Some musings

It was, if memory serves me right, Milton Jones who quipped of the sergeant major who he felt lacked self esteem on account of his standing in the centre of the parade ground each day and shouting ‘Attention!’ But, I wonder, are we any better? Might we also be far too busy asking others to look at us and approve of what they see?

Not so long ago I received some good news! I’d been ‘liked’ by the GMC! Well I say liked, I mean of course ‘revalidated’ but it came to the same thing. I”d posted a few comments of dubious value on an appraisal website and, lo and behold, I was affirmed by no less an organisation then the GMC! My wife may not have been impressed when I told her but, come on, I mean, the GMC. Does it get any better than that?

Yet the culmination of five long years producing the alleged evidence that I was OK left me feeling somewhat flat. Curiously, being approved of by a faceless organisation, who demands of me certain requirements that I must satisfy in order to have their assent bestowed upon me, turns out not to be as fulfilling as I’d hoped!

Tragically though, it seems that we are being driven by an ever greater desire to be liked. It’s not just Facebook, Twitter and the GMC. We live in a culture in which expressive individualism is the order of the day. This external encouragement panders to the internal desire we have to be approved of which, when left unchecked, leads to a situation where ugly self promotion and a need to be seen to be the best is the norm. When “it’s all about you’, you have to make ‘you’ what it’s all about. Not only is our expressive individualism bad for our patients, it is also bad for each other and ourselves, both on a professional and a personal level burdening us with the need to be awesome in a way that we are not, and, indeed, could never be.

It’s bad for patients because to focus on our own importance tends to us overvaluing our significance and that of medicine as a whole and leaves us struggling to accept anyone suggesting that they might know more than us. We doctors can be far too dismissive of patients who come to consultations with clear ideas of what they think is wrong with them. Not infrequently of course, there will be some justification for this as not all information gleaned from Dr Google is helpful and even genuine knowledge obtained from an internet search or elsewhere, needs to be applied wisely if a satisfactory conclusion is to be reached. None the less, on other occasions, not only are patients experts in being who they are, it is quite possible that, as interested parties, they might have researched their condition such that they know more about it than we do.

As doctors we need to be honest and humble enough to acknowledge, not only that we do not know all that there is to know, but also that all that there is to know cannot explain everything we would like it to. Albert Einstein had it right when he said ‘The only thing worse than ignorance is arrogance’. We must avoid such arrogance and accept what Atul Gawande calls our ‘necessary fallibility’. If we’re honest enough to admit we’ve made mistakes in the past, and are realistic enough to expect to make them in the future, we’d be wise to accept that we’re probably making them in the here and now. Caring for our patients involves doing our best and mourning our worst, being appreciated when we do well and being on the receiving end of a forgivenesses when we fail – a forgiveness that we will not experience if we arrogantly suggest we know it all. That’s why, when we smile and nod our head at this:

We should also recognise the truth in this:

Expressive individualism is bad for us professionally too since, determined to maximise our importance, it tends to minimise the help that lies outside of our own field. It is no good bemoaning how busy we are if we continue to insist that medicine can solve all of life’s difficulties. Only when we acknowledge that we do not have all the answers can we hope for patients not to expect that we do.

The need to promote self and seek approval is also detrimental to us as professionals as, no matter how hard we are encouraged to try, it is simply impossible to obtain the required approval of groups that sometimes have diametrically opposed ideas of what it is they want from us.

Take the antibiotic prescribing issue. On one hand we are quite correctly being encouraged to reduce our antibiotic prescribing and being threatened with a reprimand if we do not curtail their inappropriate use. But on the other hand, we are being judged by how satisfied our patients are by our practice and, despite what patient education programmes try to convey, the idea continues to be held, even by some of the most educated of our patients, that antibiotics are required for minor self limiting infections. Without them many of our patients won’t be satisfied.

Similarly we are being asked to avoid unnecessary admissions to hospital whilst being increasingly criticised for delays in diagnosis and referral. Despite recent calls for a doubling of our referrals to cancer services and expert advice urging primary prevention for heart disease at ever lower levels of risk, our referral rates and prescribing practices are under ever more scrutiny.

And that’s not to mention, of course, the competing demands of our responsibilities at work and the care and concern we long to give those we love the most, our families and friends.

It is impossible then to please all the people all of the time – and we are fools to try. In a society which constantly and increasingly seeks affirmation is it any wonder that we are overwhelmed by the need to please those with competing desires. Whatever we do is wrong in somebody’s eyes. The incessant double binds threaten, not only our own happiness, but also the stability of the whole system – a system already creaking from the overwhelming demand and time limitations that together drive us, perhaps, along the route of least resistance – the route that earns us a ‘like’ most easily – the one that comes from our patients.

Something is going to have to change in regards to the the way we behave if things are to improve. In short we need to be professionals who are in the job, not to be admired, but to do what is necessary. Whisper it quietly, but we are going to have to be less patient centred in order to be more patient friendly. We are going to have to be less concerned about doing what our patients want, what they will like us for, and try instead to sensitively do, to the best of our ability, what is right. Whilst on one hand some may complain, a greater acknowledgement of our inherent ordinariness may lower expectations such that complaints are less frequent and, with our self worth less tied to an unattainable perfect performance, when they do come they may not hurt us quite as keenly on a personal level. And remember, sometimes, to do less, really is to do what is right. Recently I read an excellent blog by someone whose mother, whilst pregnant with her, was disappointed when her doctor refused to treat her morning sickness but told her instead she’d just have to put up with her troubling symptoms. Years later the writer of the blog ponders what might have been were her mother to have been given the Thalidomide she had wanted. You can read that blog here.

We need to care less about how we are thought of by our patients – I’m not sure just how valid their opinion is anyway. On a single day a few years back I received two pieces of feedback – one accused me of negligent incompetence, the other rated me as unusually astute. So which is it? Well of course it is neither – I am no more ‘awesome’ than I am ‘useless’. I am in fact ‘ordinary’ – an ordinary GP who, like ordinary GPs up and down the country, knows less cardiology than a cardiologist – but more than my patients, or at least most of them. Our patients, our politicians, and we ourselves are going to have to accept this – whether they, or we, ‘like’ it or not!

Constantly promoting ourselves is unhelpful to others too. If we so massage the presentation of who we are such that we portray ourselves as better than we really are, it only adds to the pressure that others feel and leaves them anxiously striving to attain a level of perfection they imagine everyone else to have achieved. Competing with one another in a misguided attempt to prove our perfection makes losers of us all. We need to be honest about our mistakes, normalise failure and be realistic with one another about the difficulties we all experience. Rather than airbrushing reality and pretending life is always what we long it to be, we need to learn to walk together through the unwelcome mess of the everyday.

Finally, this need to be approved of is bad for us on a personal level. It makes us too sensitive to our fragile egos being upset. We are all, it seems, too easily offended. Take for example the furore a while back surrounding Jo Brand. Ironically, one of the qualities that we perhaps most desire in order that we be seen in a good light, that of being considered to have a good sense of humour, increasingly these days can get us into all sorts of trouble. For me Jo Brand’s joke was clearly simply meant as that, a joke – what else would you expect from a comedian on a comedy radio programme? – and, regardless of whether we find it funny or not, would have been best received as such.

As an aside, given that a good sense of humour is seemingly valued above integrity and compassion, my concern is more that, just as school debates were always won by the funniest argument, there is an increasing trend whereby political and social opinion is swayed more by how funny a statement may be rather than how true a comment is. Satire is important to pop the pomposity of those in power but equally comedians shouldn’t become our opinion formers merely on the strength of how much they make us laugh. That also goes for politicians who try too hard to be funny. Imagine how it would be if our Prime Minister was chosen as a consequence of enough people finding him or her amusing – a word, incidentally, which means without thought! As Neil Postman pointed out, Aldous Huxley ‘was trying to tell us that what afflicted the people in Brave New World was not that they were laughing instead of thinking, but that they did not know what they were laughing about and why they had stopped thinking.’

But be that as it may, it seems to me that the world would be a far happier place if, regardless of what we personally believe to be true, offence was taken only when it was meant. It’d be happier still if, even when meant, offence still refused to be taken. Then perhaps we might be able to talk and think well rather than shout and feel bad. But for that to occur we will, I believe, have to have a much lower sense of our own self importance.

This is not to say we do not have worth. Quite the opposite, our worth could be said to be infinite but, paradoxically, our importance, at least to all but a few, is small – it does not match our significance.

For me at least, getting this wrong and continuing along the road of expressive individualism, and portraying oneself as important, all too frequently gets in the way of anything that is genuinely worthy. At the risk of reaching new heights of pretentiousness, I’ll finish with one last thought – and it’s this: that ‘self’ even gets in the way of the unconditional acceptance, let’s call it love, that we all so want to know. To truly be loved unconditionally speaks more about the merits of the one doing the loving than the merits of the one being loved. As I have suggested though, most of us expend far too much energy trying to make ourselves worthy of love which serves then only to leave us with the burden of constantly striving to remain loveable since we have made our happiness and security dependent upon it. But love that is conditional on performance is not love at all – to be required to constantly promote oneself thus hinders the joy of knowing true love and acceptance.

Rather than striving to become loveable so that we can be loved, real security is, therefore, to simply know one to be loved because of the nature of the one who is truly loving. And in such security, I believe, lies what is needed for the one who is loved to become truly lovely. We do not improve by being constantly criticised for what we fail to achieve and having acceptance denied until we perform better – that is not the basis of a good relationship, either personal or professional. On the contrary, ultimately we are paralysed by the pressure to be perfect – crushed under the fear of failure. Genuine progress comes only as a result of the motivation that flows from being accepted for who we are – only then, are we free to flourish, only then can we truly grow, both as doctors and as human beings.

Medicine can be a cruel taskmaster – demanding and unforgiving. We need to be sure that we do not allow our relationship with it to develop in such an unhealthy manner. We must not imagine the fault is all ours when we fail to satisfy the demands that the system unreasonably imposes upon us. The inner belief, or outer demand, that it’s all about us being perfect and that we cannot be appreciated before we are, will spoil everything both inside and outside of work. It’ll make us unhappy. Real happiness comes not so much from being admired, but from admiring that which is truly admirable.

It must not be that we always have to be the best.

It must not be that we always have to do it all alone.

It must not be that we, by being perfect and pleasing everyone, have a duty to keep everyone happy.

We’re none of us that strong – not physically, not emotionally

Life should not be a competition- that’s not the way it was ever meant to be.

Travelling to work under grey skies, I sat alone in my car. Noticing those I passed, sat alone in theirs, I was left thinking that that was a lot like life – too many of us travelling alone to similar locations with nothing to look up for. And that’s not healthy. Rather than living and working in lonely isolation, we need each other. At least I know I do.

If we’re going to get through life, not as individuals who promote ourselves, but as those who live in community and know the need to lean on one another, then we going to have to grasp something that Bob Dylan captured in the words of the song ‘Forever Young’. And with those words I’ll finish:

‘May you always do for others and let others do for you’.

‘Two others, who were criminals, were led away to be put to death with him. And when they came to the place that is called The Skull, there they crucified him, and the criminals, one on his right and one on his left. And Jesus said, “Father, forgive them, for they know not what they do.” And they cast lots to divide his garments. And the people stood by, watching, but the rulers scoffed at him, saying, “He saved others; let him save himself, if he is the Christ of God, his Chosen One!” The soldiers also mocked him, coming up and offering him sour wine and saying, “If you are the King of the Jews, save yourself!” There was also an inscription over him, “This is the King of the Jews.”

