Has anyone seen General Practice?

‘No one to follow

And nothing to teach

Except that the goal

Falls short of the reach’

Leonard Cohen

A few weeks ago I made it to London’s Guilgud Theatre to see ‘The Girl from the North Country’. It’s a play by Connor McPherson which incorporates the music of Bob Dylan and, though on the face of it having nothing to do with medicine, nonetheless touches on a number of issues which relate to general practice.

The first was pretty obvious. Set in 1934 during The Great Depression, the play charts the fortunes of those staying in a rundown guesthouse in Duluth, Minnesota. Nobody is finding it easy. The various residents have each suffered some downturn or other be that the heartache of a broken relationship, the financial hardship of a failed business venture or the disappointment of a dream that has failed to materialise. And so they find themselves endeavouring together to eek out an existence at a time when hope is in short supply. As such they are not so very different to the folk we find sitting in our waiting rooms each day.

And then there is the plays’ portrayal of those with problems in relation to their mental health. The son of one couple staying in the guesthouse has learning difficulties and the wife of the owner of the hostel suffers from a form of dementia which makes her behaviour erratic and difficult to manage. Neither can find their difficulties easy to live with but it is equally apparent that neither is it easy for those who are close to them.

To love those who are distressed can be extremely painful. When supporting patients with mental health problems it’s easy for us to forget how hard it is for those they live alongside.

Inevitably there are times when those we love make life more difficult for us, but it is a measure of the depth of the love that we feel for them that we are prepared to accept and live with that difficulty. After all, to love is to bear the pain that the love brings with it.

To abandon someone when the cost is too high has nothing to do with love, and yet, because we are all still human, it should not surprise us too much when, like the characters in the play, we find ourselves struggling with conflicting emotions and frustrated by those we love the most. Sometimes we may even find part of ourself longing to be free from those to whom we are most closely bound. True love, however, does not cut itself free, no matter how strong that desire sometimes becomes.

Thinking about this I found myself wondering about my relationship with the world of medicine. It too can drive me to distraction. At times it can make my life both difficult and frustrating, all on account of the way that it sometimes behaves, ways that seem irrational, demanding from me as it does what is not only undeliverable but also that which seems nonsensical. And yet, despite all this there is something that holds me to the profession, a profession which continues to remain dear to me.

Which brings me to the final thought that I had in relation to the play, one that follows on from what I have just said. And it’s this – that the love I have for the job that I have had now for nearly 30 years often goes unrequited, not by the colleagues I work with, nor by the patients I see each day, but by the system that I work within.

For me the most powerful song in the play comes early in the first act and is sung by a character who finds herself pregnant. The father is nowhere in sight. A load is born on account of one who offers no support. The song she sings is bittersweet. Full of longing for the one who has deserted her she repeatedly pleads, ‘Has anyone seen my love?’ And yet she is honest about the hurt that she has been caused. The song, ‘Tight Connection to my Heart’, contains words that seem particularly appropriate for those of us for whom medicine remains dear, despite the fact that, as the years go by, we are forced to bear an ever increasing burden with little encouragement from those who ask us to carry it.

Isn’t our love affair with medicine sometimes like a dysfunctional one sided relationship where one individual is taken advantage of by the other?

Think about it. How often do you feel anxious before the day gets started at the mere prospect of being on call, how often could you sing along with ‘my hands are sweaty and we haven’t even started yet’. How often do we feel overwhelmed by the demands of a job that forces us to work at a speed with which we are uncomfortable and yet find ourselves tied down by the requirements of the very system that demands we practice at the rate we do. I for one this week could have readily sung, ‘I had to move fast, and I couldn’t with you around my neck’.

We all know that there’s something seriously wrong with the system and yet we struggle to find a way to change it. And so we find ourselves having to go ‘along with the charade until [we] can think [our] way out’. The ridiculousness of so much of what we do bothers us constantly, it seems sometimes like ‘a big joke’, one that ‘sometime, maybe, [we’ll] remember to forget’. Our working conditions are often far from ideal but still the work has to be done and so we press on, ‘[We’re] gonna get [our] coat[s], [we] feel the breath of a storm, there’s something [we’ve] got to do tonight’. The policy makers however, they can ‘go inside and stay warm’.

But despite our best efforts the powers that be are never satisfied with us. They ‘want to talk to [us]’. Well they can ‘go ahead and talk, whatever [they’ve] got to say to [us] won’t come as any shock.’ We’ve familiar with the constant implication we could and should do better. ‘[We] must’, it seems, ‘be guilty of something, [they] just whisper it into our ears’.

