GENERAL PRACTICE – STILL A SWEET SORROW

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Well it’s not getting any easier. A few years ago I wrote about how a then recently announced new GP contract had been met with some enthusiasm as a result of it promising to fund the additional support which, it was said, would lighten the load of primary care. What is all too clear today is that this aim has not been realised and GP workload has risen exponentially. And it’s not just primary care that’s struggling. All public services are facing a crises where there simply aren’t the number of people needed to provide the care that is required and so we find ourselves in a situation where I can be phoned up by social services to regretfully inform me that they do not have the capacity to offer any care to a frail man in his 90’s who is lives alone and is bed-bound.

Furthermore, one can’t help believing that it’s all going to get a darn sight worse. As the current financial crises lethally combines with a huge surge in energy prices, many are understandably concerned about how they will be able to heat their homes and so, with winter fast approaching, there will it seems, inevitably be many who will not be able to afford to maintain their already fragile health.

Likewise In primary care, there is simply not the capacity to provide the care that is required. And this too seems certain to only get worse as the overwhelming demand coupled with a growing sense of work dissatisfaction results in GPs leaving the profession at an alarming rate with the BMJ earlier this year reporting that a third of GPs intended to no longer be involved with direct patient within five years. Those left behind are more unhappy than ever evidenced, not only by surveys that say as much, but also by social media forums seeing an alarming increase of anonymous posts from those detailing the struggles that as health care professional they are experiencing.

Whilst the offer of additional support that was offered by the aforementioned new GP contract was not unwelcome, I wrote at the time of how I couldn’t help thinking that something important was being missed. Because, for my money, rather than employing additional support staff to give us the time to continue to pretend to be able to do what many insist General Practice must, the real problem remained was that there was not enough GPs. Only greater numbers of GPs would give us the time to properly do what GPs do best – tread the thin line between on the one hand delivering a healthy dose of medicine whilst, on the other, resisting the medicalisation of normality and easing us instead toward an understanding that we will inevitably fail to do that thing that everyone would like us to – namely to make everything OK.

But even if there were more GPs, making everything OK, is simply not something that primary care services could ever hope to bring about. Even so, encouraged by an all too often toxic press, the public has been led to believe that we are failing when we cannot bring about this impossible goal and so it is, perhaps, little wonder that patient satisfaction with general practice is currently so low. And nor is it surprising that so many GPs are disillusioned too. This week, out of interest, I calculated my PHQ-9. I scored 20. But, contrary to what many would suggest, this does not indicate that I am severely depressed but rather that I am saddened by the sadness that I see all around me and by the fact that I am powerless to do anything about so much of it.

The problem then, or so it seems to me, is the same now as it was when I wrote previously, only more so. We continue to try to practice medicine in a world that does not exist – one in which health can be indefinitely preserved, sadness can be successfully avoided and suffering can be permanently diverted. If such a world did exist, all we would need is sufficient experts, each working in their respective fields, doing what was required to deliver the desired utopia. But the truth is that we live in a world where death is inevitable, suffering is widespread and sadness is ubiquitous. Rather than specialists to steer us away from what can’t be avoided, we need generalists to be with us as we walk through the mess of the everyday.

‘There are two kinds of pity: difference perceived – which is the beginning of pride; or fellowship recognised – which is the beginning of love’.

So said J.R.R. Tolkien and, if he is right, to really care, we are going to need a kinship with our patients which will require us to live, grow old and, perhaps, die alongside them as we experience something of all that they are going through. We need to be like them, if we are to understand them. Many of them are more realistic of what they can expect to get out of life than we are. Rather than always being offered spurious solutions to the problems that can’t be solved, they are often content with the knowledge that someone simply understands them and can accompany them as they face their difficulties. Such was my experience this week. Just as joy can be found in sadness, and strength can be found in weakness, so then General Practice’s greatness is found in its lowliness – a lowliness that we must not lose.

I have a confession to make. I like the music of Leonard Cohen and was saddened a couple of years ago to learn of his death. I understand that he is not everybody’s cup of tea, it wasn’t without reason that he was known as ‘the godfather of gloom’, but, for all that he seemed to me, in his later years at least, a gentle person with a wry, self-deprecating sense of humour, who thought deeply about the big issues of life. I would have been interested to have met him and would certainly have liked to have heard him play live and see first-hand the obvious pleasure he experienced from the audience’s ironic cheer as he growled out the line ‘I was born like this, I had no choice. I was born with the gift of a golden voice.’ Some years before his death he was asked a question regarding the fact that much of his music is melancholic in tone. His answer was, for me, illuminating. He said:

‘We all love a sad song. Everybody has experienced the defeat of their lives. Nobody has a life that worked out the way they wanted it to. We all begin as the hero of our own dreams in centre stage and inevitably life moves us out of centre stage, defeats the hero, overturns the plot and the strategy and we’re left on the sidelines wondering why we no longer have a part – or want a part – in the whole damn thing. Everybody’s experienced this, and when it’s presented to us sweetly, the feeling moves from heart to heart and we feel less isolated and we feel part of the great human chain which is really involved with the recognition of defeat.’

I like this quote – its honesty about the reality of what life is really like – an honesty that we too often lack. If a melancholic song can connect singer and the one listening, and make us feel less isolated, how much more can a genuine sharing of our defeat help us feel part of the ‘great human chain’?

