Measure for Measure – Appraisal for Appraisal

“O, it is excellent

To have a giant’s strength

But it is tyrannous

To use it like a giant”

Watching the recent RSC production ‘Measure for Measure’ was not a comfortable experience. Despite the fact that Shakespeare wrote it over 400 years ago, this brilliantly performed play still managed to leave a twenty first century audience asking questions that remain prescient today. Questions regarding the abuse of power, the nature of virtue and the necessary tension that exists between justice and mercy. Never has a curtain call been such a part of the performance. Never has an applauding audience been such an integral member of the cast. Never has my desire to clap left me feeling complicit in encouraging the problems a play has addressed.

But whilst perhaps having most to say to a political world in a #MeToo culture, it also left me reflecting on how these themes work out in medicine.

In the play, the one who holds power wields it to uphold the law without mercy, despite the fact that he himself is similarly guilty of the law breaking which he judges so harshly. I wonder if sometimes we are not the same. To be a doctor is to be in a position of power. Like it or not we make judgements, not only as to the significance of the signs and symptoms that are presented to us, what they might mean and how they might be managed, but also on the individuals who present them. We constantly make judgements as to the appropriateness of their presentation and inherent in our dealing with patients are the judgements we make on their worthiness to receive the assistance that they request. This is not without some cause but we must be careful about how we use our power and remember that we too sometimes struggle. That which we sometimes disapprove of in our patients is, on occasions, all too present in ourselves. Are we really so sure that we wouldn’t present ‘inappropriately’ if we weren’t fortunate enough to have received the medical education that we have and enjoy the social support that we do? Equally are we sometimes too quick to judge the behaviours of colleagues we feel manage our patients in ways that create us work and forget that we too sometimes practice is less than perfect ways? Do we judge our behaviour that puts a burden on others less harshly than another’s actions which places a burden on ourselves? I doubt that that it is only me.

As seen also in the play, seemingly good deeds can be a cloak concealing the principal concern of the one performing them and, in reality, be little more than a means of manipulating others into positions that serve to advance the cause of the one performing the virtuous act. We like to look good, to be admired for what we do. Might we not sometimes be guilty of using our position more to build a reputation for ourselves, one that put us in a good light in the eyes of others, than a means of genuinely serving those we seek to help? Despite what we may say to patients, how often is our motivation to treat an individual more about maximising our income by the securing of additional QoF points than doing what is convincingly in the best interests of the patient? Are our cries of righteous indignation about the state of the NHS and are our occasional, ever so slightly, exaggerated descriptions of the struggles which we experience within it, really an effort to highlight how noble our efforts are and an attempt, at least in part, to invoke admiration in our audience? A doubt that that is only me either.

We must also ask about the power we exert on our patients when we diligently give them the labels we have been taught to apply and thereby control how we, others and indeed they themselves look upon those so categorised. This is particularly the case in the area of mental health where all too often we describe as disordered those who respond in ways wholly in keeping with the difficulties they have experienced. By doing so we force individuals to see themselves as sick rather than as simply experiencing understandable distress. As has been said elsewhere, madness is a label given by powerful people to those who behave in inconvenient ways.

The play infers that the rule of law is good, that it provides social order, and that justice ought therefore to be upheld but, since none are without fault, there is a need for mercy if all are not to be condemned. Grace needs to be offered to those who fail. To borrow a theological framework, though good, the law condemns and crushes those under the burden of its demand for perfection and thus serves only to highlight ones own individual shortcomings. Grace, however, the treating kindly of those who perhaps don’t deserve it, motivates those so treated by lightening their load and, as a consequence, empowers the recipient to change for the better.

This has at least two applications in medicine. Firstly it speaks to how we ought to act towards our patients. If we constantly criticise our patients, point out their shortcomings and then demand better adherence to the barrage of good health advice we offer, if in so doing we simply apply the law of medicine, they are likely to find themselves feeling guilty and condemned. They will feel powerless to change under the weight of all that they are being asked to do in order to find acceptance, and so, despite perhaps initial efforts, soon abandon any attempts at change, disheartened by their failure to make progress. This is especially true for those who, having been particularly proficient in not looking after themselves the way they should, have, over years, fallen furthest. Such people need to be understood and accepted for who they are – treated with a little grace and offered a little hope. Therein lies the power they need to start to make the small changes necessary that, over time, will lead to genuine improvement.

The second area in medicine into which the notions of justice and mercy can speak to is our own acceptance as doctors. Though we do have a degree of power, we are also under authority of those who have power over us. We have demands placed upon us, the burden of performing to the exacting standards of the law of good medical practice which insists we adhere to every medical guideline, fulfil every requirement for revalidation and meet every exacting standard of various regulatory bodies. The medical law is indeed a cruel taskmaster that we cannot hope to satisfy. We too need a little grace.

Which is why we need to return to a form of appraisal which is formative rather than summative. Summative appraisal is a law based system which simply demands of us and so serves only to crush us under the weight of all that it insists has to be done. The burden demotivates us and leaves us weary and weak, powerless to pursue change. Formative appraisal on the other hand seeks to come alongside us, to understand us and offers us a little grace. It is a system that actually serves us and better enables us to make the changes that no doubt would be helpful in us all. It will help to make me the better doctor I would like to be.

Every good play ends with a curtain call during which the audience offers it’s warm appreciation by applauding the cast who, as they take a bow, humbly accept the acknowledgement of those they have served. It’s a fitting, and gracious, way to end any performance – one we should be pleased to offer and one which we would all, no matter our trade, be glad to receive when our work is finally complete.

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