Ain’t it just like the night to play tricks when you’re tryin’ to be so quiet?
We sit here stranded, though we’re all doin’ our best to deny it
Bob Dylan – Visions of Johanna
I’ll spare you the embarrassment of me breaking into song but, as has been made very clear of late, a GPs lot is not an entirely happy one.
The last year and a half has been difficult professionally. And especially so in recent months during which time our workload has rocketed. But although it hasn’t helped, for me at least, it hasn’t simply been the busyness of the job that has made it less enjoyable. Rather it has been how we have been made to work.
I know I’ve banged on about this before but working remotely isn’t a remotely good way to work. It’s not good for our patients and it’s not good for us either.
It’s not good for our patients because, as research has shown, the more distant we are from those we interact with, the less we care about them. And the less we care about them the less we will be inclined to help. I suspect that my concern for my patients has been less this past year than perhaps it once was, and I feel that I’ve not been as good a doctor as a result, not that for one minute I’m suggesting I was ever all that great a one in the first place.
It was Bette Midler who wrote the song ‘From a distance’. In it she suggests that ‘form a distance’ it appears that we all have enough and that no one is in need. ‘From a distance’, she continues, there are no guns, no bombs, and no disease. And it would seem that there are no hungry mouths to feed.
Which only goes to show that ‘from a distance’ we haven’t got a clue about what is really going on. To live our lives separated from what hurts has its appeal of course ‘A rock feels no pain’ sang Simon and Garfunkel, ‘and an island never cries’. Looking on ‘from a distance’ makes life simpler, tidier, less painful. Even so the reality remains that life is generally complicated, it is frequently messy and all too often it hurts.
But being close enough to care makes us better doctors. And being better doctors is ultimately what will make us happier in our work despite the sadness we will undoubtedly experience in the process. That’s not to say that as doctors we will always be able to help. Often we can’t, not, at least in any material way. Henri Nouwen once 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. One who is not satisfied to look on dispassionately from a distance but who instead is willing perhaps to take a leaf out of the Beatles songbook. One who realises that it is only by letting others into our heart that we can we start to make things better. One who well knows that ‘it’s a fool who plays it cool by making this world a little colder’.
A couple of years ago retirement seemed an age away for me. Now it seems a lot closer. A few weeks back, after chatting about the imminent retirement of one my colleagues, a patient said to me, ‘You’re not thinking of retiring too are you?’. I replied: ‘All the time!’. But my partners needn’t worry, I’ve no immediate plans to go. But it’s only my being able to be close to patients again that will keep me in the job.
Because that’s what I enjoy. I need to enjoy my job, and my patients need me to enjoy my job too. For it is better to be cared for by someone who enjoys their work than someone who is dutifully going through the motions.
So let me hang some of these ideas on an example or two. On things that have brought me pleasure this year.
Firstly there was helping out at the local Covid vaccination centre. Without a doubt the most rewarding work I’ve done this year. To be part of a team doing something so simple and yet so genuinely worthwhile was immensely satisfying. Back then the daily death rate was at its highest – peaking at 1820 in a single day if memory serves me right. At the time it was tempting to console oneself with the thought that it was only the frail and elderly that were actually dying in any numbers, and that as such it somehow didn’t really matter. But in those early days it was the self same frail and elderly that were attending the vaccination centres for their jabs, each a representative of the cohort of people who were largely making up those whose deaths were being reported daily on the news. And what a warm, friendly, appreciative bunch of people they were. ‘From a distance’, it was just old people who were dying. Up close they were a group made up of delightful men and women.
And secondly there was that time up at one of the local nursing homes. I admit to having been a little frustrated to be called to visit a demented old man late one evening at the end of what had already been a busy on call day. He was ninety if he was a day and clearly close to death. The junior nurse showed me his TEP form which suggested that I should be admitting him to hospital but to my mind that seemed a far from sensible course of action. The nurse manager who, incidentally, started working at the home the same year I first worked at my practice, was there that evening. She said how she’d be sad if the man she’d known for 15 years died in hospital. So I spoke to his only relative, a younger brother, who agreed that he should be left where he was and simply kept comfortable. But what I found hugely touching was what the brother said next. ‘I want you know something doctor. That man is my hero – for caring for me when nobody else would.’
He didn’t say ‘He WAS my hero’ – he said ‘He IS my hero’. From a distance the patient was a demented old man with no quality of life, but up close he remained somebody who was someone else’s hero. It was good for me to be at that nursing home that evening. I was glad I was there.
We need to get close to our patients if we are to care for them as people rather than merely manage them as problems. Furthermore getting close to our patients increases the chance of them caring about us. Keeping our distance diminishes our patients even as it dismisses us as doctors. I hope we never think a contactless existence is the goal to which we should aspire.
Because there are too many people living contactless lives already. And some of those lives are immensely sad as a result.
Leonard Cohen, sometimes known as the ‘Godfather of Gloom’ on account for his reputation for writing songs that some consider depressing once wrote: ‘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 dramas 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 side-lines 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’.