One of the criminals who were hanged railed at him, saying, “Are you not the Christ? Save yourself and us!” But the other rebuked him, saying, “Do you not fear God, since you are under the same sentence of condemnation? And we indeed justly, for we are receiving the due reward of our deeds; but this man has done nothing wrong.” And he said, “Jesus, remember me when you come into your kingdom.” And he said to him, “Truly, I say to you, today you will be with me in paradise.”‘

[Luke 23:32-43]

When thinking about how we should view suffering, it is worth considering first the responses of those who witnessed the suffering of Jesus when he was crucified. I am indebted to Carl Trueman whose own thoughts I found particularly helpful in this regard and which form the basis of the first part of this blog.

As you’ll be aware crucifixion was a particularly unpleasant way to die. The Roman orator Cicero described it as ‘a most cruel and disgusting punishment’ and suggested that “the very mention of the cross should be far removed not only from a Roman citizen’s body, but from his mind, his eyes, his ears.” The Gospel accounts are, however, remarkably light on the details of crucifixion. In the verses above Luke is far more concerned with the four different responses of those who witnessed Jesus’ death. Three responses were wrong – each tempting Jesus to use his status as the son of God to escape suffering. The fourth was fundamentally different – and absolutely right.

First then we have the religious rulers who in v35 scoffed at Jesus saying:

He saved others; let him save himself, if he is the Christ of God, his Chosen One!’

One can understand the thinking of the religious leaders. Jesus hadn’t exactly endeared himself to them. Take the parable of the Pharisee and the tax collector. What Jesus had said in that parable was truly shocking. That God considered a truly repentant tax collector acceptable but not a Pharisee, who tithed and fasted so diligently, was hardly the stuff to win him friends in religious circles. Jesus had made the lives of the religious leaders a misery and, as a result, they had plotted for his death. Now, at last, it seemed they had won.

They didn’t get everything wrong though. In fact they got something very right. They realised that Jesus had claimed to be the Christ, the chosen one of God. Indeed, it was these claims of his that were the fundamental problem they had with him. It was why they sought to have him put to death. They were also right to understand that the Christ’s coming was to bring about salvation and the coming of the kingdom of God. The fact that Jesus was now dying on the cross was, to them, proof positive that his claims were exaggerated for, surely, the Christ would not suffer and die in such a way. It seemed, to them, that as Jesus hung dying, their rejection of him as Messiah was being vindicated.

This however was their big mistake – a mistake they made because they couldn’t see what was happening on the cross in any other terms than their own. They didn’t understand the kind of salvation that Jesus would secure or the type of kingdom that the Christ would bring in. They mistakenly thought that that salvation would be a salvation from death.

The next response that we see is that of the soldiers. They too mocked Jesus saying:

If you are the King of the Jews, save yourself!

Soldiers bring about the ends for which they are employed by force. They looked at the cross – and saw nothing but overwhelming defeat. Powerful men wield that power by force. If one thing is certain, it is that power is not epitomised by a man dying on a cross. But, like the religious leaders, they too were aware that Jesus had claimed something – that he was the King of the Jews – and they understood that his claims had something to do with salvation and a bringing in of a kingdom. ‘If you are the King of the Jews’ they said, ‘save yourself!’ But again, like the religious rulers, they too, could not see the cross in any other terms than their own. Death in such a dreadful way was, for them, unquestionably, defeat.

The next voice we hear is that of the first thief. He is in just about as bad a position as one can imagine. He knows he is going to die soon – and in the most unpleasant of circumstances. And yet he chooses to add his sneers to those that have gone before saying:

Are you not the Christ? Save yourself and us!

On the verge of death he tragically makes the same mistake as the religious rulers and the soldiers before him. Like them he understands that Jesus has made claims about being the Christ and about salvation – but he too can only think of God on his own terms – that salvation is a salvation from death. Tragically he dies without an understanding of what is really going on right next to him.

So all three responses thus far rightly understand that Jesus has made claims about being the Christ and about bringing salvation. But they all make the same mistake – believing that salvation is a salvation from death. Consequently they see Jesus as fraudulent, weak and pathetically defeated.

But there is one more response for us to consider – that of the second thief. Often he is considered as an example of somebody with a simple faith – a simple faith which is, none the less, sufficient to save. But if we look carefully at the details of what he says we’ll see that his is a very profound theology.

Firstly, in v40 he asks of the first criminal:

Do you not fear God, since you are under the same sentence of condemnation?

This second thief is in the exact same predicament as the first. Though experiencing the worst sort of torture, his focus is not on his present suffering, but rather, what is going to happen to him after his death. Being crucified is nothing compared to falling into the hands of a holy, fearsome and just God. Such a God should not be treated lightly. Such a God should be feared.

Do we, I wonder, appreciate our predicament as vividly as this thief did? We should.

In v41 the thief goes on:

And we indeed justly, for we are receiving the due reward of our deeds

He acknowledges the justice of his earthly punishment. He makes no excuses for his crimes but instead accepts his guilt and that the punishment he is receiving is deserved. Quite an admission.

Do we, I wonder, admit the same? We should.

In v41 the thief continues with the words:

But this man has done nothing wrong

He may not have understood that Jesus was totally without sin but he does appreciate that there is a fundamental difference between the two thieves and Jesus. He understands that Jesus is not on the cross because of anything that he had done wrong. He understands that Jesus doesn’t deserve to be there.

Do we, I wonder, understand similarly the reality, beauty and importance of Jesus’ sinlessness? We should – for if Jesus had sinned even once in his life, then his death could not have atoned, could not have paid for, our sin.

Then comes the thief’s remarkable statement in v42 – the moment he doesn’t make the same mistake that everybody else has been making. He says:

Jesus, remember me when you come into your kingdom

These words cast doubt on the idea that his is a minimal faith. Do you see their significance? Like everybody else that day, he sees Jesus suffering and dying on a cross but, unlike the others, doesn’t see defeat. He continues to speak of Jesus coming into his kingdom. For him Jesus’ death doesn’t mean an end to all the kingdom and salvation talk. All the others understood salvation as being a salvation from death, but this man sees that the salvation Jesus brings is a salvation THROUGH death – primarily the death of Christ. Jesus’ death isn’t the end of Christ kingdom – rather his death brings in his kingdom.

Do we, I wonder, understand so clearly such profound truth as this thief did? We should.

The faith the thief displays is why we should not be surprised by Jesus’ response when he says:

Truly, I say to you, today you will be with me in paradise

Jesus sees in the second thief somebody who gets it! Somebody who trusts the power of God despite seeing that which to unspiritual eyes is nothing but weakness. Somebody who sees victory where most would see defeat.

Do we, I wonder, get it too?

And so the second thief witnesses, at close quarters, Jesus’ substitutionary death on a cross that takes the punishment the thief, and we who also put our trust in Christ, deserve and which thereby spares him and us from Gods just wrath at our sinfulness – and secures for us a place in paradise with him.

So what about ourselves – how do we view the world? By nature, we think differently to the way that God thinks and, as a result, if we are not very careful, we will make all kinds of mistakes. Romans 12 reminds us – we need to change our way of thinking:

Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect.

God thinks differently to us (Isaiah 55:8)

For my thoughts are not your thoughts, neither are your ways my ways, declares the Lord

We must learn to think more like God if we are to understand the Cross.

For the word of the cross is folly to those who are perishing, but to us who are being saved it is the power of God.

The fact that God thinks differently to ourselves should challenge the way we think about our lives. Do we, like the Pharisees, soldiers and first thief, expect to escape suffering as Christians and live lives of comfort and ease. Or do we, like the second thief, expect suffering, perhaps great suffering, in our lives – and even see the need for it. And if so are we ready to accept it when it comes as part of God’s good plan for us?

As I have said, God thoughts are not our thoughts. We make a mistake if we think God is bound to act the way we think he should. Luther would have said that we are all prone to be theologians of glory – or as we might term it today, purveyors of a health, wealth and prosperity gospel. However much we may say we disapprove of such a gospel, we are all prone to think that God wants for us what we think is good for us. We need to be, as Luther would have said, Theologians of the Cross and understand not only that Jesus had to suffer – and ultimately die – as an atoning sacrifice for our sins, but that we are called to suffering too.

I’ll consider our suffering under four headings.

So firstly: We suffer because all suffer – Christians and non-Christians alike

There is vast suffering in the world – one only has to look at the news to realise that. And we all know something of what it is to suffer – some of you all too well. Fundamentally we suffer because we are living in a fallen creation. Suffering exists because of the reality of sin and, though we should guard against the inference that one’s individual suffering is a result of one’s individual sin, the fact remains that, were there no sin in the world, there would be no suffering.

I spent a brief time in hospital a year or two ago but more significant than my relatively trivial suffering was that of those around me. As I recovered and got to know the nursing staff better, I learned of the one whose niece died of breast cancer in her 30s, days before my admission, of the one whose son had died a few years previously, aged two; of the one whose mother died during my inpatient stay, and of the one whose husband had just been diagnosed with lymphoma.

Suffering is everywhere – I could tell you of a husband who lost a wife aged 40 and is left, himself with a crippling disease, to bring up his 11 year old son, of a mother who within a year lost two prematurely born children hours after birth and whose first child had previously lost her legs to meningitis, of a married couple who within weeks both received bad diagnoses – he of Parkinson’s Disease, she of inoperable cancer. I could tell you of colleagues and friends whose children died tragically young, who gave birth so prematurely that life was unsustainable, who delivered a baby whose stomach contents herniated into their chest compromising their ability to breath. I could tell you of those with crippling anxiety and hope destroying depression.

Some of the above are Christens – others are not. But we must not think that, as Christians we deserve better than those who don’t believe. We do not have a right to a healthy life without pain disability and bereavement? It’s normal for Christians to suffer – but we do not suffer without hope.

‘We know that the whole creation has been groaning together in the pains of childbirth until now. And not only the creation, but we ourselves, who have the first fruits of the spirit grown inwardly as we wait eagerly for adoption as sons, the redemption of our bodies. For in this hope we were saved.’ Romans 12:22-24

Consider this illustration of John Piper. If, whilst walking through a hospital, you heard somebody screaming in pain – how you felt about what you heard would differ greatly depending on whether you were on an oncology ward or a labour ward. Our cries of anguish in our suffering are not unto death but rather they are unto life – and life eternal at that.

Heading number two – we will suffer because of the very fact that we are Christians. The Christian is called to a life of suffering.

We may not like the idea but it is one that is in the scriptures. In Acts, God, speaking of Paul, says

‘…I will show him how much he must suffer for the sake of my name’ Acts 9:16

Paul himself writes to the Philippians

‘For it has been granted to you that for the sake of Christ you should not only believe in him but also suffer for his sake’ Philippians 1:29

And to Timothy he says

‘… share in suffering for the gospel by the power of God, who saved us and called us to a holy calling.’ 2Timothy 1:8-9a

Most well known of all, Jesus calls us to take up our cross daily and follow him – ‘for whoever would save his life will lose it,’ he says, ‘but whoever loses his life for my sake will save it.’

The suffering may be great. The writer to the Hebrews doesn’t pull any punches when he describes some of the suffering endured by Christians.

‘Others suffered mocking and flogging and even chains and imprisonment. They were stoned, they were sawn in two, they were killed with the sword. They went about in skins of sheep and goats, destitute, afflicted and mistreated – of whom the world was not worthy – wandering about in deserts and mountains, and in dens and caves of the earth.’ Hebrews 11:36-38

As Christians, we must not demand a decent standard of living, fulfilling relationships, rewarding jobs and all that goes to make up what the world considers a good life. We have no right to health, wealth and prosperity. That is not normal Christian experience.

But surely you say, God wouldn’t want to deprive us of these things. We might like to think not. But remember, God thoughts are not our thoughts. Would God want Jesus to be beaten and tortured and left to hang on a cross? Well it seems He would. For the joy set before Him Jesus endured the cross despising the shame – we too are called to suffer.

