Some musings

HAPPY TO HELP: STRENGTHENING OUR RESILIENCE BY SAYING NO TO DEFENSIVE MEDICINE.

Shortly before my grandfather died we covered his back with lard.
After that he went down hill very fast.

So quipped Milton Jones. Doctors joke about death and have long had a reputation for subverting the pressures of their job with black humour, laughing together to cope with what work throws at them. But I wonder if, rather than laughing amongst ourselves, an even better defence would be to connect with our patients and enjoy sharing the humour with them. Recently I have had the pleasure of laughing with patients over a couple of malapropisms. Firstly there was the lady who was concerned that one of her nipples was more extroverted than the other. What did she mean? Did it keep embarrassing itself at parties? And then there was the patient who didn’t feel her thrush was improving with the vaginal patisserie she was using. Now I’m all for patients seeking medical advice from a local pharmacist, but deciding to approach the local pastry chef for guidance always seemed to me like a half baked plan.

Of course not all that life presents to us as GPs can be so easily laughed about. I have been a partner in my practice now for a little over 21 years and can’t remember a busier, more demanding time than the past few months. A measure of resilience has never been more necessary. The pressures on us are huge because, as well as the tidal wave of genuine need, we are all sometimes asked to do things that are not strictly our job. At times our response can be that, if we are to survive in what seems to be an increasingly hostile professional world, then, in the name of a hard resilience, we have no option other than to practise a form of defensive medicine that puts up barriers between ourselves and those in need. This can be manifested in a resistance to take on any work that is not strictly ours, covering our backs by investigating and referring more than is necessary, and generally passing onto others as much responsibility as we can. In addition we can sometimes fail to be gracious to both those who ask of us anything that we feel they shouldn’t, and those who have disappointed us in the past, regardless of their actions in the present. Our secondary care colleagues, rather than being those we look to help and support, can all too easily be viewed as the enemy to be repelled. And vice versa, thereby creating a disastrous divide between primary and secondary care. Likewise, we can also sometimes feel that the patients are the enemy but, as with secondary care, we would do well to view our interactions with them as collaborative rather than antagonistic. Such misdirected attribution of hostility is all the more likely if we fail to acknowledge that the real enemies driving the demands upon us are the causes, and the ’causes of the causes’, of the ever more broken society in which we live.

Resilience though should be soft. It is the ability to spring back from difficulties, not a becoming so hard that nothing ever hurts you, or so insensitive that nothing ever stirs you enough to want to help. We must not allow our attempts at resilience to result in our losing all our compassion for those who come to us in need.

Of course the expectations imposed on us are sometimes far beyond what is reasonable and requests that are clearly inappropriate should be resisted – for example, a request to assess a prematurely discharged, acutely unwell patient’s ongoing oxygen needs comes readily to mind. But sometimes we are best placed and could help meet a need that is not strictly ours to meet, a blood test here perhaps, a prescription there and, yes, sometimes more complex matters. This, I know, will divide opinion and I do appreciate why some will, no doubt, disagree and advocate a hard resilience. None the less, to assert that practising defensive medicine is the answer to the overwhelming demand upon us is, to my mind at least, a mistake. Such practise is, I believe, bad for patients, bad for the NHS and bad for the medical profession as a whole. And, counterintuitively perhaps, I think defensive medicine is bad for us too since it reduces our own capacity to build resilience.

Firstly then, defensive medicine is bad for patients because, as well as being frequently both inconvenient and financially costly for them, it also exposes patients to unnecessary investigations and treatments which are themselves not without risk. Furthermore, defensive medicine burdens patients with unnecessary anxiety since, out of our unwillingness to carry the anxiety ourselves, we become reluctant to give patients the appropriate reassurance they need.

