On not remotely caring

‘Those who feel the breath of sadness, sit down next to me

Those who feel they’re touched by madness, sit down next to me

Those who find themselves ridiculous, sit down next to me’

James

Back in the 1960’s, in the days before research required ethical approval, American social psychologist Stanley Milgram carried out a series of experiments designed to investigate the extent to which subjects would submit to the demands of those in authority. Individuals, believing that they were assisting research into how punishment influenced somebody’s ability to learn, were, on the instruction of an ‘experimenter’, asked to act as ‘teachers’ and administer electric shocks to ‘learners’ every time they failed to answer a question correctly. With each wrong answer the ‘learner’ gave, the strength of the administered electric shock increased. Unbeknownst to the ‘teachers’ however, it was they and not the ‘learners’ who were the real subjects of the experiment. In reality, no electric shocks were being given and the ‘learners’ were merely actors who were simulating the effects of the shocks that they were supposedly receiving. The study revealed an alarming willingness on the part of subjects to act against their conscience when told to do so by authority figures with some, on the say so of another, even prepared to give potentially lethal electric shocks to vulnerable individuals with supposed heart conditions.

But what, to me at least, is more interesting still, is how the subjects of the study were prepared to give significantly higher shocks, when those supposedly receiving them were at a greater degree of separation from they who were administering them. That is, as the strength of the shocks got increasingly more dangerous, subjects were more inclined to refuse to administer them when they were able to see the one supposedly being shocked than when they could only hear their apparent cries of anguish. And they were more willing to administer the most dangerous shocks to those from whom they more separated, those who they were kept from both seeing and hearing.

It would seem therefore that the less contact people have with others the less they are concerned about their welfare and the more they are prepared to act against conscience in order to just get the job done.

I wonder if this has something to say us who, over the last year in particular, have been encouraged to remain remote from our patients. Leaving aside the dangers of missing important diagnoses and the withholding of human contact from those who really would profit simply from sometimes seeing us, could it be that working remotely has adverse effects on us too? Might it be that the less contact we have with those for whom we are supposed to care leaves us less concerned about their welfare than we might otherwise have been and result in our being more likely to simply going through the motions as we too just seek to get the job done? Furthermore, as a result of less time with us, might our patients also end up caring less about us?

A year ago we heard a lot about the so called ‘new normal’ but make no mistake, there has been nothing normal about the virtual world we have been living and working in this last year. We are all diminished by such a virtual existence. As tentative steps now begin to be made towards a life without restrictions I hope we won’t seek to hold on to our remote methods of consulting, or, at least, not too tightly. For though some problems may genuinely benefit from such an approach, many do not. And even though some conditions can be managed perfectly safely over the phone, that doesn’t mean that they aren’t better dealt with face to face. I know for sure that this week I have made at least one better, more humane, decision as a result of seeing a patient I might otherwise have even tempted to manage from a distance.

Since, as Milgram’s experiments seem to suggest, remote care runs the risk of us not remotely caring, avoiding patient contact is detrimental for both patients and doctors alike. Furthermore, by working at arms length from our patients, we have allowed much of the satisfaction that the job once held to slip though our fingers. As restrictions begin to lift, rather than holding onto the remote consulting that some see as more efficient, I believe we would do well to once again make face to face consultations with patients our normal working practice. By doing so, not only will we providing better care, we will begin to grab back some of the job satisfaction that has been lost in the last year.

Two years ago I wrote of my unease about how medicine was being encouraged to adopt more remote ways of delivering healthcare. That article can be read here. I never imagined then that I would be practicing the way I have been forced to this past last year, encouraged as I have been to avoid patient contact wherever possible. For me it has not been a happy transition and it has not been one I have found terribly easy. Nor is it something that I have done terribly well, for which I am not sure I’m sorry. Even so, as we now move slowly out of lockdown, such a remote existence must not be allowed to become the norm, not for medicine, nor, indeed, for any other area of our day to day lives. Because it’s simply not healthy.

Humans are social creatures, to fully live we need to have contact with one another, we need to touch. When lovers kiss, it’s more than just a sign of their love, it is an act of love too. And that’s important because more than simply knowing we’re loved, we need to feel it too.

We need to be present in each other’s lives. As in the words of the song, ‘It’s hard to carry on when you feel all alone’. Sometimes, when it seems there is nothing one can do, to simply be there is of genuine value. 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.’

Perhaps that is also the type of GP who cares. If Milgram’s experiments have anything at all to teach us, perhaps it is this: that it is not simply that those who care will draw close to those in difficulty but rather it is those who draw close to those in difficulty who will find themselves caring for others in ways that they wouldn’t otherwise have been able.

We have all had to endure it for nearly a year now, but over the coming months let’s look to leave social distancing behind – in all its forms. And let’s look to sit down with, and care for, each other once more.

Because living a contactless life isn’t a remotely good idea. It would be shocking to think otherwise.

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To read ‘Contactless’, the article mentioned in the above post that was written two years ago, click here

To read ‘Eleanor Rigby is not at all fine’, click here

To read ‘Hannah Arendt is completely fine, click here

To listen to the song ‘Sit Down’ by James, click here. You can even sing along – you know you want to!