So we must ask ourselves some tough questions – as to why we are Christians. Most fundamentally, we should ask ourselves are we Christians because Christianity is true – or because we see it as a means to personal fulfilment. Do we accept the scriptures as true because they are the word of God – or only so far as we agree with it? Do we know God to be good because we know that that is what He is – or do we only consider him good when he gives us what we want?

Paul learnt what it was to submit to God’s way of thinking – and so must we. He would dearly have loved the thorn in his flesh to have been removed, requesting three times for it to be taken from him. Paul no doubt believed that it would have been good if God had acceded to his request but God said ‘No’. Instead God simply told him ‘My grace is sufficient for you’. And so it is for us.

So then, God chooses for us to sometimes suffer. But how that suffering is perceived distinguishes the Christian from the non-Christian. The unbeliever looks on suffering and concludes that God must be either non-existent, or, alternatively, that He is not powerful or loving enough to prevent it. But to the one who believes, suffering doesn’t suggest any of these things. Rather, suffering reveals a God who thinks differently to us. Suffering ceases to be something to be avoided at all costs but rather, trustingly accepted for the sake of Christ.

Yes we are all called to suffer. But know two things – know your place in heaven will not be dependent on how well you endure that suffering – how patiently you bear it. If you, like me, can lose it over even the most trifling of hardships, take heart. Only Jesus ever endured suffering the way he should – and for Christians, for those ‘in Christ’, the way Jesus bore his suffering will, by God’s grace, be the way that God looks on as us as having suffered. Praise God that we are saved by grace. Know too that however great the sufferings of this present time may be, they are light and momentary compared to the glory that is to be revealed to us. Our suffering is preparing for us an eternal weight of glory beyond all comparison, as we look, not to the things that are seen, but to the things that are unseen.

The call to us to embrace suffering is an offensive one – the gospel was ever thus – offending before it comforts. We are called to suffer and it will not be pleasant for any of us but we must accept that God works through suffering even as he worked through the suffering of his son. We are called to be like him – to join him in his suffering.

Rather than be offended that we are called to suffer, perhaps we should be amazed we are not called to suffer more. We have no rights – we are not our own – we are slaves of God – called to obedience. But remember – even as we are called to suffering we are caused to be born again to a living hope through the resurrection of Jesus Christ from the dead, to an inheritance that is imperishable, undefiled and unfading, kept in heaven for us, who, by God’s power, are being guarded through faith for a salvation ready to be revealed in the last time.

But first, I’m afraid, suffering. Only then is there glory. That is God’s way.

But why does God chose to allow us to suffer? This is mysterious ground and we should step carefully. The answer may never be ours to know and the wisest counsel may be to keep silent when asked to give a reason for a persons suffering – there is certainly no easy, concise, one size fits all answer. God’s answer, from out of the whirlwind, to the questions Job asked of his suffering was

“I will question you” (Job 38:3)

G.K. Chesterton writes:

…God comforts Job with indecipherable mystery, and for the first time Job is comforted…Job flings at God one riddle, God flings back at Job a hundred riddles, and Job is at peace. He is comforted with conundrums. The riddles of God, Chesterton writes, are more satisfying than the solutions of men’

In the prologue to the book of Job we see that Job was tormented, not because he was the worst of men, but because he was the best. There is a sense, therefore, in which Job points us towards Jesus. Job is not told that his misfortunes were due to his sins, or part of any plan for his self improvement – but we are, none the less, told that he was allowed to suffer under God’s sovereign care. That a good man should suffer at the hands of a loving God is a paradox. Chesterton calls it ‘the very darkest and strangest of … paradoxes’ which is, none the less, ‘by all human testimony the most reassuring’. The truth is that the infinite mystery of God is enough to inspire our trust in his sovereign goodness, even when the specific reasons to why we suffer remain a mystery.

So why do we suffer – we will never fully know the answer to that question. But, having hopefully stressed the mystery inherent in the question, and the foolishness of trying to give specific reasons for our specific suffering, God isn’t, I believe, totally silent as to some of the reasons why we might suffer. At least part of the answer comes in our third and fourth headings the first of which is:

When we suffer for the sake of Christ’s and the gospel – we glorify him

If you were to ask yourself : ‘Where, in all of history, has God most glorified himself ?’ the answer you would be right to come up with would be: ‘At the cross of Jesus Christ’. And it wasn’t by delivering Jesus from the cross that he was glorified – rather it was by his being crucified that Jesus was glorified.

What was true for Jesus is also true for ourselves. Paul writes:

‘Now I rejoice in my sufferings for your sake, and in my flesh I am filling up what is lacking in Christ’s afflictions, for the sake of his body, that is, the church.’ Colossians 1.24

Paul is not saying here that Christ’s sufferings were not sufficient for our salvation – but, for the sake of the church being reached, for the sake of the gospel being spread, suffering on the part of those who share it, is necessary.

Peter makes clear that we glorify God as we suffer for his sake. He writes

‘…if anyone suffers as a Christian, let him not be ashamed, but let him glorify God in that name.’ 1 Peter 4:16

Jesus, speaking after his resurrection, told Peter of how, when he was old, he would stretch out his hands, be dressed by another and be carried to where he did not want to go. This he said to show by what kind of death Peter was to glorify God.

Faith is not believing in a God who provides health wealth and prosperity – there is nothing in such a belief that makes the world sit up and take notice – who wouldn’t want to follow such a god. The truth is that those who embrace a prosperity gospel do not honour God – rather they honour that which their imagined god can give. True faith is trusting in the God who is there – the God who has revealed himself to us by his Spirit, through His word and in His son Jesus Christ. And when we suffer for what we believe about that God, for the sake of Christ and the gospel, and yet still continue to hope in Him – well then the world looks on and wonders why. And it concludes that we must value this God very highly if He is more valuable than the earthly comforts the rest of the world chases after. Surely he must be great to warrant such devotion.To pinch a phrase from John Piper, ‘God is most glorified in us in our suffering, when we are most satisfied in Him, in our suffering.’

And this is also true when we continue to hope in God in our every day, non-gospel related suffering. And the reasons for our hope? Those reasons we should be ready to give to those puzzled folk who, looking on, enquire of them? Well here are just three!

First Peter gives us this:

‘Resist him, firm in your faith, knowing that the same kinds of suffering are being experienced by your brotherhood throughout the world. And after you have suffered a little while, the God of all grace, who has called you to his eternal glory in Christ, will himself restore, confirm, strengthen and establish you. To him be the dominion forever and ever. Amen’ 1 Peter 5:9-11

Secondly Jesus himself says

‘Truly, I say to you, there is no one who has left house or brothers or sisters or mother of father or children or lands, for my sake and for the gospel, who will not receive a hundredfold now in this time, houses and brothers and sisters and mothers and children and lands, with persecutions, and in the age to come eternal life.’ Mark 10:29-30

And then thirdly he says in Revelation:

‘Do not fear what you are about to suffer. Behold the devil is about to throw some of you into prison, that you may be tested, and for ten days you will have tribulation. Be faithful unto death, and I will give you the crown of life.’ Revelation 2:10

And so to our last heading – another reason why God may choose to allow us to suffer.

Our suffering is for our own good

Again this is counterintuitive. How can suffering be for our good? But we must not lean on our own understanding but believe God’s word that assures us that suffering is indeed good for us. First Paul:

‘We rejoice in our sufferings, knowing that suffering produces endurance, and endurance produces character, and character produces hope and hope does not put us to shame, because God’s love has been poured into our hearts through the Holy Spirit who has been given to us.’ Romans 5:3-5

And Peter writes:

‘But rejoice insofar as you share in Christ’s sufferings, that you may also rejoice and be glad when his glory is revealed. If you are insulted for the name of Christ, you are blessed, because the Spirit of glory and of God rests upon you’ 1 Peter 4:13-14

This is counter cultural and counter intuitive stuff – but true none the less. Suffering should not surprise us. Rather than shaking our confidence in God when it comes our way – if we have an understanding of the way God uses it, we will trust that he sends it our way for our good.

The truth is we grow through suffering. Jesus, the book of Hebrews teaches us, was made

‘…perfect through suffering’ Hebrews 2:10

and amazingly.

‘…learned obedience through what he suffered. Hebrews 5:8

It will be no different for us.

A couple of years ago, as I mentioned, I had a brief spell in hospital. In the early days of my hospital stay, I was pretty crook and there was a concern, as doctors undertook tests, that I had an underlying malignancy. I remember lying in my hospital bed conscious of the fact that I might die. I would like to have been sure that God would heal me and I never doubted that he could. But I do not believe I had a right to assume he would. I had to face the fact that God may have chosen for me to die. If that was his will – then I had to be OK with it – for if he loves me, then he loves me even as he calls me to die. And had that been his will, it would have been for my good. Why he chose to bring that tricky time my way I do not know, and in all probability, not for me to ever fully understand. But I do believe it was for my good. If nothing else, suffering is an effective way to break our love affair with all that the world tells us we should want. If nothing else suffering helps us to fix our eyes on Jesus, the author and perfect or of our faith – and that is always a good thing for us to do.

J.C. Ryle, the 19th century Bishop of Liverpool, had it right when he said this:

“Let us mark this well. There is nothing which shows our ignorance so much as our impatience under trouble. We forget that every trial is a message from God and intended to do us good in the end. Trials are intended to make us think, to wean us from the world, to send us to the Bible, to drive us to our knees. Health is a good thing. But sickness is far better, if it leads us to God. Prosperity is a great mercy. But adversity is a greater one, if it brings us to Christ”

In suffering, our comfort doesn’t come from false assurance that in this life all will end well in worldly terms. Rather our comfort comes from knowing that our suffering is in the sovereign hands of our loving Heavenly Father who wills it for our good. If we, by God’s grace, are able to grasp something of his wisdom in our suffering then, perhaps we too may be able to respond like Paul who wrote:

‘For his sake I have suffered the loss of all things and count them as rubbish, in order that I may gain Christ and be found in Him, not having a righteousness of my own that comes from the law, but that which comes through faith in Christ, the righteousness from God that depends on faith – that I may know him and the power of his resurrection and may share in his sufferings, becoming like him in his death that by any means possible I may attain the resurrection from the dead.’ Philippians 3:8b-11

And

‘For the sake of Christ then, I am content with weaknesses, insults, hardships, persecutions and calamities. For when I am weak, then I am strong.’ 2 Corinthians 12:10

We must learn to embrace suffering – we cannot look forward to eternal glory without giving up all rights now. It is not all about us and our fulfilment in this life. As Paul writes in 1 Corinthians 15,

if Christ was not raised, and we have hope in this life only then we are of all people most to be pitied.

Christian faith may well, in worldly terms, make things worse for us in this life – not better. If Christianity is not true then eat drink and be merry for tomorrow we die – go for maximum pleasure today for to behave in any other way makes no sense whatsoever. But Jesus WAS raised from the dead and Christianity IS true. As such we should be different from the world around us – in it and all its suffering – but not of it. We should stop living for this life only, for our own fulfilment and comfort today. Instead we must live according to the truth – valuing above all else the spiritual blessings we already have in Christ and accepting suffering when it comes, as come it shall, confident that the God who loves us has ordained it for our own good.

