Some musings

I’m 53 now and due something of a midlife crisis, so you’ll forgive me for looking back on my career in general practice and asking how worthwhile it has been. No doubt I’m not the only doctor in the country that looks critically at their performance and sees their weaknesses rather more readily than their strengths. And yet, as the years go by, there seems to be an ever greater requirement to justify myself, to prove my value.

Paradoxically this leaves less time to do valuable things. The need to look inward and prove myself, as well as being a crushing burden personally, is detrimental to my patients since the pressure to tick boxes all day renders me content to have ticked those boxes rather than to do something that would actually make a difference.

Once, when things didn’t go as we would have hoped, we talked about the event of significance, as professionals. Then such discussions became formalised as significant event audits (SEAs) and in time they became a requirement, necessary for revalidation. But with the addition of a list of situations that the SEA meeting had to cover, they largely lost their value. Once when we came across something we didn’t know, we looked it up, as professionals. Now we have to document our learning and reflect on the process. Once training was an apprenticeship, now it is a tiresome collecting of CBDs, COTs, DOPs, PSQs, and MSFs. Once we sought to advise, help, and treat patients who were sick, now we have to chase QOF points and are rewarded for them regardless of how meaningless the chase for them actually is.

What have you done this last week that you felt was particularly worthwhile? I’d wager a small coin it wasn’t starting someone on a statin.

And the result of all of this is, I think, a devaluation of general practice, such that it is in danger of becoming a profession of which I am no longer proud to be a part. Medicine as a whole is becoming a job not a vocation. We need to wise up to the fact that general practice is being dumbed down as we are forced to focus on the minutiae at the expense of the whole.

Others have remarked that wisdom is being lost for the sake of knowledge, which in turn is being lost for the sake of facts. And now facts are losing out for the sake of data. The fact that our computers urge us to consider lowering the blood pressure of the patient consulting with on account of their recently having suffered the death of their spouse, proves the point.

Computers can process data, they may even be able to carry out a form of thinking, but I’m pretty sure that they can not feel. If we allow them to, computers will ensure that we will find ourselves moving toward an ever greater validation of the sacredness of a patient’s clinical parameters at the expense of our capacity to consider the individual as a whole

There is a place for data, of course there is, but I want to be wise, not merely accurate. Do we really want our legacy to be successfully filling the local nursing home with the next generation of older mentally infirm patients who really may have been better served staying away from our life-prolonging medicines? The point of living is not a long life. It may not be wise to strive for it.

A while back I filled out my appraisal forms and, for my plans for the coming year, I put down that I wanted to approach the problems that would be presented to me with a degree of medical know-how, mixed with a healthy measure of common sense, pragmatism, and good fortune. I wondered if that would satisfy my appraiser? Or would I just have to prove I’m ok, by producing the ‘evidence’ that would prove no such thing?

As I say, I want to do things more wisely, and that just may mean my doing less.

Those of you still reading this post and who are of a similar age to myself may recall the television series that first aired in 1973 entitled ‘Why Don’t You Just Turn Off Your Television Set And Go And Do Something Less Boring Instead’. Amazingly the series ran until 1995 when, presumably, the producers realised they were losing the argument. There is of course an irony inherent in the fact that the only medium through which the message to stop watching television stood a chance of being listened to was the very medium the producers were reacting against.

They were not the only ones to be concerned by the influence television has on us. In the preface to his book, ‘Amusing Ourselves to Death’, a critique of the effect of television on our culture, Neil Postman compared the concerns of George Orwell in ‘1984’ to those of Aldous Huxley in ‘Brave New World’. He wrote:

“What Orwell feared were those who would ban books. What Huxley feared was that there would be no reason to ban a book, for there would be no one who wanted to read one. Orwell feared those who would deprive us of information. Huxley feared those who would give us so much that we would be reduced to passivity and egoism. Orwell feared that the truth would be concealed from us. Huxley feared the truth would be drowned in a sea of irrelevance. Orwell feared we would become a captive culture. Huxley feared we would become a trivial culture.”

What is particularly astonishing is the fact that Postman’s book was published in 1985, long before the exponential rise in the number of TV channels and the dawn of Facebook, Twitter and the like which has only served to confirm Postman’s view that Huxley, not Orwell, was right.

The point is well made that the very presence of the medium demands that it be filled regardless of whether there is anything worthwhile to be said. Trivia thus reigns. One only needs to compare the number of ‘likes’ attracted by my Facebook post of Dorothy L. Sayers’ admittedly lengthy article ‘The Lost Tools of Learning’ to that of a friend who posted a picture of a dog balancing biscuits on it’s nose to see my point. And yes I am too narcissistic not to care. Having said that, to be fair, the picture did amuse – by which I mean ‘a-muse’ in it’s literal sense of requiring no thought. But then maybe I’m just a grumpy old man, guilty of ‘triste supercillium’ – intellectual snobbery!

And it’s not just Facebook where there is too much information.

The same could be said of medicine and, no doubt, many other professions. Every day, countless new periodicals pour through our letterboxes, both real and virtual. None of us can pretend to consider all that even the most respected journals offer up for our delectation – what chance then the legion of lesser publications that are produced each week?

And it doesn’t end there. The media presents its own view of ‘what’s what’ in medicine and feeds it to patients as fact. And this, in turn, is mixed with the opinion of all and sundry with the result that, as the juggernaut of medical opinion lumbers on to the next medical hot potato, seeking its own 15 minutes of infamy, nobody left in its wake knows what to believe. But then, everybody’s entitled to their opinion aren’t they? What do you reckon?