Sometimes I feel that sense of defeat at work, and sometimes outside of work too. But that’s ok. At least it is in my saner moments. Because I am of course getting older. I’m way passed my best, finished with growing stronger, and done with constantly striving to get better. Mine is a ‘necessary fallibility’. At my next appraisal I hope to talk with my appraiser, not about what I need to improve nor even what I can do to simply maintain the position I now find myself in but rather how I might best manage my inevitable decline! But though being defeated may be painful at times, it is not without meaning. Like Leonard Cohen in his song ‘The Goal’, I need to be able to smile a ‘smile of defeat’. For me that will only come from understanding that it is OK for me to lose when the one by whom I am defeated is one to whom I can happily surrender, one who is able to rule my life far better than I could ever rule it myself and is the one whose own apparent defeat led to what I consider to be the greatest victory of all, that over even death itself.
‘Anthem’ is another of Leonard Cohen’s songs. In it he sings ‘Ring the bells that still can ring, forget your perfect offering. There’s a crack, a crack in everything, that’s how the light gets in.’. I take that to mean that we should be content to do what we can and stop imagining we can ever be perfect. We learn through our mistakes, and sometimes it’s our mistakes that enable us to better understand. Bob Dylan expresses something similar in lines reflecting the fact that he knows he’s getting older and will soon die. ‘It’s not dark yet’ he says, ‘but it’s getting there’. Even so ‘behind every beautiful thing there’s some kind of pain’. I love these songs. I find them helpful. And I think the reason for that is the one that Cohen suggested, the connection that they make between those who feel the same.
I am of course grateful too for all the support that I have received from those I work alongside, both my clinical and non clinical colleagues some of whom are themselves finding life difficult. I hope I am never so wrapped up in my own problems that I am not a support to others. Because I really do like them, they are amongst my best friends and I couldn’t wish for a better bunch of people to go through life with. Or perhaps I could. I wish the colleague who is soon to retire could hang around longer. I am going to miss him. When he’s not there. Hugely. Because not only is he the best doctor I have ever had the pleasure to work with but he has also been a genuine and generous friend, someone I have known I could ring anytime day or night if I had need. And over the last twenty five years there have been times when I have had just such a need. When we first met in 1996 he promised me that he’d make me a millionaire as a result of some scheme he had back then of exporting medicines to America. Well I’m still waiting for that but I’ll forgive him because his friendship has been worth vastly more than a mere million pounds. His replacement has big shoes to fill!
But before you imagine that my life is all doom and gloom, let me assure you it’s not. Somerset had quite a good season this year and I enjoyed introducing my sons girlfriend to the joys of singing ‘Sweet Caroline’ with thousands of others one memorable August evening at the county ground in Taunton. There was the evening of laughter with my wife watching Ed Byrne at a packed Bridgwater Art Centre. Hilarious! And Bob Dylan recently had a cracking new album out and, at the age of 80, 24 years after he first noted the light was fading, he has, perhaps optimistically, just announced a new three year world tour. Hopefully I’ll get to see him on stage once more before he dies – because everything is better done live. The Korean food beautifully cooked by my daughter is best experienced when tasted rather than when seen via a photo shared on messenger. Things done remotely don’t come close! Oh and I nearly forgot, I have become a grandad too and after a hairy start my grandson is doing just fine. He too can now smile as well as cry. I’ve some lovely photos I could show you but he’s even more gorgeous in the flesh. It feels good to hold him.
In what has been a difficult year, these are things that have brought me pleasure. I have long considered that we make a mistake if we wait until there is nothing in life that makes us sad before we allow ourselves to be happy. Because, as it seems to me, happiness and sadness sit constantly alongside one another, we must allow ourselves to be happy even though there are things that make us sad just as we must allow ourselves to be sad even though there are things that make us happy.
Finally back to that song by Bette Midler. For me the saddest lines of the song are the ones suggesting that God is watching us from a distance. I don’t believe that’s true. Rather, I believe that He is close, intimately involved in my life, in all our lives and indeed in the lives of those who are struggling in circumstances far, far greater than our own. And though I’m aware that not everyone will share my faith I nonetheless believe that God really does knows what we are all facing, that He is in absolute control of it all, and that He will ultimately make everything right.
Written shortly before his death, ‘You want it darker’ contains, for me, one of Leonard. Horn’s finest lines. It goes like this: ‘There is a lullaby for suffering and a paradox to blame. But it’s written in the scriptures and it’s not some idle claim’
And it’s in those scriptures that I read that though weeping may tarry for the night, joy will come with the morning, that though I may fall I will nonetheless one day rise and that a day is coming when God will wipe away every tear from our eyes, and death shall be no more.
It’s promises like these that provide me with the hope I need to enable me to keep on keeping on irrespective of how dark it sometimes still seems.
And, from where I’m standing, I reckon that we can all have good cause to believe that that hope, that ‘hope of hopes’, is one which is very well founded indeed.
And so, for me at least, for this and for many other reasons, a GPs lot is not an entirely unhappy one either.Continue reading “FROM A DISTANCE – REFLECTIONS AS THE NIGHTS START DRAWING IN”