The Third Rail

Don’t touch it. Okay? Why would you? High-voltage electric current runs through it. As the live rail on the track, the third rail is dangerous. It can kill you. Fortunately, in an open society, death is not the usual outcome of expressing a point of view.

Canadian Family Physician has been preparing to launch the Third Rail (page 449),¹ but COVID-19 has made it even more relevant. This new section will be a space for thought-provoking dialogue on topics that might normally be considered too taboo or controversial to discuss.

The science of medicine changes constantly. New drugs are created; old ones are forgotten. Medical practices once mainstream are now absurd or even cruel. Frontal lobotomies for mental illnesses. Bloodletting for the common cold. Mercury to treat syphilis. It is fascinating and disturbing that these were once standards of care. What will we look back on, a century from now, only to realize how wrong we were?

The concept of half-life is not limited to radioactive decay. In medical school, our instructors emphasized that half of what we learned would be obsolete just a few years after graduation. This is backed by research, as described in The Half-Life of Facts.² Some researchers study “scientometrics,” the study of how quickly research becomes outdated. (Wait, then who studies them?) The pace of changing information is especially rapid in the current pandemic. Never mind year to year. Try day to day.

But medicine is about more than clinical therapies. Advances in bioethics, law, technology, and other fields inform the policies that ultimately drive our work. Astrophysicist (turned pop scientist) Dr Neil deGrasse Tyson was recently a guest on a late-night talk show. He said what he fears most is that which he does not realize he should be fearful of. Let’s think about that.

We know there has been an evolution in health policies affecting women, for example. Contraception was available in Canada in 1960, but use was permitted only for treating hormonal regulation. It could not legally be prescribed as birth control until 1969.³ The battle for reproductive rights is ongoing, and even regressing in some areas.

Historically, racist policies have influenced medical training formally and overtly. Flexner is best known for his 1910 report, Medical Education in the United States and Canada.⁴ Flexner argued for fewer and better doctors. He is often lauded for transforming medicine from an art into a science. Did you also know Flexner argued black physicians should focus on the speciality of hygiene medicine, rather than surgery? “The negro ... has his rights and due and value as an individual; but he has, besides, the tremendous importance that belongs to a potential source of infection and contagion.”⁴ He adds that black individuals are not only at risk of infection themselves, but that they can also communicate disease to their “white neighbours.” Today, 110 years later, we are faced with the uncomfortable reality that systemic racism in medicine persists.⁵ The lack of representation of racial minorities in medical schools is unacceptable.

Shane Neilson is the author of our inaugural Third Rail article.¹ He challenges us to think about how we view disability in the context of the pandemic. He reflects on a recent article, “Fair allocation of scarce medical resources in the time of COVID-19,”⁶ and highlights problems with this piece.

It appears there is an appetite for these conversations. Last year, Aruna Dhara’s essays about emotional labour⁷ and gender expectations⁸ were among the most read articles of the year. Dr Dhara’s essays helped open up conversations about the nature of family medicine and who is doing what kinds of work. In her essay “Smile! Women as family doctors,” she describes some of the differences in expectations between genders: “As a woman, I am expected to be approachable and friendly. I’m expected to smile, regardless of the context, what else might be on my mind, or, frankly, whether I feel like it.”⁸

As we enter new paradigms of clinical care, with virtual visits and avoiding physical contact, we must work without many of our usual tools. We might be practising differently, but our work is more important than ever. So is communication. Discussing difficult issues is not always easy, but it is essential for continued moral and social development. Medical journals are an ideal space to spark this type of dialogue. Our patients deserve this. And so do we.

We want to hear from you, especially as we navigate these strange times. Don’t leave our third rail untouched! To comment or contribute, please send your work and ideas to info{at}sarahfrasermd.com.

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