Without doubt, it is all too easy to miss the significant in the tidal wave of trivia.

So why do we find ourselves so inundated with information and opinion? And why do so many of us insist on adding to the noise?

Undoubtedly the internet and improved communications systems have made it possible to disseminate information faster and more efficiently than ever before, but that doesn’t fully answer the question. To understand how and why we use that technology we need to appreciate how we have been changed by it. For all our on-line connectivity, we are, perhaps, lonelier than ever before and are, therefore, increasingly desperate to be noticed. We are becoming increasingly narcissistic as we insist on our opinions being heard, considered important and approved of. The irony of my saying so here does not go unnoticed, but the truth is that, for many of us, we need to be ‘liked’.

Because, with apologies to Orwell: ‘Many likes good, few likes bad’.

However popularity does not define what is good and truth is not determined by how many assent to a point of view. Furthermore, if the important is lost in a sea of trivia, might not our adding to that ocean be an attempt, all be it a subconscious one, to deny that there is anything important at all. Because, as the important goes by unnoticed amidst the trivial, so also, with all our incessant comment, does not the important itself become trivial?

Which brings me to the thorny issue of our being patient centred. Is it all it’s cracked up to be? Of course we should seek to understand where a patient is coming from but there is a difference between respecting a patient and respecting what that patients tells us. As with our reading of the medical press, we need to discern just how meaningful what a patient says is on a personal level. And be professional enough to disagree. As a patient said to me ‘It’s all very well you saying that the mark on my head is nothing serious doctor, but my hair dresser says it’s cancer’. Perhaps I should have offered to cut her hair!

Yes we should understand our patients’ ideas, concerns and expectations, but that doesn’t mean we should surrender to them any more than our politicians should surrender to the patients expectation of GPs being open seven days a week. Of course the difference there is that the politicians need votes, GP’s don’t, or at least shouldn’t – except at patient satisfaction survey time of course. We really do need to be motivated by a desire to be good doctors – whatever that might be – not just doctors who are liked as a result of giving patients what they want. But with all the information out there it is becoming increasingly difficult to know just what the good doctor should do.

As well as questioning what the system demands of us, we need to become more discerning of what we hear. Just because a thing is said confidently, repeatedly or passionately, doesn’t make it true or worth listening to – and that includes, of course, these words. A thing is true because it’s true – not because its popular or ‘true for me’. The problem is that discerning what is true is increasingly difficult as the tidal wave of information crashes over us each day, the sources of which are often far from clear, and opinions are continuously shouted by those with questionable authority to pass comment on the matters they profess expertise.

So what should we do?

Well here’s the thing – perhaps we should do nothing. Or at least nothing new until we really, really know what is worthwhile.

Medicine needs to take a long hard look at itself and question the validity of the information that is inexorably presented if it is to avoid jumping between successive bandwagons, each promising to deliver us to the promised land where perfect health is enjoyed by all. Rather than more, we need less information – information that is more considered and reliable. Medical journals shouldn’t publish information just because they have pages left to be filled, study days shouldn’t include sessions run just to fill the hours required, and educational activity shouldn’t be undertaken simply to satisfy our appraiser. Before ticking the box, we need to ask whether the box is necessary at all.

As Christopher Hitchins warns us, we should ‘not take refuge in the false security of consensus’ because as George S. Paton reminds us ‘If everyone is thinking alike, then someone isn’t thinking’.

And so we need to think, but in a way that leaves us free to feel as well. We need to ask the questions which matter – and attend to the answers that will really make a difference to our patients and not simply burden them with a load more anxiety as we admire the ‘emperor’s new clothes’ of medical certainty. It’ll take time but anything that is worthwhile needs just that – be it a relationship, an education or a fine bottle of wine. Nothing of worth can be said in 280 characters, and wisdom is not immediate.

So we need to take some real time to consider the wisdom of what we do. Let’s have jam tomorrow rather than yeast extract today. That way we may avoid imposing on our patients all our self important interventions, along with all of their adverse effects and dubious benefits, before, confusing them, and ourselves, when the medical consensus changes again next week.

Ancient wisdom calls us to ‘Be still’ – such a phrase doesn’t refer just to the absence of movement – it’s a call to be quiet and realise that we make too much noise and that much of what we say and listen to would have been better left unsaid.

Wouldn’t it be great then if we could just ignore it all? If we could be that wise! But of course we couldn’t…could we? We have to be seen to be learning to comply with revalidation regardless of whether that learning is helpful. And just to make sure that we’re doing it, we must reflect on how that learning has helped us lest we conclude that it hasn’t. It all seems just a little bit, dare I say it, Big Brother. There seems to me an irony in the fact that the very educationalists who, not so long ago, encouraged us to understand our learning style and play to our strengths, are the very same educationalists who now insist that reflection is king.

All learning styles are equal, but, it seems, some learning styles are more equal than others.

Is it just me or has anybody else noticed that those of us who actually are more reflective by nature, aren’t activist enough to record the process of doing so and those of us who are activist enough to record their reflections aren’t reflective enough to have anything to reflect upon!

So let’s at least spend less time reflecting on ourselves. We’re really not that interesting you know. Narcissus, from whose name we get the words ‘sleep’ and ‘numbness’, came to a soggy end. So let’s wake up and feel something other than the sense of being drowned by the information bombarding us.

So why don’t you just stop reading this medically related post and go and do something less boring instead? Come on – who’s up for doing less?. Who’s ready for such a brave new world? Because something really does need to change.

And with that, I think I’ll take my own advice and shut up for a bit because I suspect I’ve said far too much already.