It was, if memory serves me right, Milton Jones who quipped of the sergeant major who he felt lacked self esteem on account of his standing in the centre of the parade ground each day and shouting ‘Attention!’ But, I wonder, are we any better? Might we also be far too busy asking others to look at us and approve of what they see?
Not so long ago I received some good news! I’d been ‘liked’ by the GMC! Well I say liked, I mean of course ‘revalidated’ but it came to the same thing. I”d posted a few comments of dubious value on an appraisal website and, lo and behold, I was affirmed by no less an organisation then the GMC! My wife may not have been impressed when I told her but, come on, I mean, the GMC. Does it get any better than that?
Yet the culmination of five long years producing the alleged evidence that I was OK left me feeling somewhat flat. Curiously, being approved of by a faceless organisation, who demands of me certain requirements that I must satisfy in order to have their assent bestowed upon me, turns out not to be as fulfilling as I’d hoped!
Tragically though, it seems that we are being driven by an ever greater desire to be liked. It’s not just Facebook, Twitter and the GMC. We live in a culture in which expressive individualism is the order of the day. This external encouragement panders to the internal desire we have to be approved of which, when left unchecked, leads to a situation where ugly self promotion and a need to be seen to be the best is the norm. When “it’s all about you’, you have to make ‘you’ what it’s all about. Not only is our expressive individualism bad for our patients, it is also bad for each other and ourselves, both on a professional and a personal level burdening us with the need to be awesome in a way that we are not, and, indeed, could never be.
It’s bad for patients because to focus on our own importance tends to us overvaluing our significance and that of medicine as a whole and leaves us struggling to accept anyone suggesting that they might know more than us. We doctors can be far too dismissive of patients who come to consultations with clear ideas of what they think is wrong with them. Not infrequently of course, there will be some justification for this as not all information gleaned from Dr Google is helpful and even genuine knowledge obtained from an internet search or elsewhere, needs to be applied wisely if a satisfactory conclusion is to be reached. None the less, on other occasions, not only are patients experts in being who they are, it is quite possible that, as interested parties, they might have researched their condition such that they know more about it than we do.
As doctors we need to be honest and humble enough to acknowledge, not only that we do not know all that there is to know, but also that all that there is to know cannot explain everything we would like it to. Albert Einstein had it right when he said ‘The only thing worse than ignorance is arrogance’. We must avoid such arrogance and accept what Atul Gawande calls our ‘necessary fallibility’. If we’re honest enough to admit we’ve made mistakes in the past, and are realistic enough to expect to make them in the future, we’d be wise to accept that we’re probably making them in the here and now. Caring for our patients involves doing our best and mourning our worst, being appreciated when we do well and being on the receiving end of a forgivenesses when we fail – a forgiveness that we will not experience if we arrogantly suggest we know it all. That’s why, when we smile and nod our head at this:
We should also recognise the truth in this:
Expressive individualism is bad for us professionally too since, determined to maximise our importance, it tends to minimise the help that lies outside of our own field. It is no good bemoaning how busy we are if we continue to insist that medicine can solve all of life’s difficulties. Only when we acknowledge that we do not have all the answers can we hope for patients not to expect that we do.
The need to promote self and seek approval is also detrimental to us as professionals as, no matter how hard we are encouraged to try, it is simply impossible to obtain the required approval of groups that sometimes have diametrically opposed ideas of what it is they want from us.
Take the antibiotic prescribing issue. On one hand we are quite correctly being encouraged to reduce our antibiotic prescribing and being threatened with a reprimand if we do not curtail their inappropriate use. But on the other hand, we are being judged by how satisfied our patients are by our practice and, despite what patient education programmes try to convey, the idea continues to be held, even by some of the most educated of our patients, that antibiotics are required for minor self limiting infections. Without them many of our patients won’t be satisfied.
Similarly we are being asked to avoid unnecessary admissions to hospital whilst being increasingly criticised for delays in diagnosis and referral. Despite recent calls for a doubling of our referrals to cancer services and expert advice urging primary prevention for heart disease at ever lower levels of risk, our referral rates and prescribing practices are under ever more scrutiny.
And that’s not to mention, of course, the competing demands of our responsibilities at work and the care and concern we long to give those we love the most, our families and friends.
It is impossible then to please all the people all of the time – and we are fools to try. In a society which constantly and increasingly seeks affirmation is it any wonder that we are overwhelmed by the need to please those with competing desires. Whatever we do is wrong in somebody’s eyes. The incessant double binds threaten, not only our own happiness, but also the stability of the whole system – a system already creaking from the overwhelming demand and time limitations that together drive us, perhaps, along the route of least resistance – the route that earns us a ‘like’ most easily – the one that comes from our patients.
Something is going to have to change in regards to the the way we behave if things are to improve. In short we need to be professionals who are in the job, not to be admired, but to do what is necessary. Whisper it quietly, but we are going to have to be less patient centred in order to be more patient friendly. We are going to have to be less concerned about doing what our patients want, what they will like us for, and try instead to sensitively do, to the best of our ability, what is right. Whilst on one hand some may complain, a greater acknowledgement of our inherent ordinariness may lower expectations such that complaints are less frequent and, with our self worth less tied to an unattainable perfect performance, when they do come they may not hurt us quite as keenly on a personal level. And remember, sometimes, to do less, really is to do what is right. Recently I read an excellent blog by someone whose mother, whilst pregnant with her, was disappointed when her doctor refused to treat her morning sickness but told her instead she’d just have to put up with her troubling symptoms. Years later the writer of the blog ponders what might have been were her mother to have been given the Thalidomide she had wanted. You can read that blog here.