J.C. Ryle again:

“The Lord Jesus makes no mistakes in managing His friends’ affairs. He orders all their concerns with perfect wisdom: all things happen to them at the right time, and in the right way. He gives them as much of sickness and as much of health, as much of poverty and as much of riches, as much of sorrow and as much of joy, as He sees their souls require. He leads them by the right way to bring them to the city of habitation…He mixes their bitterest cups like a wise physician, and takes care that they have not a drop too little or too much. His people often misunderstand His dealings; they are silly enough to fancy their course of life might have been better ordered: but in the resurrection-day they will thank God that not their will, but Christ’s was done”

So let’s be like the second thief who hung on that cross alongside Jesus. Let’s not see suffering as a contradiction of what Christianity should be – rather let’s see suffering as a necessary means to our eternal hope, lovingly ordained for us by our Heavenly Father for our good and his glory. And above all else let us hope in Christ alone – whose perfect sacrifice on the cross for us is what guarantees for us a place in the eternal holy city, the new Jerusalem, where God will dwell with us. We will be his people and God himself will be with us as our God. Then he will wipe away every tear from our eyes, and death shall be no more, neither shall there be mourning, nor crying nor pain anymore, for the former things will have passed away.

---

Related posts:

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

To read “Why do bad things happen to good people – a tentative suggestion”, click here

To read “Luther and the global pandemic – on becoming a theologian of the cross”, click here

To read ‘On NOT leaving your comfort zone’, click here

To read “Hope comes from believing the promises of God”, click here

To read ‘Looking back to move confidently forward’, click here

To read ‘on the FALLEN and the FELLED’, click here

To read ‘The Resurrection – is it just rhubarb?’, click here

To read “Hope comes from believing the promises of God”, click here

To read ‘Faith and Doubt’, click here

To read ‘What becomes of the broken hearted? Sorrowful yet always rejoicing on Palm Sunday’, click here

To read ‘Why do bad things happen to good people? Sorrowful yet always rejoicing on Good Friday’, click here

To read ‘Was it not necessary that the Christ should suffer these things? Rejoicing, though temporarily sorrowful, on Easter Day’, click here

How about impressing your appraiser with this as one of your goals for personal development in the coming year. ‘Be drunk’.

Charles Baudelaire (1821 – 1867) wrote:

“You have to be always drunk. That’s all there is to it – it’s the only way. So as not to feel the horrible burden of time that breaks your back and bends you to the earth, you have to be continually drunk.

But on what? Wine, poetry or virtue, as you wish. But be drunk”

I know this because yesterday morning, having dealt with his chronic cough, a patient quoted the above to me – in the original French. He also plays jazz professionally and in the past has, on occasions, performed with Acker Bilk. How cool is that?

The poem goes on:

And if sometimes, on the steps of a palace or the green grass of a ditch, in the mournful solitude of your room, you wake again, drunkenness already diminishing or gone, ask the wind, the wave, the star, the bird, the clock, everything that is flying, everything that is groaning, everything that is rolling, everything that is singing, everything that is speaking. . .ask what time it is and wind, wave, star, bird, clock will answer you: “It is time to be drunk! So as not to be the martyred slaves of time, be drunk, be continually drunk! On wine, on poetry or on virtue as you wish.”

I suspect many of us have woken again this week, ‘in the mournful solitude’ of our consulting rooms, stone cold sober as a consequence of having had the cold water of another day on the front line thrown in our face. Baudelaire tells us that to avoid being the ‘martyred slaves of time’ the only way is to be intoxicated by something good that consumes us. Many of us will have an interest outside of work that does this for us but what if, in addition, it were possible to be continually drunk on our practice of medicine?

Currently this is far from easy, given the way we are forced to practice. Rather than losing ourselves in our work, delighting in it, we are forced to be too self aware – having as we are to constantly justify ourselves. Have you ever thought how the system inherently criticises us.? Our constant need to demonstrate improvements in our practice implies that we are never considered to be good enough whilst our endless need to gather feedback is a system of policing employed by those who can not bring themselves to trust us.

Medicine, like life itself, is a team game in which we all play our part. Highlighting individual weaknesses rather than emphasising team strengths is like a lion isolating the injured in a herd of antelope and going in for the kill. Together we can survive, leaning on our colleagues in both primary and secondary care even as we allow them to lean on us.

How does the poem go? ‘If a child lives with criticism, he learns to condemn’. Is it any different for doctors? Is it any wonder that sometimes we are a little condemning, a little bitter, a little negative? But if instead we lived with encouragement, might we not learn to be a little more confident, if we lived with approval, might we not learn to like ourselves a bit more, (something too many of us struggle with), and if we lived with acceptance, might we not learn again to love what we do. And wouldn’t that make us better, more caring, doctors?

So let’s get drunk this weekend on whatever it is that does it for us but don’t forget that, leaving aside the nonsense, being a GP remains a worthwhile endeavour. Yes it could be better but it still has the capacity to be both wonderfully enjoyable and genuinely satisfying. Of course we’re not perfect, it’s an impossible job, but regardless of what some might say, remember that, as we frequently say to our patients by way of encouragement, together we are ‘good enough’.

Stick that knowledge in your hip flask and sip from it frequently this coming week.

Recently I came across Hugh McLeave’s biography of Professor Ian Aird entitled ‘A Time to Heal’. In it Aird is described as having been ‘a brilliant surgeon, an inspired teacher and one of the great medical personalities of his generation’. He was also, if I have my family tree correct, my grandfather’s cousin. Born in 1905 in Edinburgh he attended George Watson’s College where school certificates record he never achieved anything less than ‘Excellent’ and where contemporaries described him as one who ‘could not help himself, being a perfectionist’. He subsequent studied medicine at Edinburgh University and embarked on a career which, in time, saw him rise to become Professor of Surgery at the Hammersmith Postgraduate Medical School. Here he became best known for separating Siamese twins, most notably the Nigerian pair of Boko and Tomu. Dying in 1962, five years before I was born, meant I never met him but photographs of him are strangely familiar as, in appearance, he bore a striking similarity to my Uncle John.

Few, despite his pioneering work, remember him today and I have only once in my own career come across anybody for whom his name meant anything. My first house job was in Bristol, working as part of a urological firm in Southmead Hospital. The consultant under whom I worked, Mr Roger Feneley, had himself studied from Aird’s Textbook of Surgery, and he took some delight in imagining he was nurturing ‘the young Aird’ to become a fine surgeon in his own right. Disappointingly, I suspect, for Mr Feneley, I was in no way cut out for surgery and chose instead to become ‘just a GP’, a decision that has led to an equally satisfying career.

That textbook of surgery was not the last thing that Ian Aird wrote. His final words were found in a notebook alongside a Bible opened at Ecclesiastes 3 where he appeared to have been reading these words: ‘To everything there is a season, and a time to every purpose under the heaven: a time to be born and a time to die’. This is what, in a ‘bold and unequivocal hand’, he had written:

‘To the Hammersmith Coroner: I have taken a fairly substantial dose of barbiturates. I have never taken a drug before in my life. I have passed my apogee. My skill is going and I am in deep despair. I find myself in unmitigated gloom. Although I am a sincere and practising Christian, I cannot continue. I have burnt myself out. There is too much to do. I cannot write my book again. My department has produced the electronic control of patients in operating theatres, done the first intra-cardiac operations, transplanted the first kidney homografts in Britain, shown the connection between blood groups and disease – and there has been no distinction given to us…Ian Aird’

McLeave, who knew Aird well, interpreted that final comment, not as an embittered comment at the lack of personal recognition, such was not his nature, but rather as a reflection of the struggles he’d long had in attracting funding for his work and the active discouragement he’d experienced from within the medical profession. The frustration that he was not achieving all that he could, together with his own excessively high standards that fuelled that frustration, culminated in producing the emotional distress with which he no longer felt able to cope.

The conclusion McLeave then drew was that ‘Had [Aird] taken a holiday, sought medical advice or resigned himself to living at a slower tempo, he might have lived – but he demanded nothing less than perfection in himself’.

Though I never knew Professor Aird, I recognise, both inside and outside of medicine, that same perfectionism that demands of individuals more than they are able to give and renders them both guilt ridden and unhappy. As expectations increase both from within and without, what Atul Gawande describes as our ‘inevitable fallibility’ leaves us imagining we are moral failures simply because of our inherent ordinariness. We, and those with whom we live alongside, need to be kinder to one another, acknowledge our humanness, and stop insisting that we are more than we could ever become. There are many factors that drive individuals to take their own life, and none but those who follow this drastic course can fully understand those reasons, if indeed they can ever understand them themselves, but amongst those factors lie the unhelpful and unrealistic demands and expectations put upon individuals by both themselves and others. Hannah Arendt had it right when she said ‘In order to go on living one must try to escape the death involved in perfectionism’.

In life, Ian Aird was fond of quoting Shakespeare’s words spoken by Cardinal Wolsey in Henry VIII:

And, when I am forgotten, as I shall be,

And sleep in dull cold marble, where no mention

Of me more must be made of, say I taught thee.

A fitting memorial for my long forgotten relative would be that he did indeed teach, and that we learnt, that perfectionism, and the demand for it, kills, just as it surely, at least partly, killed him.

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And now three blogs which, in my mind 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

Other related blogs:

For more on being ‘only a GP’, click here

For more about Hannah Arendt, click here

And finally, for a blog reflecting my Christian worldview and offering perhaps a perfect solution to our imperfection, click here

Supporting Somerset – Good for the Soul

May 25th 2019 was a great day. Why? Because Somerset CCC won the Royal London One Day Cup at Lord’s, beating Hampshire by six wickets. Supporting Somerset for the last 40 odd years has been good for me, and not just because I have got to enjoy days like last weekend. Here’s why.

Over the years supporting Somerset has been full of highs and lows. There have been the glory days of the late 1970’s and early 1980’s, the likes of which fans are hopeful of being matched, or even exceeded, by the current team, but there have also been days of disappointment, days of all too frequently finishing second best. To experience these ups and downs is to experience real life – disappointment is not abnormal. To face disappointment and keep on going in sport is to be reminded that life too will sometimes let you down – that those set backs must be faced and life must go on just the same, with the hope, always, of better days to come.

Loyalty and commitment are important too – it is good to stick with something, or someone, you care about in life, regardless of their ‘performance’, to support them come what may. When a batsman plays a reckless shot and gets needlessly out, when a bowler bowls with poor control, though disappointing, it is hardly something for which, given they are almost certainly doing their best, they should be castigated and rejected as of no longer any use. I for one am grateful for all necessary second, and third chances I’ve been given.

To be ‘for’ someone only in the good times is to use them for your own satisfaction, for the pleasure you can derive from their existence, and is, therefore, inherently selfish. But to be ‘for’ someone come what may, even when their behaviour disappoints, is to really care and, what is more, heightens the joy that comes when the dark clouds eventually roll away and the sun shines through.

Supporting Somerset has also taught me that the result is more important that the individuals who bring about that result. I have supported Somerset ever since first watching them as a lad the day Brian Rose scored 205 at Clarence Park in Weston-suoer-Mare. Since then players have come and gone. For sure there have been players I have particularly enjoyed watching but, in the end, it is the team that matters more than the individuals. It is the team I support and who I want to see do well. After all, as the Twitter hashtag has it, #WeAreSomerset. Ultimately it doesn’t really matter who scores the most runs or turns in the best bowling performance.

And so with life. We each have our part to play, but ultimately what is important is that good prevails, not that I myself am admired for any contribution I may sometimes make in bringing that good about.

And then there is the capacity for sport to remind me that it is good to forget about myself and focus on something bigger and better – something outside of me. To do so is always helpful but particularly in a world that increasingly insists that I must strive to be awesome. This is burden which, given my inherent ordinariness, I can not bear. Watching cricket allows me to forget myself and enjoy the greatness of others.

