‘I’ll go along with the charade until I can think my way out’
Bob Dylan
Recently a patient presented at the practice where I work having been sent to us by a doctor from the local minor injuries unit. She had been advised to request an urgent blood test to determine her blood levels for a certain heavy metal after an ECG she’d had had shown some minor abnormalities. It subsequently turned out however that the automated report had attributed these abnormalities not, as had been believed, to lead poisoning but merely to lead positioning!
An embarrassing mistake to have been made by somebody who had clearly not been thinking properly. But before we laugh too loudly, I wonder how many times we too have stopped thinking for ourselves, failed to see what was there to be seen and addressed only our own ideas, concerns and expectations rather than those of our patients.
As time pressured clinicians it is all too easy for us to stop thinking for ourselves and fall into stereotypical patterns of behaviour based on the assumptions we make and which, though they may speed our decision making, too often serve our purposes more than they do our patients causing us as they do to draw conclusions which steer us down those familiar paths along which we find it more comfortable to travel.
Might it be that we too have stopped thinking properly, failed to see what was in plain sight and thereby absolved ourselves from any responsibility to help as we have passed blindly by on the other side? I don’t doubt that I have, on occasions, done just that and am left asking myself why that might be.
Of course the easy answer to that question would be to say that it’s because I’m either too lazy, too incompetent or too busy to address the problems that are presented to me properly. I suspect that, if I am honest, each of those explanations have almost certainly sometimes been true, but another explanation might be that, rather than face the distress of a problem that cannot be solved, it has sometimes been easier for me to not notice what medicine cannot fix.
In his book, ‘How to think’, Alan Jacobs writes of how, once established, the consensus is hard to challenge because there is great comfort in sharing the commonly held position. He quotes Marilynne Robinson who suggests we have a ‘collective eagerness to disparage without knowledge or information’ alternative or unpopular views ‘when the reward is the pleasure of sharing an attitude one knows is socially approved.’
If this is true, as doctors we are, in the medical setting, predisposed, without thinking, to endorse the view that medicine can solve all our problems because we know that, given they have presented to us, those we are talking to are likely to share this view, and will approve of us for so doing. This is, perhaps, particularly true on account of how so many of us in medicine do so want to be liked.
We are, in the moment of the consultation, invested in not thinking because, it would feel too uncomfortable to disagree because, as Robinson puts it, ‘unauthorised views are in effect punished by incomprehension…as a consequence of a “hypertrophic instinct for consensus”.’
Jacobs asserts that if we want to think, then we ‘are going to have to shrink that “hypertrophic instinct for consensus.” But, he says, ‘given the power of the instinct, it is extremely unlikely that [we will be] willing to go to that trouble”
Jacobs believes that the ‘instinct for consensus is magnified and intensified in our era because we deal daily with a wild torrent of what claims to be information but is often nonsense’. That is certainly true in the medical world where nonsensical demands are too often unjustifiably imposed upon us. Jacobs quotes T.S. Eliot who, almost a century ago, wrote, ‘When there is so much to be known, when there are so many fields of knowledge in which the same words are used with different meanings, when everyone knows a little about a great many things, it becomes increasingly difficult for anyone to know whether he knows what he is talking about or not.’ And in such circumstances, ‘when we do not know, or when we do not know enough, we tend always to substitute emotions for thoughts.’
That is, confused about what to believe, we will default to what feels comfortable and agree with the consensus, the perceived wisdom. Could it be then that when we are presented with a problem we cannot fix, a problem for which medicine is not the answer, the cognitive dissonance we therefore experience serves to make it less likely that we will see that problem at all and and end up seeing only those with which we feel we can deal.
Jacobs believes that ‘anyone who claims not to be shaped by such forces is almost certainly self-deceived.’ We are social beings who need to feel accepted and, since agreeing feels good, we are prone to toe the line. ‘For most of us’, Jacobs suggests, ‘the question is whether we have even the slightest reluctance to drift along with the flow. The person who genuinely wants to think will have to develop strategies for recognising the subtlest of social pressures…The person who wants to think will have to practice patience and master fear.’
So could we as General Practitioners do that? Could we practise patience and master fear and thus resist the ‘hypertrophic instinct’ which insists that medicine is the answer to all our problems.
I’d like to think we could but it will be uncomfortable, as speaking the truth often. It’ll mean giving up the charade that as doctors we have all the answers and accepting instead that there are times when we can do no more than simply notice the distress our patients are experiencing, acknowledge it for what it is and, perhaps, try to ease it a little by being human enough to sit alongside them and share in it with them for a while.
Which will be a whole lot more use than another unnecessary blood test.
Some musings 