Defensive medicine is bad for an NHS which can ill afford the expense of inappropriate referrals both in terms of finances but also in respect to an already overstretched workforce. Ironically, to practise defensively, by admitting or referring patients ‘just in case’ whilst indiscriminately batting away requests from secondary care, serves only to stretch still further our hospital colleagues with whom we say we sympathise. We may all have commendably signed petitions supporting Hadiza Bawa-Garba but such defensive behaviour only adds to the very set of circumstances that increase the likelihood of the errors of that tragic case being repeated. Never mind “#IamHadiza”, practise defensive medicine and we might as well tweet “#NotmyproblemHadiza”.

And defensive medicine is bad for the medical profession itself since to practise so is to practise unprofessionally. Acting professionally as a doctor isn’t easy. It is to deal with uncertainty, to apply knowledge and wisdom in complex, never before experienced situations, to do what seems best in less than ideal circumstances. And that’s hard – mistakes will sometimes be made, bad things will sometimes happen. To need professionals is to acknowledge the uncomfortable truth that life, and death, is uncertain. There are those who would like to see the end of professionals, to have them replaced by an ever increasing barrage of rules and regulations, protocols and proformas, all in the misguided belief that somehow certainty exists, that what needs to be done is always clear and that a good outcome can be guaranteed for all. Thinking only of ourselves and not being willing to make a professional judgment, not being willing to do what’s best for our patients, to do what seems wise based on our years of training and experience, reduces us to the likes of the 111 protocols we so often delight to criticise and thus only serves to suggest that we ourselves are surplus to requirements. Practising defensive medicine dehumanises us and plays into the very hands of those who would undermine the need for professionals at all.

To be clear, we all need to acknowledge our uncertainties and make decisions accordingly. We need to be conscious of how confident we are feeling at work, aware of how the level of that confidence can fluctuate over time and how our practice is consequently affected. Sometimes we may imagine we have finally mastered this being a doctor lark and will have to guard against overconfidence. More often perhaps, when we doubt we’re convincing anyone we ever went to medical school, we need to acknowledge our lack of confidence and accept that to ask for help by referring more patients is a normal part of being a GP, part of what it takes to remain in practice for 30 years rather than burning out with the stress of it all within six months. That, however, is not practising defensively – that is practising responsibly, practising wisely, something we should all be doing. Practising defensively is different in that its primary concern is the doctors welfare – it is the ultimate in being doctor centred. Like it or not, part of what it means to be professional is to be patient centred, not to do what they want but to do what, to the best of our knowledge and ability, is best for them. It is to take responsibility and, when appropriate, carry a patients anxiety so that they do not have to. To be professional is to know when to work for the best interests of our patients rather than our own.

And, as I say, practising defensively risks reducing our own resilience. Now I know I have written previously that we need to guard against demanding a resilience in ourselves and others that is not possible, that we need to acknowledge and accept our inability to meet every need. And yet here I am arguing that we should take on more than is ours to take on – and suggesting we should do so for our own good. So which is it? As in life, few things in medicine are black and white, and the line between when we should protect ourselves from the demands of others and when we should make ourselves more available to their needs is certainly one that is blurred. But here’s the thing. What if resilience was built by giving more of ourselves – not less?

Not that long ago I read an interview given by the novelist Joanna Trollope who, speaking in favour of assisted dying, commented that, if necessary, she would take her own life were she to develop dementia. Hating the thought of becoming a ‘nuisance’, she said: ‘I have no intention of moving in with either of my daughters and ruining their lives.’ Leaving aside for a moment the rights or wrongs of euthanasia for the alleviation of one’s own suffering, that is a debate for another time, note that Trollope here is advocating euthanasia for the alleviation of the suffering of others – those who have the task of caring for the one to be euthanised.