Let me explain further by describing a game I saw in 2017. Somerset fans will remember it well. It was a fantastic day – Somerset v. Surrey (the old enemy). Surrey batted first and, in their 50 overs scored 291. Somerset started their innings but before very long, disaster struck and they were in in all kinds of trouble at 22 for 5. Somerset looked to be down and out. But then Roelof van der Merwe joined Dean Elgar in the middle and the pair put on 213 for the 6th wicket leaving just 56 more to win, a task that van der Merwe and Lewis Gregory managed with several overs to spare. You can imagine the tension as that great stand progressed – one more wicket and surely it would be over. But gradually the crowd became more hopeful and the excitement built such that, when the winning runs were scored, I was out of my seat – as were most of the crowd – celebrating in a way that could possibly have embarrassed my son had he been with me – which he was! It was a genuinely memorable victory. I was high as a kite with excitement – the crowd cheered and applauded the players as they left the field. It was a great, great day!

The match left me thinking – thinking how healthy my emotions were that early summer’s evening in Taunton and how I wished they would be like that more often. I was an unimportant member of a large crowd that day – not thinking about myself and how significant I was but instead rejoicing in the greatness of the players and what they had done in bringing about the victory. I had contributed nothing to Somerset’s victory. Indeed my faith in their ability to win varied during the course of the match but whether I believed in them or not had no effect on the outcome of the game. But win they did and I rejoiced in praising Somerset CCC that evening. And I did so joyfully – not reluctantly. Nobody at the ground that evening was there out of duty. Every Somerset fan would have felt ‘better is one day at the county ground Taunton, than a thousand elsewhere’. There was a real sense of fellowship as we left the ground – strangers united in the joy they had just witnessed, smiling and chatting with one other, enjoying together the moment. I came home and just had to talk about it – even posting a photo of the scoreboard on social media. I had seen the glory of Somerset Cricket – I was satisfied by it and just had to talk about it.

 We all would do well sometimes to forget self and be caught up in something bigger and better than ourselves. It’s extraordinarily healthy to do so. Of course not everyone (astonishingly) will be in to cricket, but hopefully we all will have had similar experiences with something that genuinely thrilled us – something that took us out of ourselves, something that made us feel really alive. For some it may be a music concert, a film or a trip to the theatre, for others perhaps an experience of nature such as standing on the top of a mountain or a trip to the Grand Canyon. It’s good for us to take pleasure in these things and be reminded as we enjoy them that true happiness comes not from being admired but admiring the truly admirable.

Charles Baudelaire (1821 – 1867) wrote a poem called ‘Be Drunk’ . He wasn’t referring to the consequences of overindulging on the Thatcher’s Terrace. It goes like this:

“You have to be always drunk. That’s all there is to it – it’s the only way. So as not to feel the horrible burden of time that breaks your back and bends you to the earth, you have to be continually drunk.

But on what? Wine, poetry or virtue, as you wish. But be drunk”

And if sometimes, on the steps of a palace or the green grass of a ditch, in the mournful solitude of your room, you wake again, drunkenness already diminishing or gone, ask the wind, the wave, the star, the bird, the clock, everything that is flying, everything that is groaning, everything that is rolling, everything that is singing, everything that is speaking. . .ask what time it is and wind, wave, star, bird, clock will answer you: “It is time to be drunk! So as not to be the martyred slaves of time, be drunk, be continually drunk! On wine, on poetry or on virtue as you wish.”

It is good for me to be taken out of myself – to be ‘drunk’ on something other than who I am, and to enjoy the sense of release that comes from realising that it’s not all about me. Glorious days at the County Ground do that for me. And of course, on less successful days, when tragedy strikes and results disappoint, I am remind that not even Somerset can fully satisfy, and that it would be unfair to lay that burden on the club. For that I will need to look elsewhere, to something, or someone, even greater still.

So it’s good to be caught up in something bigger than yourself. It’s healthy. It’s not so much that that we simply need enough self esteem to be happy – rather, to truly be happy, we need to esteem highly that which is genuinely worthy of our praise. As John Piper once said,

‘Do people go to the Grand Canyon to boost their self esteem? Probably not. This is at least a hint that the greatest joys in life come not from savouring the self, but from seeing splendour.’

To go the Grand Canyon and pull out a spade, then dig a little trench and seek to draw the attention of tourists to what one has done is surely folly of the highest order. It would be an attempt to distract others from what is worth seeing – to try to deprive them of a greater joy.

The truth, for me at least, is that the ‘self’ all too frequently gets in the way of the genuinely worthy. At the risk of reaching new heights of pretentiousness, I’ll finish with one last thought – and its this: the self even gets in the way of the love we all so want to know.

To truly be loved speaks more about the merits of the one doing the loving – not the merits of the one being loved. Most of us spend all our efforts in trying to make ourselves worthy of love which serves only to leave us with the burden of needing to constantly strive to remain loveable since we have made our happiness and security dependent upon it. To promote self thus hinders the joy of knowing true love.

Rather than striving to become loveable so that we can be loved, real security is to know one to be loved by one who is truly loving. And in this security, I believe, lies what is needed for the one who is loved to to become truly lovely. Only when truly loved are we free from the fear of not being good enough – only then can we truly grow.

Watching Somerset, forgetting myself, reminds me of this.

So Somerset CCC – thank you, not only for wonderful childhood memories, (an Ian Botham century between lunch and tea, five Viv Richard’s sixes in a single JPL over, and numerous run chases characterised by scampered ones and twos from the bats of Vic Marks and Peter Denning) not only for more recent glories, (a T2O hundred from James Hildreth against Glamorgan, Arul Suppiah’s world record bowling of 6-5 also against Glamorgan, and last wicket heroics by Tim Grownwald twice in a week with first Jack Leach and then Jamie Overton to beat Surrey and Gloucestershire – what could be better?!)*** not even for just the joy of last Saturday’s success, but even more than that, thank you that, over the years, by directing my attention away from myself you have been good for my soul.

*** I could add many other great memories by others not yet mentioned, – attacking striking of the ball from Peter Trego, Craig Kieswetter, Johann Myburg, Jos Buttler and Tom Banton, classic stroke play from Sunil Gavaskar and Azhar Ali, match winning bowling from Joel Garner, Andy Caddick and Alfonso Thomas, game changing performances by George Bartlett, Josh Davey and Dom Bess, brilliant fielding from Tom Abell, Craig Overton and Max Waller and wonderful wicket keeping by Derek Taylor, Steve Davies and yes, in addition to his countless batting master classes, Marcus Trescothick. Thank you one and all.

A cricket team mascot called Stumpy

Arriving at Lord’s got all jumpy

Till R. Van de Merwe’s

Cure for his nerve-ers

Proved to be flagons of scrumpy.

*****

Old Farmer Time’s all a muddle

Wherever he turns he sees double

Twins Ali and Trego

Plus Jamie and Craig O

Are sure to give Hampshire some trouble

*****

A farmer from near to Bridgwater

Supported the county he oughta

So on Finals Day

He stopped making hay

And saw Hampshire put to the slaughter

*****

Tom Banton, he strides to the crease,

He’ll give Hampshire bowlers no peace

Cos no one can fathom

How, with back still in spasm,

From six hitting he will not cease

*****

When tactics demand change of tack

Rolef comes in to the attack

But success from his arm

Might do him some harm

When hyperextending his back

*****

The captain is willing and Abel

And Hildy brings class to the table

With Gregory enthralling

When batting or ‘balling’

The day will be most ‘memor-rable’.

Writing in the BMJ back in 2007, Des Spence said ‘Medicine should admit that it’s offer to ‘cure’ depression was naive and wrong. Drug treatment should be reserved for the very few, not the many’. Twelve years on it seems we were not listening. In the last ten years antidepressants prescribing in the UK has doubled and, in a Mental Health Awareness week that would, given that increase, seem to have been unnecessary, professors at Oxford University have pledged once more to find the cure for mental illness.

Why then have we seen such an escalation in antidepressant prescribing?

Of course one explanation might be that the country is more unhappy than it was a decade ago. Despite the fact that the UK now ranks 15th in the World Happiness Index, it’s highest position since the measurements began, with its highest ever World Happiness Index Score, living in the UK has undoubtedly become harder. The BBC recently reported that UN Special Rapporteur, Prof Philip Alston, has described poverty in the UK currently as ‘systematic’ and ‘tragic’ with 14 million people in the UK living in poverty and 1.5 million people experiencing destitution. Furthermore he accuses the DWP of the ‘systematic immiseration of the British population’.

This has certainly translated into more people visiting their doctor with low mood. But to explain the increased prescribing of antidepressants on this is to acknowledge that we have come to believe that understandable unhappiness can be resolved by pharmacological treatment. No doubt much unhappiness has resulted from these and other social factors but do we really believe that the answer to such unhappiness is found in a pill? Sadly the answer to that question appears to be ‘Yes’.

We doctors, not without some reason, are all too fond of the quotation ‘Please don’t confuse your Google search with my medical degree’. But equally we would do well to acknowledge that our medical degrees are not to be confused with something that is sufficient to fully understand the personal experience of those who consult us.

Too many in medicine have lost sight that we are more than biological organisms. This is perhaps not surprising as we live in a reductionist world where everything is explainable by the purely tangible with the result that we our reduced to nothing more than biochemical automaton. Sadness then is seen as sickness, not just by doctors, but by society itself. Of course the media fuels much of this. Society has changed and now believes happiness is a right. For years doctors were, sometimes justifiably, criticised for acting as if they were God – now it seems that society demands that doctors fulfil that role and meet its every need. Patients are sent to us by teachers, employees, health visitors and other family members all with the belief that the patient needs tablets in order to restore the happiness that we have come to believe is normal.

But sadness is normal too. Please don’t misunderstand. To say someone’s emotional distress is a normal and understandable response to circumstances rather than due to illness is not to diminish the extreme pain of that distress or to imply that the person needs to simply get over it and pull themselves together. People who suffer like this are not stupid, lazy or pathetic. Far from it. It is simply that, for all of us, life sometimes is more than we can bear. In a world where we are constantly urged to be awesome, to be ordinary can sometimes feel like failure. It is not. I for one am slowly learning to be content with being ordinary.

Not only is sadness normal, it also has purpose. As Des Spence wrote back in 2007, ‘Depressive pain has a psychological purpose in the same way that physical pain has physiological purpose. Low mood is as normal and as important to our sense of well being as happiness is.’ Interestingly of course we are seeing an epidemic of opiate prescribing suggesting that we have become as intolerant to pain as we have to an unhappiness. Prescribing antidepressants without attempting to address the cause of the unhappiness is as foolish as giving painkillers for a broken leg without any attempt to fix the fracture.

We have forgotten too that sadness and difficulty can be good for us. In his book ‘Lament for a Son’, Nicolas Wolterstorff wrote ‘I shall look at the world through tears. Perhaps I shall see things that dry-eyed I could not see’. And Marcel Proust in his ‘In Search of Lost Time’ comments that ‘We do not receive wisdom, we must discover it for ourselves after a journey through the wilderness which no one can make for us, which no one can spare us, for our wisdom is the point of view from which we come at last to regard the world’

In my practice, the cause of a persons distress is generally at least partly explainable within a few minutes of talking. It’s lovely then to tell folk that they’re not as ‘mad’ as they thought they were – that in fact they’re not ‘mad’ at all. With patients now, when talking about antidepressants, I liken them to strong analgesics – they may have the potential to numb pain a little in the short term but they fix nothing, have nasty side effects, risk dependency and, as is increasingly being recognised, cause significant withdrawal effects that can make stopping them very difficult.

Another problem is that the supposed chemical imbalance theory, a theory increasingly under fire, is convenient for the state. A year of antidepressants only costs about a tenner whilst delivering talking therapies costs far more. Those services are already unable to cope with demand and patients on the NHS often have to wait over a year to see somebody for psychological support.

But the cost of bringing about the real social change that would address the causes of emotional distress and reduce the number who experienced significant adverse childhood experiences would be far more financially costly. None the less this is where governments should concentrate their efforts rather than lazily cough up for dubious pharmacological solutions. What’s needed fast is the healing of our broken society which leads to so much emotional distress – together with an acknowledgment that, even in the healthiest of societies, sadness is normal and inevitable and love and support needs to be provided by friends and family rather than being outsourced to professionals in the misguided belief that sadness equals illness.