To be that kind of a doctor, despite all the good we can genuinely do, we need to acknowledge and share our own failures, our own ordinariness, our own inadequacy. Rather than consider some tasks beneath us, we need to deal with the dull, because, out in the sidelines, the mundane is every bit as meaningful as that which allows us to pretend we’re still the hero in centre stage. We really aren’t any different from our patients – the more we realise that and stay close to them, the better General Practice will be for it.

Take sadness. Despite the joys that are undoubtedly present, this is often a sad world, frequently a vale of tears. And regardless of the cause, the sorrow of sadness hurts. Frequently that pain, for want of anywhere else to take it, is brought to the GP. Without doubt, there is a lot of it about, and it cannot easily be dismissed with the psychological equivalent of ‘it’s probably a virus’ and a facile assurance that the feeling will soon pass. What then are we to do?

First we need to make the right diagnosis – distinguish normal sadness from pathological depression, if such a thing exists at all. Certainly the former is by far the most common. In almost every presentation the cause for the sadness is all too apparent with no need to suppose a pathological biochemical imbalance to account for it.

Be that as it may, having made our diagnosis we need to resist the temptation to medicalise normality, even if by presenting to the GP, the person in front of us has themselves sought out a medical solution to their distress. It’s then that we need to be truly general practitioners, super generalists even. In fact we need to be so general that we are not medical at all since it is then that the labels of ‘doctor’ and ‘patient’ become barriers to what we really need to be – simply human.

Of course we all want to help and we may understandably want to offer what only we as medics can, namely medication. But whilst the pills may help to numb the pain, they don’t take fix the problem any more than morphine may alleviate the agony of a broken leg that is still made up of fractured bones. Furthermore an undue reliance on medication, as well as potentially leading to dependence, risks telling the patient they are wrong to feel the way they do, that their sadness is inappropriate when, in truth, as we have all surely known ourselves, it is nothing of the sort.

There is, perhaps, a better, though less comfortable remedy. We need to understand the sadness – even if we cannot fully explain it. Having recognised the normality of the sorrow ourselves, the sad patient in front of us needs to be helped to see the normality of their feelings. To those who are new to sadness this may come as a shock, especially in the entertainment rich and superficially upbeat culture we inhabit. Abraham Lincoln once commented that, ‘In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares.’ Rather depressingly, but perhaps accurately for some at least, Lincoln continued with, ‘The older have learned to ever expect it.’

To acknowledge the normality of sadness is not to deny the intensity of the suffering – because it’s normal doesn’t make it any less awful. But only having acknowledged its normality can we truly accept the sadness, and allow the grief to be expressed without trying to explain it away. After all, you can’t rationalise away that which is not irrational.

We like to solve problems – to ease suffering – and sometimes, wonderfully, we can. But sometimes there is no pill to take away the distress, no wise insight that will alleviate the pain of sadness, no remedy to stem the flow of tears. To pretend otherwise is untruthful, unhelpful and unkind. As physical pain alerts us to something being wrong and indicates action must be taken, so too emotional pain can serve a similar purpose. Denying its normality, its usefulness, removes all hope of the cause ever being addressed.

But sometimes, of course, the cause can’t be addressed – there is no earthly solution, there is no going back, no doing things differently next time. Sometimes not even time will help. Sometimes the pain of sadness may go on and on.

In such circumstances we may well feel useless, but that’s not necessarily so. Knowing our inadequacy allows us to stop being doctors who can’t help and allows us to become people who can – by entering a little into the grief of those with whom we sit. There is a sweetness in sharing sorrow because being alone in one’s sadness is too great a burden for anyone to bear.

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.’

And sometimes at least, that is also the way GPs care. The question then becomes, at a time when it is, perhaps, more necessary than ever that they do, will those working in primary care be allowed to practice in such a way. Or will it be the case they will be just too busy to care.

We must surely hope not.

[This is an updated version of a blog first published in February 2019]

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Related blogs, starting with one about the dangers of perfectionism:

To read ‘Professor Ian Aird’ – A Time to Die?’, click here

To read ‘On being overwhelmed’, click here

To read ‘I’ll miss this when we’re gone’, click here

To read ‘The Abolition of General Practice’, click here

To read ‘On being crazy busy – a ticklish problem’, click here

To read ‘Blaming it on the Boogie’, click here

To read ‘Health – it’ll be the death of us. Is there institutional arrogance in the NHS?’, click here

To read ‘It’s all right ma (I’m only GPing)’, click here

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

To read ‘Hearing the grass grow’, click here

To read ‘The Repair Shop’, click here

To read ‘Gratitude and Regret’, click here

To read ‘An audience for grief’, click here

To read ‘Do you hear the people sing?’, click here

To read ‘On keeping what we dare not lose’, click here

Three blogs which, in my head at least, make up a trilogy on the subject of burnout:

To read ‘Somewhere over the Rainbow’, click here

To read ‘When the Jokes on You’, click here

To read ‘With great power…’, click here

A couple of stories about GP life:

To read ‘Mr Benn – the GP’, click here

To read ‘A GP called Paddington’, click here

And finally, a couple of explicitly Christian blogs to finish with:

To read ‘T.S. Eliot, Jesus and the Paradox of the Christian Life’, click here

To read ‘Because the world is not enough’, a version of the above blog with a Christian twist, click here

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