Some musings

GENERAL PRACTICE – A SWEET SORROW

So the new contract is out and, in some circles at least, it has been met with some enthusiasm -particularly in regard to the plan to fund additional GP support staff. Now, although this is not unwelcome and may lighten the load a smidge, I can’t help thinking that something is being missed. Because, for my money, rather than employing additional support staff to give us the time to continue to pretend to be able to do what many insist General Practice must, the real problem remains that there are not enough GPs. Only greater numbers of GPs will give us the time to properly do what GPs do best – tread the thin line between on one hand delivering a healthy dose of medicine whilst, on the other, resisting the medicalisation of normality and easing us instead toward an understanding that we will inevitably fail to do that thing that everyone would like us to – that is make everything OK.

The problem, it seems to me, is that we continue to try to practice medicine in a world that does not exist – one in which health can be indefinitely preserved, sadness can be successfully avoided and suffering can be permanently diverted. If such a world did exist, all we would need is sufficient experts, each working in their respective fields, doing their part to deliver the required utopia. But in fact we live in a world where death is inevitable, suffering is widespread and sadness is ubiquitous. Rather than specialists to steer us away from what can’t be avoided, we need generalists to be with us as we walk through the mess of the everyday.

‘There are two kinds of pity: difference perceived – which is the beginning of pride; or fellowship recognised – which is the beginning of love’.

So said J.R.R. Tolkien and, if he is right, to really care, we are going to need a kinship with our patients which will require us to live, grow old and, perhaps, die alongside them as we experience something of all that they are going through. We need to be like them, if we are to understand them. Many of them are more realistic of what they can expect to get out of life than we are. Rather than always being offered spurious solutions to the problems that can’t be solved, they are often content with the knowledge that someone simply understands them and can accompany them as they face their difficulties. Just as joy can be found in sadness, and strength can be found in weakness, General Practice’s greatness is found in its lowliness – a lowliness that we must not lose.

I have a confession to make. I like the music of Leonard Cohen and was saddened a couple of years ago to learn of his death. I understand that he is not everybody’s cup of tea, it wasn’t without reason that he was known as ‘the godfather of gloom’, but, for all that he seemed to me, in his later years at least, a gentle person with a wry self-deprecating sense of humour, who thought deeply about the big issues of life. I would have been interested to have met him and would certainly have liked to have heard him play live and see first-hand the obvious pleasure he experienced from the audience’s ironic cheer as he growled out the line ‘I was born like this, I had no choice. I was born with the gift of a golden voice.’ Some years before his death he was asked a question regarding the fact that much of his music is melancholic in tone. His answer was, for me, illuminating. He said:

‘We all love a sad song. Everybody has experienced the defeat of their lives. Nobody has a life that worked out the way they wanted it to. We all begin as the hero of our own dreams in centre stage and inevitably life moves us out of centre stage, defeats the hero, overturns the plot and the strategy and we’re left on the sidelines wondering why we no longer have a part – or want a part – in the whole …. thing. Everybody’s experienced this, and when it’s presented to us sweetly, the feeling moves from heart to heart and we feel less isolated and we feel part of the great human chain which is really involved with the recognition of defeat.’

I like this quote – its honesty about the reality of what life is really like – an honesty that we too often lack. If a melancholic song can connect singer and the one listening, and make us feel less isolated, how much more can a genuine sharing of our defeat help us feel part of the ‘great human chain’?

To be that kind of a doctor, despite all the good we can genuinely do, we need to acknowledge and share our own failures, our own ordinariness, our own inadequacy. Rather than consider some tasks beneath us, we need to deal with the dull, because, out in the sidelines, the mundane is every bit as meaningful, as that which allows us to pretend we’re still the hero in centre stage. We really aren’t any different from our patients – the more we realise that and stay close to them, the better General Practice will be for it.

Take sadness. Despite the joys that are undoubtedly present, this is often a sad world, frequently a vale of tears. And regardless of the cause, the sorrow of sadness hurts. Frequently that pain, for want of anywhere else to take it, is brought to the GP. Without doubt, there is a lot of it about, and it cannot easily be dismissed with the psychological equivalent of ‘it’s probably a virus’ and a facile assurance that the feeling will soon pass. What then are we to do?

First we need to make the right diagnosis – distinguish normal sadness from pathological depression, if such a thing exists at all. Certainly the former is by far the most common. In almost every presentation the cause for the sadness is all too apparent with no need to suppose a pathological biochemical imbalance to account for it. Be that as it may, having made our diagnosis we need to resist the temptation to medicalise normality, even if by presenting to the GP, the person in front of us has themselves sought out a medical solution to their distress. It’s then that we need to be truly general practitioners, super generalists even. In fact we need to be so general that we are not medical at all since it is then that the labels of ‘doctor’ and ‘patient’ become barriers to what we really need to be – simply human. Of course we all want to help and we may understandably want to offer what only we as medics can, namely medication. But whilst the pills may help to numb the pain, they don’t take fix the problem any more than morphine may alleviate the agony of a broken leg without fusing the bones. Furthermore an undue reliance on medication, as well as potentially leading to dependence, risks telling the patient they are wrong to feel the way they do, that their sadness is inappropriate when, in truth, as we have all surely known ourselves, it is nothing of the sort.

There is, perhaps, a better, though less comfortable remedy. We need to understand the sadness – even if we cannot fully explain it. Having recognised the normality of the sorrow ourselves, the sad patient in front of us needs to be helped to see the normality of their feelings as well. To those who are new to sadness this may come as a shock, especially in the entertainment rich and superficially upbeat culture we inhabit. Abraham Lincoln commented that,

‘In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares.’

Rather depressingly, but perhaps accurately for some at least, Lincoln continued with,

‘The older have learned to ever expect it.’

To acknowledge the normality of sadness is not to deny the intensity of the suffering – because it’s normal doesn’t make it any less awful. But only having acknowledged its normality can we truly accept the sadness, and allow the grief to be expressed without trying to explain it away. After all, you can’t rationalise away that which is not irrational.

We like to solve problems – to ease suffering – and sometimes, wonderfully, we can. But sometimes there is no pill to take away the distress, no wise insight that will alleviate the pain of sadness, no remedy to stem the flow of tears. To pretend otherwise is untruthful, unhelpful and unkind. As physical pain alerts us to something being wrong and indicates action must be taken, so too emotional pain can serve a similar purpose. Denying its normality, its usefulness, removes all hope of ever addressing its cause.

But sometimes, of course, the cause can’t be addressed – there is no earthly solution, there is no going back, no doing things differently next time. Sometimes not even time will help. Sometimes the pain of sadness may go on and on.

In such circumstances we may well feel useless, but that’s not necessarily so. Knowing our inadequacy allows us to stop being doctors who can’t help and allows us to become people who can – by entering a little into the grief of those with whom we sit. There is a sweetness in sharing sorrow because being alone in one’s sadness is too great a burden for anyone to bear.

In ‘Out of Solitude’, Henri Nouwen wrote,

‘When we honestly ask ourselves which persons in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand. The friend who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, not healing and face with us the reality of our powerlessness, that is a friend who cares.’

And perhaps that is exactly the type of GP who cares too.