But the increase in antidepressant prescribing is not solely the result of life being more difficult. It is also a consequence that we are less tolerant of the sadness we do experience.

“What Orwell feared were those who would ban books. What Huxley feared was that there would be no reason to ban a book, for there would be no one who wanted to read one. Orwell feared those who would deprive us of information. Huxley feared those who would give us so much that we would be reduced to passivity and egoism. Orwell feared that the truth would be concealed from us. Huxley feared the truth would be drowned in a sea of irrelevance. Orwell feared we would become a captive culture. Huxley feared we would become a trivial culture.”

So wrote Neil Postman in his book ‘Amusing ourselves to death’. Entertainment has become the opium of the people so much so that we can not tolerate unhappiness.So fundamental to our nature has the pursuit of happiness become that its absence is deemed pathological and something for which a cure must be found. And so we have pills that seek to make us happy so we can die amused – that is without a thought – regarding the reasons of our unhappiness. Huxley, who predicted there would come a time when a pharmacological method existed that would make people ‘love their servitude’ certainly knew a thing or two.

Last week I saw Arthur Miller’s play ‘All My Sons’. It devastatingly charts the collapse of a family as the lies, secrets and greed needed to maintain the American Dream are exposed. Surely there are parallels for us today where the dream is that life should be nothing but fun. The gambling industry has a lot to answer for, not least for it’s recent advertising tag line which attempts to suggest it’s a responsible organisation that only wants to be one of life’s many entertainments offering enjoyment to those who indulge in having a flutter. But with ‘When the fun stops, stop’ they are in fact adding to the clamour that that is what life is all about. By suggesting that where fun is absent from our lives we should immediately look to find something else to amuse us is to suggest that life should be nothing but happiness. The dream that we can live anaesthetised to every pain – physical end emotional – is one we must wake up from lest we continue to live a lie. Insisting that those who persist in being unhappy are ill is wrong. To paraphrase Jenna Coleman’s line in last weeks episode of ‘Victoria’ (I know – sorry!) ‘Madness is a label given by powerful people to those who behave in inconvenient ways.’

And this is where the medical profession needs to acknowledge its own part in the over use of antidepressants, a practice every bit as concerning as the overuse of antibiotics. Though for the most part out of a desire to help as best we can, we have colluded with patients that medication can take away their pain. Furthermore, in the misguided belief that medicine has the answer to all our patients problems, those who have had the audacity to refuse to benefit from the pharmacological solutions they are offered for their supposed illness, rather than being accepted as those for whom medicine does not have an answer, are all too readily labelled as psychological ill. What’s more, those who react to the antidepressants they are given or suffer withdrawal effects from their cessation are too readily seen to confirm the psychological illness with which we labelled them. Interacting with those who have suffered at our hands is humbling. We owe them the courtesy of listening to them and an acknowledgment that we were wrong. We need to be sorry.

That said it is not all the fault of GPs. We have been misled to believe in the merits of antidepressants by a pharmacological industry who has reported exaggerated benefits and minimised side effects. The pressure of workload that requires us to see more patients than it is accepted is safe means that there is little time to spend with patients to uncover the causes of their emotional distress or follow them up adequately. And even when the time is taken to determine the cause, and talking therapies are deemed to be the way to go, counselling services are not resourced sufficiently to provide the support that is required.

Though not excuses, these are all factors for why doctors themselves are at least partly responsible for antidepressant prescribing increasing so dramatically. We need to be professional enough to acknowledge the truth and seek to bring about change, not only within our consulting rooms but also on a local and national level. We need to stop believing that science and medicine can solve all our problems. Medicine needs to acknowledge its limitations but equally society must accept that limitation and not constantly demand solutions that medicine can’t give.

Des Spence’s words 12 years ago are just as relevant today. We should have listened then – we must listen now. Antidepressants are over prescribed and should be used not as a first port of call but only as a last resort, and even then with extreme caution.

Evidence suggests giving somebody a label of mental illness makes them more likely to be treated pharmacologically but that they will fare less well. Furthermore being labelled as mentally ill can worsen the isolation such people experience as someone who is deemed to be unhappy because of circumstances generally garners sympathy and support whilst those seen as mentally ill can come to be seem as less predictable, less approachable and less able to be helped by simple kindness and understanding.

What then is the answer? For some it’ll be an encouragement for science to go further to find solutions to the problems we currently can not solve. For others it’ll be to accept that they are more than their physical make up and cause them to look elsewhere for something they can hope in. And for others, like me, who are grateful for all that medicine has to offer but hopes in something more than mere science, it’ll be both.

So when the fun stops, as someday it surely will, let’s take a moment and, in that rare moment of stillness ask, ‘Is there more to life than merely having fun?’ And then, rather than stopping until the next shot of fun is provided, carry on, content to sometimes do without amusement and experience life as it really is.

They say that politics and religion shouldn’t be discussed in polite company…in which case…we better hope that this isn’t polite company. But it is all getting a bit messy isn’t it? On their 1988 album, ‘Sunshine on Leith’, The Proclaimers asked the question, ‘What do you do when democracy fails you?’ At the moment, what ever party you might support and whatever position you hold regarding membership of the EU, I think it’s probably fair to say that democracy isn’t really succeeding for anyone.

Back in November 1947, Winston Churchill said:

‘Many forms of Government have been tried, and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all wise. Indeed it has been said that democracy is the worst form of Government except for all those other forms that have been tried from time to time’.

To be frustrated with the limitations of democracy then is nothing new – we shouldn’t be surprised when democracy fails. But what should we do when it does. First, perhaps, it would be wise to consider why it comes up short.

Firstly democracy will ultimately fail because of the nature of the people who run for government – and the nature of those given the responsibility and privilege to vote.

Those who run for election aren’t omniscient. Politics is a complicated business and no politician can genuinely know what is best in all situations for all individuals. Furthermore, though I don’t doubt that most are in it for the right reason, politicians aren’t devoid of selfish ambition and are therefore prone at times to promote themselves and their own ends in preference to what may be best for the country.

We who vote are no different. We are not infinitely wise either and can not appreciate what is always for the best. Like turkeys who, in the excited anticipation of a visit from Santa Claus, vote for Christmas, we too can be swayed by promises of short term gains without fully appreciating the long term consequences. Like politicians, neither are we selfless. Concerned for our own welfare, anxious about our future, and understandably longing to be sure that we’ll be looked after when we need to be, we are prone to vote in ways that serve us best rather than the country as a whole.

This is not to suggest that we or our politicians are incapable of doing good – created in the image of God there is much that is good in the human condition. But despite this we are all, at our heart, flawed. The one time Dean of King’s College London put it like this:

‘It is precisely when you consider the best in man that you see there is in each of us a hard core of pride or self centredness which corrupts our best achievements and blights our best experiences. It comes in all sorts of ways: in the jealousy which spoils our friendships, in the vanity we feel when we have done something pretty good, in the easy conversion of love into lust, in the meanness which makes us depreciate the efforts of other people, in the distortion of our own judgement by our own self-interest, in our fondness for flattery and our resentment of blame, in our self-asserted profession of fine ideals that we never begin to practice.’

A second reason that democracy fails is the failure by those in power to be sufficiently gracious to the less than perfect and thus not fully deserving people like me they govern.

At one end of the political spectrum there is the view that everyone is worthy and all have a right to the support of government. To one holding such a view, a question asked regarding the worst thing they had ever done might be laughed off with a nod and a wink as if there was no such thing as wrongdoing, nothing at least for which one ought to be ashamed. But denying the existence of wrong in oneself or others is both naive and ultimately precludes justice.

Considering everyone as deserving isn’t what grace is all about.

At the other end of the political spectrum there is the view that only those who have been responsible enough should have the support of government. To one holding such a view a question asked regarding the worst thing they had ever done might be answered in such a way that makes it clear that at heart they consider themselves as pretty good – they wouldn’t have done anything really bad, nothing worse perhaps than running through a field of wheat. But imagining that one is fundamentally good is naive and leads to arrogance.

Only helping the sufficiently deserving isn’t what grace is about either.

Grace though is being generous to the undeserving. It fully acknowledges the sinfulness of those one acts generously towards – but acts generously towards them just the same. One can understand why a government might be anxious about embracing such a notion. Apart from anything else, to be genuinely gracious is impossible for those with finite resources. Who could possibly fully meet everybody’s needs – there has to be limits doesn’t there? After all, there isn’t a magic money tree.

So democracy fails because of human nature, a misunderstanding of the nature of grace and the lack of sufficient resources to act genuinely graciously even if a government genuinely wanted to. This is not to suggest that democracy should be abandoned or that we should not be fully engaged in the democratic process. It is the best form of human government but ultimately it remains inadequate.

So what do you do then when democracy fails you? Well perhaps we should look for an alternative form of government. A government led by a genuinely good ruler, one with a truly good heart who is wise enough to be trusted to rule over us well. A government led by one who not only understands grace but who is benevolent enough to want to act graciously and who has the requisite infinite resources to do so. But where might we find such a ruler?

To continue the gospel according to the music of my youth, as Feargal Sharkey sang:

A good heart these days is hard to find,
True love, the lasting kind.
A good heart these days is hard to find
So please be gentle with this heart of mine

We can relate to these words, can’t we? We all want to be loved with a perfect and everlasting love all the while conscious of the frailties of our own. The Bible tells us in no uncertain terms though that ‘the heart is deceitful above all things and desperately sick’ [Jeremiah 17:9]. A good heart, a heart able to love us the way we would like, therefore is ‘these days’, and indeed always has been, hard to find. I certainly don’t find one in myself.

And the problem that we face is all the greater for God. We may be fooled by our looking on the outward appearance but God looks on the heart [1 Samuel 16:7] – he sees us as we really are. This is not good news. He has searched us and known us, discerned our thoughts from afar and is aquatinted with all our ways [Psalm 139:1-3]. And his verdict is that ‘none is righteous, no not one’ [Romans 3:10].

The problem becomes all the more pressing when we start looking for a good leader. Consider Psalm 24. ‘Who shall ascend the hill of the Lord and who shall stand in his holy place?’ asks King David, the writer of the Psalm. Who is the one worthy to rule, to be the ‘King of Glory’, to be God’s chosen King – to be the Christ. The psalmist answers his own question: ‘He who has clean hands and a pure heart, who does not lift up his soul to what is false and does not swear deceitfully.’ And with these words King David rules himself out of the running for the job – he is not fit to be the King. His hands are not clean, his heart is not pure. Like everybody else, David’s heart was deceitful above all things and desperately sick. His was a heart capable of adultery and murder. Since God was all too well aware of this as he looked on David’s heart when he selected him to be King of Israel in 1 Samuel 16, it follows that David was never intended to be God’s ultimate King.

A better King than David is needed. Who might that be? Who might God chose? The prophecy of Isaiah gives us a clue when in Chapter 42 we find the first of the so called Servant Songs in which Isaiah speaks of one who was yet to appear on the scene.

‘Behold my servant, whom I uphold, my chosen, in whom my soul delights; I have put my Spirit upon him; he will bring forth justice to the nations. He will not cry aloud or lift up his voice, or make it heard in the street; a bruised reed he will not break, and a faintly burning wick he will not quench; he will faithfully bring forth justice. He will not grow faint or be discouraged till he has established justice in the earth; and the coastlands wait for his law.’

Here then is somebody who is qualified for the title King of Kings and Lord of Lords. One in whom God delights. But to whom does this prophecy refer? The answer, of course, is Jesus, of whom God spoke, as he put his Spirit upon him at his baptism, ‘This is my beloved Son, with whom I am well pleased’. Jesus is God’s chosen King – Jesus is the Christ.

