer. In the developing world, however, the World Health Organization estimates that approximately 800 pregnant or peripartum women still die every day.
What seemed very familiar in this episode was the conflict between the family doctor and the specialist. While, as a primary care doctor (a modern-day Clarkson, so to speak) I enjoy a collegial relationship with the many specialists to whom I refer patients, there is, at times, a certain tension between our perspectives. Often, it can be summed up like this: I know more about the patient, while the specialist knows more about the disease. Usually we pool our knowledge, but once in a while we clash.
The doctors did play a role that I think is undervalued today: That of companion, and witness to death and suffering. With health professionals and patients alike re-evaluating whether it’s wise to spend 25 percent of Medicare resources during the last months of life, we doctors may find ourselves more often in a palliative rather than “do everything at any cost” mode.
We’ll never again stand by and watch a woman die of eclampsia — thank goodness — and we won’t wear dinner jackets or silk dressing gowns (alas), but we may be more like our professional ancestors than we acknowledge.