This is a troubling point of view, one that is worth considering further. On the surface, not wanting to be a ‘burden’, appears a selfless attitude, one even to be admired. But is it really true that rather than ever significantly imposing on others, we should all do the decent thing and take our life when our needs become too great. Are we really all too proud to admit the need for help? Where would we draw the line if we were to take such a view? – an extreme position would solve the problems of the NHS at a stroke. Caring for family, friends and neighbours, not to mention those in need nationally and internationally, always has the capacity to disrupt the smooth running of those who provide that care – it can be physically, financially and emotionally draining. But unless we are so superficial, so inhuman as to think that life is simply about our living a carefree, fun filled life, costly caring for others must be part of our everyday experience. Life hurts sometimes. Love hurts too.

This belief, that the struggle to care for others is an unacceptable inconvenience, explains, perhaps, why some try to minimise the care they show to those in need and why others sometimes, rather than getting their hands dirty themselves, too readily pass that care onto others. Obviously the care some people need is way beyond what can be provided by individuals and expert help is frequently essential, but it a beautiful thing to see families and friends supporting those they love in times of real difficulty. Regardless of where they come from, people in need who come to others for help, are not simply nuisances who ruin the lives of those burdened with their care. Rather, they are those whose lives still have meaning and value despite the struggles they face. Furthermore, their lives have the potential to enrich, rather than ruin, the lives of those who care for them, be those people professional or not.

This is not to say that we should hope for hardships to befall others so that we can be needed. Nor am I trying to suggest that there is some perverse beauty in suffering. No — suffering is suffering and, be it physical or emotional, it is horrible — frequently terribly so. But suffering is a part of our human existence and must not be swept under the carpet with the assistance of, as Trollope suggests: ‘ … a nice man with a pot of happy pills and a plastic bag to pop over [the] head.’

One can understand where she is coming from but it saddens me that a life that is given over to caring for somebody else is considered a life that is ruined. I can understand that nobody wants to be a ‘burden’, but it needs to be remembered that, even in the sadness that comes from entering into the suffering of others, there can be a deep satisfaction, perhaps even a joy, in carrying the burdens of another. And a burden carried joyfully is, of course, no longer the burden that it once was.

We hear constantly about the desirability of high self-esteem but Trollope’s comments raise the question as to what it is that we derive a positive self-image from. She is not alone in undervaluing a life given over to the care of another. A while back I listened to a young woman who felt her life was pointless despite the fact that she spent much of her time caring for the young child of her terminally ill friend. I don’t consider that a pointless life — far from it. As society becomes increasingly fragmented and individuals feel more and more isolated, we need to remember that humans are meant to live in a community, supporting one another. We are not meant to be anything other than dependent on others – after all, if we all sometimes want to be needed, then all of us are sometimes going to have to be those who have needs. As Bob Dylan sang, ‘May you always do for others, and let others do for you’.

I wonder if we have forgotten what a real need is and what is of real value. In a celebrity culture which thrives on the superficial it seems too many of us want to be lauded for our entertainment value rather than our character. Whilst we may admire the work of those who give themselves selflessly for others, too few of us want to be those people. Naturally enough perhaps, some want quick returns on their investment, preferring the dream of all that flows from overnight success than the quiet satisfaction that comes from walking the long, hard road of performing a demanding job well. Perhaps such an attitude underlies the view that a life given over to the care of others is a life ruined, since such a life threatens our pursuit of more superficial pleasures.

But caring for others need not be a dutiful burden, virtuous, but without an accompanying sense of satisfaction. Far be it for me to suggest it but Immanuel Kant was wrong when he said an action was only truly virtuous when done out of duty, with no associated gain for the one who acts. The truth is that, despite the awful pain and terrible sadness, there really is a satisfaction and pleasure to be had in caring for those who suffer – I’ve seen and experienced it. What is more, where there is that joy in caring, the sufferer is more honoured in the giving of the care than if it were done out of duty alone.