Jesus’ is the only perfectly good heart we will ever find. He alone is worthy to ascend the hill of the Lord and stand in his holy place. But, we must ask, will he be gentle with these hearts of ours? Will he be gracious? Isaiah’s prophecy assures us he will ‘a bruised reed he will not break, and a faintly burning wick he will not quench’. Our frail hearts are safe with Jesus.

Such grace sounds too good to be true – but true it is. It can be hard to receive such unmerited favour – generally we don’t like to be indebted to others, we’re too proud to be helped. And so, if someone does something for us, we are inclined to want to repay the compliment – to return the favour. But God’s grace to us doesn’t create a debt – rather it pays one. We have only to be humble enough to accept the kindness he shows us. Any good work we may subsequently do having been the recipient of grace is not by way of pay back for that kindness. It is, or should be, done out of a joy to serve the one in whom we delight.

Now, not only can it be hard to receive grace, it can be hard to see others treated graciously. Indeed some people hate the idea of grace. As an example, remember the hoo-hah a few years back in 2009 over the release of Abdelbaset Ali Mohmed al Megrahi – the Libyan man convicted of the Lockerbie bombing. Released on compassionate grounds as doctors believed he’d less than three months to live, the Scottish justice system was being gracious.

But many criticised the move – reacting angrily – crying out ‘where is the justice’. I wonder whether those who shouted so loud will be so eager for justice when they stand before God and their lives are on trial. Will they want justice then – or will they want grace. I know what I will want – what I’ll need. I will need grace. And if on judgement day, as I am declared “Not Guilty” on account of Christ work on my behalf, any then shout ‘Where is the justice?’ the answer I’ll give will be ‘On the cross at Calvary – where Jesus paid the price for my crime, where as my substitute he bore the punishment for my sin, where God’s justice and mercy so perfectly met.’

Finally on this point I word about the triumphant homecoming of Megrahi to Libya. You may remember it. All I can say is that, however inappropriate that response was, it in no way alters the value of the gracious act. But when a repentant sinner receives grace, their response is a humble not arrogant joy. They don’t mock the one who has shown grace to them but respond in love and praise for the one that has shown them such favour.

So too should be our response to the grace we have received.

Which brings us to the question of how our hearts should be now. Certainly they should be growing in goodness. Though counted righteous now, declared to be so on the basis of Christ’s work outside of ourselves. our justification should be followed by a growing sanctification, the gradual and ongoing gracious transformation of our character by God such that we are changed into the likeness of Christ, a process that, in me at least, is sadly far too slow and which will only fully be realised on the day of Jesus’ return.

But there is another characteristic that our hearts should display. Contrition. In Psalm 51, all too conscious of his adultery with Bathsheba and his having her husband Uriah killed, David asks of God

‘Wash me thoroughly from my iniquity, and cleanse me from my sin! For I know my transgressions, and my sin is ever before me.’ [Psalm 51:2-3].

David acknowledges his sin and expresses repentance and then, in verse 17, he asserts

‘The sacrifices of God are a broken spirit; a broken and contrite heart, O God, you will not despise.’

Perhaps that is what God saw in David when he identified him as the one Samuel should anoint. One who, acknowledging his weakness, was prepared to plead,

‘Create in me a clean heart, O God, and renew a right spirit within me’ [Psalm 51:10].

King David is one who knows he is undeserving, one who recognises his need for grace, and one who, in his humility, is prepared to cry out to a God who is gracious. This would be a wise course for us all to take for:

‘God opposes the proud, but gives grace to the humble.’ [James 4:6].

Here then is comfort for the contrite heart. Contrition is the quality that God is looking for our hearts to possess. It is the contrite heart to which salvation comes.

‘For thus says the One who is high and lifted up, who inhabits eternity, whose name is Holy: “I dwell in the high and holy place, and also with him who is of a contrite and lowly spirit, to revive the spirit of the lowly, and to revive the heart of the contrite.’ [Isaiah 57:15]

This is a truth echoed by Jesus in the sermon on the mount

‘Blessed are the poor in spirit, for theirs is the kingdom of heaven. Blessed are those who mourn, for they shall be comforted.’ [Matthew 5:3-4].

A good heart these days is hard to find. But though we do not see one in ourselves, we do find one in Jesus. His is a true love of the lasting kind. A good heart these days is hard to find, but Jesus is one who will be gentle with these contrite hearts of ours.

So if you’re hopeful about what politicians will achieve – don’t be too hopeful
And if you despair at what they get up to – don’t despair too much.

Psalm 121 begins:

‘I lift up my eyes to the hills. From where does my help come?
My help comes from the LORD, who made heaven and earth.’

The psalm is one of the so called psalms of ascent sung as travellers headed to Jerusalem. On the way they would have seen on the hills the evidence of pagan worship but the psalmist affirms that, rather than looking to such sources for assistance, his help comes from the Lord. Similarly today there are those who put there hope in science and technology, medicine and sociology and especially at election time, politics and economics. But these sources of help will all fail. The truth is, regardless of who you voted for in the last general election – Theresa May, Jeremy Corbyn, or Tim Farron, Lord Buckethead, Elmo or Mr Fishfinger, nobody will be able to govern the nation in the way that is ultimately required. We need a leader whose qualifications to govern are infinitely greater – one who is truly good and has the resources to be infinitely gracious, one indeed who has shown us ‘the immeasurable riches of his grace in kindness towards us in Christ Jesus’ [Ephesians 2:7]

But will such a government really last. Well yes – in Isaiah’s prophecy we hear these words made 700 years before the birth of Jesus, words well known even to non-Bible types through another big hit – Handel’s ‘Messiah’

‘For to us a child is born, to us a son is given; and the government shall be upon his shoulder, and his name shall be called Wonderful Counsellor, Mighty God, Everlasting Father, Prince of Peace. Of the increase of his government and of peace there will be no end, on the throne of David and over his kingdom, to establish it and to uphold it with justice and with righteousness from this time forth and forevermore. The zeal of the LORD of hosts will do this.’ [Isaiah 9:6-7]

God’s kingdom will endure, his government will last – and the reason we can be so sure is given in that final sentence. It will last because it won’t depend on us – rather it will all depend on God – his zeal will ensure that what He has promised will be delivered.

Nearly 3000 years ago King Uzziah died, and the future seemed so uncertain for the people of Isaiah’s day. Isaiah, however, saw beyond the immediate political uncertainty.

‘In the year that King Uzziah died I saw the Lord sitting upon a throne, high and lifted up; and the train of his robe filled the temple. Above him stood the seraphim. Each had six wings: with two he covered his face, and with two he covered his feet, and with two he flew. And one called to another and said: “Holy, holy, holy is the LORD of hosts; the whole earth is full of his glory!” And the foundations of the thresholds shook at the voice of him who called, and the house was filled with smoke.’ [Isaiah 6:1-4]

There is an image of one who is utterly in command. Uzziah may have died but God was still on the throne. He still is today. Many today are yearning for a leader who is wise enough, good enough and powerful enough to bring about real positive change. The good news is that that is exactly the kind of ruler God is. He is not fretting anxiously over the rights or wrongs of Brexit which, in universal terms, is no more than a falling out in the playground. On the contrary – God is unphased by all the uncertainty that causes us such concern. He will fulfil all that he has promised.

So what do we do when democracy fails us? We stop being surprised and look outside of ourselves to one who, undeserving though we are, is gracious toward us and can deliver what He promises. We remain confident that no matter the political instability that may be going on all around us, God is sovereign. And we hold fast to what we know with absolute confidence – that our loving God’s authority is absolute, his power is infinite, and his wisdom is supreme, He really is in total control of every second of our lives.

What do we do when democracy fails us? We rejoice that the Lord is King,

This week has seen me relieved of a burden that was becoming too hard to bear – that of watching ‘Silent Witness’. Of late it has been a show I have been watching more out of a misplaced sense of loyalty, more in appreciative memory of when it was entertaining, than because I was still genuinely enjoying it. Of course the programme has always been ridiculous – nothing has changed from that point of view. Now, it’s not that there is anything wrong, for the sake of entertainment in having pathologists, in their attempt to single handedly make all our lives safer, straying from their natural habitat of the post mortem room and running around the countryside on the trail of anyone involved in the many nefarious practices which result in bodies ending up on the dissection table. For an hours distraction, I can forgive such nonsense. But what I found difficult to swallow in the last story in the most recent series, was Dr Nikki Alexander’s constant maintaining that she was perfect, her repeatedly insisting that ‘I did not make a mistake’ – a position taken, not so much because of the details of the particular case in question, but rather, it seemed to me, because she could not conceive that she might sometimes get things wrong.

Now for some time I have felt that Dr Alexander has been close to the edge. And if she fails to accept the normality of her ordinariness, if she admits no possibility of her own fallibility and insists that only personal perfection is acceptable, it’ll surely not be long before she topples over it.

And the same will be true for us.

I wonder how many mistakes I have made this week. Thankfully most won’t have mattered all that much but, inevitably, over a career, there will be those which do. Human error is a reality – not necessarily because we are negligent, lazy, or lacking in knowledge, but simply because we are human, and all of us are flawed. Atul Gawande speaking of what he calls our ‘necessary fallibility’ is reassuring. If the Professor of Surgery at Harvard knows he’s fallible, then I guess I shouldn’t be too surprised that I am too! And knowing it’s normal to be less than perfect helps me in a small way to live with the fact – and the sometimes painful emotional consequences.

As less than perfect people in a less than perfect world, difficulty and disappointment is to be expected. We should not be surprised by it. That is not to say we should fatalistically accept it. On the contrary, as doctors we should try to change what we can for the better, both in others and indeed within ourselves. Sometimes that will be possible be that by the prescribing of an antibiotic, the administration of an injection or the simple offering of a comforting word. But oftentimes we won’t be able to help as much as would like and may have to be content to share some of the sadness that our patients feel. Such sadness, does not necessarily mean there is something wrong with us, though it might if we are the cause of the sadness, which sometimes we will be. On the contrary, sadness in ourselves more commonly will indicate that there is something very right in us – that we have a degree of compassion for those who suffer.

But unlike Dr Nicky Alexander we need also to be realistic of our real limitations because of both the enormity of the problems we are trying to help and our own personal frailties which inevitably make us a part of the problem too. Rather than wearing ourselves out trying to convince ourselves and others that we are without fault, we must accept the sadness of our own inadequacy. Demanding of ourselves perfection is unhelpful for our patients who will thus be encouraged to have unrealistic expectations of what we can do for them and thereby find that their trust in medicine is all too frequently misplaced. And demanding perfection of ourselves is unhelpful for us too, leading as it will to a sense of overwhelming despondency, an excessive self criticism and a constant fear of reproach from others which will ultimately deprive us of any joy and satisfaction in the good we do achieve in our work.

Mistakes are part of life. And when they are made, what is needed is an abundance of kindness. When we make mistakes, rather than others demanding of us their pound of flesh, we will be glad if others are kind to us, forgiving us of our errors and accepting us as we are – warts and all. Sometimes, if we are to last the course, we will need to show ourselves such kindness and, when we know we have reached our limit, demand of ourselves no more.

And when we are those who are affected by the mistakes of others, when we are disappointed and frustrated by our patients, our colleagues and even total strangers, we would do well to try and be understanding of, and equally kind to, those who, having reached their limit and can ask no more of themselves, ask of us instead – even, sometimes, on those occasions when we are unreasonably put upon and the kindness is undeserved. To be kind in such circumstances is hard, very hard – it costs us something be it our time, our energy or our emotions. But true kindness makes a difference, because when done with no expectation of a returning of the favour, it changes what has gone before, allowing past mistakes to be left behind.