We need to care less about how we are thought of by our patients – I’m not sure just how valid their opinion is anyway. On a single day a few years back I received two pieces of feedback – one accused me of negligent incompetence, the other rated me as unusually astute. So which is it? Well of course it is neither – I am no more ‘awesome’ than I am ‘useless’. I am in fact ‘ordinary’ – an ordinary GP who, like ordinary GPs up and down the country, knows less cardiology than a cardiologist – but more than my patients, or at least most of them. Our patients, our politicians, and we ourselves are going to have to accept this – whether they, or we, ‘like’ it or not!
Constantly promoting ourselves is unhelpful to others too. If we so massage the presentation of who we are such that we portray ourselves as better than we really are, it only adds to the pressure that others feel and leaves them anxiously striving to attain a level of perfection they imagine everyone else to have achieved. Competing with one another in a misguided attempt to prove our perfection makes losers of us all. We need to be honest about our mistakes, normalise failure and be realistic with one another about the difficulties we all experience. Rather than airbrushing reality and pretending life is always what we long it to be, we need to learn to walk together through the unwelcome mess of the everyday.
Finally, this need to be approved of is bad for us on a personal level. It makes us too sensitive to our fragile egos being upset. We are all, it seems, too easily offended. Take for example the furore a while back surrounding Jo Brand. Ironically, one of the qualities that we perhaps most desire in order that we be seen in a good light, that of being considered to have a good sense of humour, increasingly these days can get us into all sorts of trouble. For me Jo Brand’s joke was clearly simply meant as that, a joke – what else would you expect from a comedian on a comedy radio programme? – and, regardless of whether we find it funny or not, would have been best received as such.
As an aside, given that a good sense of humour is seemingly valued above integrity and compassion, my concern is more that, just as school debates were always won by the funniest argument, there is an increasing trend whereby political and social opinion is swayed more by how funny a statement may be rather than how true a comment is. Satire is important to pop the pomposity of those in power but equally comedians shouldn’t become our opinion formers merely on the strength of how much they make us laugh. That also goes for politicians who try too hard to be funny. Imagine how it would be if our Prime Minister was chosen as a consequence of enough people finding him or her amusing – a word, incidentally, which means without thought! As Neil Postman pointed out, Aldous Huxley ‘was trying to tell us that what afflicted the people in Brave New World was not that they were laughing instead of thinking, but that they did not know what they were laughing about and why they had stopped thinking.’
But be that as it may, it seems to me that the world would be a far happier place if, regardless of what we personally believe to be true, offence was taken only when it was meant. It’d be happier still if, even when meant, offence still refused to be taken. Then perhaps we might be able to talk and think well rather than shout and feel bad. But for that to occur we will, I believe, have to have a much lower sense of our own self importance.
This is not to say we do not have worth. Quite the opposite, our worth could be said to be infinite but, paradoxically, our importance, at least to all but a few, is small – it does not match our significance.
For me at least, getting this wrong and continuing along the road of expressive individualism, and portraying oneself as important, all too frequently gets in the way of anything that is genuinely worthy. At the risk of reaching new heights of pretentiousness, I’ll finish with one last thought – and it’s this: that ‘self’ even gets in the way of the unconditional acceptance, let’s call it love, that we all so want to know. To truly be loved unconditionally speaks more about the merits of the one doing the loving than the merits of the one being loved. As I have suggested though, most of us expend far too much energy trying to make ourselves worthy of love which serves then only to leave us with the burden of constantly striving to remain loveable since we have made our happiness and security dependent upon it. But love that is conditional on performance is not love at all – to be required to constantly promote oneself thus hinders the joy of knowing true love and acceptance.
Rather than striving to become loveable so that we can be loved, real security is, therefore, to simply know one to be loved because of the nature of the one who is truly loving. And in such security, I believe, lies what is needed for the one who is loved to become truly lovely. We do not improve by being constantly criticised for what we fail to achieve and having acceptance denied until we perform better – that is not the basis of a good relationship, either personal or professional. On the contrary, ultimately we are paralysed by the pressure to be perfect – crushed under the fear of failure. Genuine progress comes only as a result of the motivation that flows from being accepted for who we are – only then, are we free to flourish, only then can we truly grow, both as doctors and as human beings.
Medicine can be a cruel taskmaster – demanding and unforgiving. We need to be sure that we do not allow our relationship with it to develop in such an unhealthy manner. We must not imagine the fault is all ours when we fail to satisfy the demands that the system unreasonably imposes upon us. The inner belief, or outer demand, that it’s all about us being perfect and that we cannot be appreciated before we are, will spoil everything both inside and outside of work. It’ll make us unhappy. Real happiness comes not so much from being admired, but from admiring that which is truly admirable.
It must not be that we always have to be the best.
It must not be that we always have to do it all alone.
It must not be that we, by being perfect and pleasing everyone, have a duty to keep everyone happy.
We’re none of us that strong – not physically, not emotionally
Life should not be a competition- that’s not the way it was ever meant to be.
Travelling to work under grey skies, I sat alone in my car. Noticing those I passed, sat alone in theirs, I was left thinking that that was a lot like life – too many of us travelling alone to similar locations with nothing to look up for. And that’s not healthy. Rather than living and working in lonely isolation, we need each other. At least I know I do.
If we’re going to get through life, not as individuals who promote ourselves, but as those who live in community and know the need to lean on one another, then we going to have to grasp something that Bob Dylan captured in the words of the song ‘Forever Young’. And with those words I’ll finish:
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