Deep down though, we believe, or at least want to believe, that General Practice remains ‘the one [we’ve] been looking for, the one that’s got the key’. Nonetheless, we not infrequently find ourselves wondering if we’re up to the task whilst, at the same time, questioning why we continue to put up with what we are asked to. And so we feel unable to ‘figure out whether [we’re] too good for [the job] or [it’s] too good for [us]’.

‘Oh but it’s sad when a love affair dies but’ as Tim Rice penned, ‘we have pretended enough’. But about our relationship with medicine in this way might just help us to understand why we find ourselves where we are. So why do relationships sometimes fail?

One reason perhaps is that the one who was loved was originally viewed through rose tinted spectacles, perceived far most positively than was ever warranted. This may largely be because the idealised version of the beloved was the one that the person who once loved wanted to believe. In time though, the true nature of the beloved becomes apparent and, with the truth no longer deniable, love grows cold. How many of us I wonder went into medicine encouraged by a careers advisor who promised us that it was the best of all possible jobs and how many of us imagined that our working lives would look like something out of the ‘Doctor at Large’ films. I doubt I’m the only one who went into medicine with my eyes firmly closed and subsequently found the reality somewhat different.

Another, and far more important, reason why relationships fail is that the one who was loved changes. Somebody who once genuinely promised good things to another changes and becomes somebody who now takes advantage of the one who loves them and demands from them only what they themselves desire. Might not medicine have been a little like that?

Where once medicine promised secure employment along with plenty of opportunity to genuinely help people, it has now become, for many, a cruel task master who, as well as demanding we act in ways that we are not always sure are in the best interests of our patients, constantly threatens us with severe reprimand if we ever fall short of its definition of perfection.

And finally, of course, relationships can fail because the one who once loved changes, perhaps as a result of the very relationship they entered into so enthusiastically. Over time, the one who once loved no longer wants the things that the beloved once offered. Broken by the system, I wonder how many of us now realise what we should have appreciated long ago, that the financial reward and degree of social status that medicine offers, comes, for some, at too high a price.

Of course it’s not just medicine. We live in a world where too many people are treated as commodities to be consumed. The media uses individuals for as long as they are useful and individuals are exploited by those who are only out to make a quick buck. And it also seems to me that increasingly many of our patients, regardless of the genuineness of their illness, are unaccountably facing ‘disciplinary meeerings’ when, on account of their sickness record, they are not as productive as their employers would like.

A wise old counsellor once said to me that when we find ourselves in a unhealthy relationship we have three options. We can put up and shut up, we can get out or we can change.

Whilst the first of these options is undoubtedly the worst, and the second, though understandable, is frequently a cause for sadness, the third, if it is at all possible, is the most preferable option. My counsellor friend may have missed an option however because, of course, sometimes, getting out or change simply isn’t possible, not immediately at least. And when that’s the case, better than ‘putting up and shutting up’ it’s far better to voice ones struggles to a friend who can be with you through the pain even if they can’t take it away.

That said, positive change, making good what currently is not, is, undoubtedly the ideal and therefore, what we need to try to bring about. But it’s not our colleagues that continue to support us and who are a joy to work alongside that need to change, and nor is it our patients who are generally a pleasure to interact with day by day. Rather it is the system that needs to change, a system on whose behalf we must no longer make excuses.

Rosa Parks was the woman who, in 1955, lit the spark that ignited the civil rights movement when she was asked to give up her seat on a Montgomery bus for a person with white skin. She simply said ‘No’. Our problems are comparatively trivial, but I can’t help thinking that we would do well to say a quiet yet determined ‘No’ to the ‘general practice’ that is being forced upon us. Not only is it unsustainable, it is also, for all its frenetic earnestness, threatening to have as its goal something that falls short of what it could be reaching. Medicine needs to stop sacrificing its soul on the alter of algorithm driven protocols and seek, instead, to retain its heart and mind and remember how to think and feel. Although we may have to accept the consequences, it may just have the effect of maintaining the profession which we chose to become a part of and mean that, when our time comes to retire, we are genuinely sad to leave.

For anyone interested, you can listen to Sheila Atim’s wonderful rendition of ‘Tight Connection to my Heart’ from the Original London Cast Recording of ‘The Girl from the North Country’ here. Do have a listen, it’s well worth it even if, unaccountably, you’ve no interest in Bob Dylan himself.

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