An illustration, for which I am indebted to John Piper, may help. Suppose I come home on my wedding anniversary and present my lovely wife with 12 red roses. Unlikely I know – have you seen the price of flowers these days – but go with it and try to imagine that, in her astonishment, she asks me why I should do such a thing. Woe betide me if I claim ‘duty’ as my only motivation. Giving my wife flowers on our anniversary because I consider it my duty to do so as her husband will not impress her and it certainly does not honour her; if anything it would honour only me. But consider her response if instead I was to reply that the reason I bought her flowers was that I couldn’t help myself, and that, what’s more, she should go and get ready because I was taking her out for dinner whilst adding that nothing makes me happier than my being with her. I suggest that such a response, if true, far from being considered selfishness on my part, would add to her joy and honour her all the more.

Of course, loving someone is more than buying them flowers and taking them out to dinner. It is often hugely costly – but it doesn’t always have to be a burden. A valueless job may be a burden, chasing meaningless QoF points may be a burden and satisfying the demands of the CQC most certainly is a burden, but it is a sad day if we’re saying loving someone, or caring for someone, is nothing but a burden. If those we love become nothing but an unwanted problem, become those who do nothing but ruin our lives, those whom we can take no satisfaction in caring for the moment they have needs, then can we really claim to ever have loved them at all? Likewise with our patients – if we take no pleasure in being able to help, it might mean we are in the wrong job. I recall arriving late at a party one evening some years ago having been held up at work admitting a patient with meningitis. Many at the party were sympathetic towards me, wrongly assuming that my long hours at work must have meant I’d had a bad day. They did not realise that, on the contrary, my long hours that day, doing something worthwhile, were a source of genuine pleasure. We are fortunate to be GPs, that our job affords us such opportunities. Worthwhile work done well is satisfying to the worker. It really is a joy. And caring for others, professionally or otherwise, is always worthwhile work.

As a doctor if a patient ever thanks me for some care I may have given, I try to remember that responding with a curmudgeonly ‘Just doing my job’ doesn’t honour my patient half as much as a heartfelt, ‘It’s my pleasure’. Caring for friends and family, for strangers near and far, is no different – it can and should be a joy.

So let’s stop imaging that those who suffer can be conveniently swept out of sight along with our need to care for them. Remember that those who suffer most aren’t doctors. Our fleeting contact with patients exposes us to but a fraction of the distress that is experienced by patients and those who love them, and live alongside them, as they suffer. We must not always keep our distance but rather be prepared to pay – not only with our time and energy, but also, through at least our tax bill, with our money. One day it’ll be we who suffer, we who will need the care. And let’s stop imagining that those who want to die with dignity will achieve this best by being encouraged to do the decent thing and end their ‘inconvenient’ lives prematurely. Rather, we will dignify their final days and years most by loving them enough to find a degree of contented satisfaction in looking after them.

And finally lets not imagine that we win when we avoid taking on the care of somebody with real needs. We don’t – on the contrary, we lose. There is a joy in helping others, a joy that builds resilience even when it is not strictly our job to offer the help. Maybe all the more so when it’s not our job, when we have acted, not out of duty, but out of delight. Defensive medicine is dangerous not least because it deprives us of the satisfaction that comes from doing what is still, despite everything, a great job.

So let’s laugh with our patients – and when there’s nothing to laugh about, let’s cry with them. Let’s subvert the pressures that threaten to crush us by moving towards the needs of others rather than distancing ourselves from them. Because, even when there’s little practical we can do to help, nothing demonstrates a springing back from difficulty, nothing demonstrates resilience better, than showing a little compassion and finding a satisfaction in connecting with those who present their needs to us.

I don’t pretend this will be easy, I know we will often fall short of this ideal, that often we simply won’t be able to give as much as we might like. We’ll need to lean on each other even as others lean on us. But could we not at least acknowledge the possibility that it is good for us, as well as our patients, when we sometimes go the extra mile?

Compassionately connecting with others has the capacity to build our resilience more than anything I know. And a soft resilience will be stronger and healthier than one that is hard because, renewing our pleasure in caring may, as a consequence, mean we might just enjoy our work a little more.