That sort of kindness eases burdens, lightens loads – it pays a debt without creating another.

Kindness like that is something we, and all who fall short of perfect, need far more of.

Kindness like that will allow us to keep on keeping on.

THE LIFE I LEAD

Some while ago I was fortunate enough to be sat in Exeter’s Northcott Theatre to see the opening night of ‘The Life I Lead’. It is a brilliantly written play by James Kettle performed single handedly with equal brilliance by Miles Jupp. Through a conversation with the audience, it tells the story of the life of the British character actor David Tomlinson best known for his portrayal of Mr Banks, the father in the Walt Disney film version of ‘Mary Poppins’. It is a warm and gentle two hours which manages to be seriously funny as well as poignant and moving. It leaves those watching with a genuine affection for a man who few will have previously known much about. I’ll not spoil it for those who may yet go and see it but, suffice to say, the play reveals that behind the genial public image, Tomlinson’s personal life, though generally happy was not without tragedy – he was a man who had to live with sadness.

Tomlinson is not alone in having to bear the inevitable sorrows that come as the years pass. Whilst continuing to live and work, attending to the everyday and endeavouring to find happiness, meaning and satisfaction, we all, to a greater or lesser extent, have to endure grief. In that respect, the performance was made more poignant still from knowing that, as he portrayed Tomlinson so perfectly, Miles Jupp was himself carrying a grief of his own, having lost to cancer, less than a week previously, his friend and colleague, comedian Jeremy Hardy. I hope Jupp was able to enjoy performing despite the sadness he was no doubt still feeling – and appreciated the very warm reception that resulted. If he did, then he was not so different from me who was also able to thoroughly enjoy the show, laughing frequently, despite my own ongoing sadness regarding the sudden death of a friend of mine, in particularly tragic circumstances, just four weeks previously.

The evening left me reflecting once more how few lives are devoid of tragedy, but that life is a mixture of the good and the bad and that even when sadnesses come thick and fast, happiness can still be a close companion, intermingling with the sorrow. Life can and does go on, a complex mix of fortune and disaster. Such was the life that Tomlinson led, such is the life I lead and such too are the lives my patients lead.

T. S. Eliot was right when he wrote: ‘People change and smile: but the agony abides’. I see it all the time in my work when a little scratching of the surface all too readily uncovers, beneath the cheery facade, a back story to my patients that I may never have otherwise known about and without which I cannot begin to fully understand their presentation. Why did that woman burst into tears quite so readily over a relatively modest degree of back pain when she consulted this morning? What hidden pain was behind her presentation? What sorrow was she bearing, possibly alone? It’s sure to have been there because ‘everybody hurts’.

I met Jeremy Hardy once. He was performing his stand up show in Taunton many years ago and I went to see him one evening with a friend who was on call for a local GP practice. Those were the days when one could risk, if covering a small practice population as was he, combining an evenings on call with a trip to the theatre provided one was careful to position oneself in close enough proximity to an exit. Predictably enough, my friends mobile went off and as he sloped out to attend to the sick, Jeremy Hardy took the opportunity to extend his routine by ten minutes with a good humoured berating of anyone who would allow their phone to ring in such a setting. My friend made it back in good time though and, having enjoyed the rest of the performance, we were able to indulge in a post show drink in the bar together. Jeremy Hardy was there too, amiably chatting with anyone who cared to spend the time with him. My friend’s phone went off once more and, realising he was a doctor, Jeremy Hardy had a brief chat with us, apologising for his on stage criticism and wishing us well. He seemed to be a genuinely warm and friendly person and I am sorry that he will no longer be entertaining us with his fine sense of humour coupled with the earnestness of his politics. His life too, of course, also knew what it was to experience tears amid the laughter.

Sadness then, is universal, even in the happiest of lives. The causes are many, but can perhaps be divided into the grief felt for the thing which is lost – the regret of the broken relationship, the missed opportunity, the faded dream – and the sorrow resulting from the fear that the future will bring no relief – the loss of hope itself. Sometimes the sadness is easier to feel than the joy.

For some time now, I have been involved with somebody I love who has been experiencing a period of prolonged personal sadness. It is a sadness that makes me sad too. Many will be familiar with the words of the psalmist who wrote, ‘Weeping may tarry for the night but joy comes in the morning’. I don’t doubt the truth of these words but the night for some has already been very long and the day seemingly remains an eternity away. Elsewhere in those ancient writings are chronicled the trials of Job and the ineffectual efforts of his comforters who needed to learn what we too must appreciate – that sometimes it is best to simply ‘weep with those who weep’ rather than to try to argue them out of their sadness or, worse still, point out to the one who is sad the mistakes we think they have made to bring about their misery. Regardless of whether we believe in God, we can I think agree that there is wisdom here.

Regret and sadness have much in common. In my first year as a GP Principal I recall one Sunday morning visiting a patient who had had a few days of severe diarrhoea and vomiting. He appeared sufficiently dehydrated to require admission and I requested an ambulance to attend, not immediately, as I was soon to regret, but within the hour. There was, uncharacteristically for those days, some delay in the ambulance attending, and sadly the patient suffered a cardiac arrest and died on route to hospital.

The next day I chatted to my partners about the case. All were supportive and quick to point out that I had acted appropriately, that if anyone was at fault, it was the ambulance service and that the outcome would likely not have been any different even if the ambulance had attended earlier. But the response that helped me most was that of my senior partner who simply acknowledged that it was tough when things went wrong and related an incident when he had regretted a judgement he’d made some years previously. That such an experienced and respected GP could ‘regret with those who regret” was very comforting for me.

We are all flawed – inevitably even the best doctors make mistakes – mistakes which we may regret for years but from which, having honestly acknowledged them to both ourselves and those affected by them, we can, none the less, learn much. Perhaps it is even true to say that mistakes are in fact necessary if we are to become the more experienced and better doctors we desire to be.

Experience comes over time so older doctors perhaps feel this most. Perhaps they are more accepting of their mistakes and are more used to knowing at first hand what it is to experience the associated regret. Just as Abraham Lincoln suggested that the old have come to ever expect sadness, so older doctors have perhaps come ever to expect regret.

And if mistakes and regret are an inevitable but necessary part of being a doctor then perhaps sadness is an equally inevitable and necessary part of being human. Though for the most part I am happy, sadness sits constantly beside me. That is the life I lead. And If mistakes and regret have the capacity to make us better doctors then maybe sadness has the capacity to make us better people. Perhaps wisdom is acknowledging this. Rather than trying to constantly avoid sadness and, when it does make it’s inevitably unwelcome appearance, attempting to rationalise it away, perhaps we would do well to learn to accept that life is often sad and our lives can, paradoxically perhaps, be enriched by those times

If so, I hope I can become that wise.

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Related blogs:

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

To read ‘Dark Reflections’, click here

GENERAL PRACTICE – A SWEET SORROW

So the new contract is out and, in some circles at least, it has been met with some enthusiasm -particularly in regard to the plan to fund additional GP support staff. Now, although this is not unwelcome and may lighten the load a smidge, I can’t help thinking that something is 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 remains that there are not enough GPs. Only greater numbers of GPs will give us the time to properly do what GPs do best – tread the thin line between on 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 – that is make everything OK.

The problem, it seems to me, is that 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 their part to deliver the required utopia. But in fact 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. Just as joy can be found in sadness, and strength can be found in weakness, 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 …. 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 without fusing the 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 as well. 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 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 ever addressing its cause.

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 perhaps that is exactly the type of GP who cares too.

HERE’S TO 2019

At the end of one year, and the beginning of another, we can, no doubt, look back on what made last year hard and consider what may make this coming year harder still. Unquestionably, there will be bad times in the coming months – times when life will be difficult. There may also be moments when, in the face of overwhelming demand, some of us will hold our head in our hands and wonder if we can keep on going. But, amidst all the very real problems, there will be good times too. So, for today at least, here’s to those good times:

Here’s to the young couple who, together, will consult us, excited about their expecting a baby for the first time.

Here’s to the anxious parent we will be able to reassure that their child hasn’t got meningitis and is going to be just fine.

Here’s to the depressed patient, who after months of support, we will see begin to smile again.

Here’s to the early diagnosis we will make in a patient who goes on to make a full recovery.

Here’s to that restorative cup of tea the receptionist will bring when we’re running an hour behind.

Here’s to the laughs we will share with colleagues – and to those we will share with patients.

Here’s to the advice and support we will receive from our secondary care colleagues.

Here’s to the blood sample which, allegedly, no one will be able to get as well as we can.

Here’s to the ‘thank you’ we will receive from a genuinely appreciative patient.

Here’s to the empty waiting room we will be pleased to see at the end of the day.

Here’s to the practice nurse who will manage our patients with chronic disease better than we ever could and who will reapply a dressing we’ve just undone, and here’s to the HCA who will squeeze in an ECG because they’re only too happy to help.

Here’s to the patient we will reassure isn’t as mad as they think they are.

Here’s to the prescription we will write that the pharmacy has in stock and which actually does make our patient better.

Here’s to the patient we will encourage back to work.

Here’s to the couple who, for want of knowing where else to go, will do us the honour of coming to see us because they think we might just be able to help them sort out their differences.

Here’s to the practice manager who will solve problems before we even knew they existed.

Here’s to the patient who will not have a stroke because of our urging them to stop smoking twenty years ago.

Here’s to the patient who we will be able to tell that the scan that they were so concerned about is normal.

Here’s to the lonely who will find in us a friend.

Here’s to the colleague who will help us out when we’re struggling.

Here’s to the terminal patient we will enable to stay at home to die.

Here’s to the secretary who will transform our mumbled dictation into a letter that makes sense and who will understand referral pathways however many times they change.

Here’s to the prompt emergency treatment we will give ensuring a patient arrives safely at hospital.

Here’s to the one with whom we will simply sit and listen – the one whom we will be privileged to be allowed, just a little, into their sadness.

Here’s to those who will pass their CSA and will be welcomed into practices with open arms.

Here’s to those who, at the end of a hugely worthwhile career characterised by care and compassion, will reach retirement and be sorely missed.

Here’s to those times when we will somehow find ourselves bringing comfort, offering hope, sharing joy.

Here’s to the times we will know that, against all the odds, we really have made a positive difference.

Here’s to when we will be glad we did a little more than was required of us just because we could.

Here’s to the job that is unlike any other and still has the capacity to be among the best in the world.

Here’s to everything that will be good about working as a GP this year.

And here’s to ensuring that there will be many more good years to come.

HAPPY NEW YEAR!

‘Twas the week before Christmas and all cross the nation

People prepared for the great celebration.

And any who suffered a cough or a sneeze

Wanted a drug for their symptoms to ease

.

So everyone contacted their health care providers

Knowing that they were the licensed prescribers

To getting appointments they showed dedication

Twas simply a must to have right medication

.

The clinical leads checked protocols twice

(Ensuring compliance with guidance from NICE)

Relaying their learning to practice clinicians

On management options for Christmas conditions

.

There’s a tablet for when you’re deficient in joy

A tablet for when you’re not given that toy

A tablet to counter the courage that’s Dutch

A tablet for when you have eaten too much

.

A tablet for all of the stress of the crackers

A tablet to give to the washing up slackers

A tablet to help you put up with Aunt Jean

A tablet to keep you awake for the Queen

.

Whilst sitting on sofas and watching TV

And longing for chocolates that hang on the tree

By taking these drugs nobody need fear

They’re sure to stay healthy right through to New Year

.

On Codeine, on Senna, on Brufen, on Zantac

On Statin, on Zoton, on Calpol, on Prozac,

And so that the cooking, guilt free they can shirk

There’s always a note to say they can’t work

.

The Medicine Management Advisor’s away

I don’t think he’s working on this Christmas Day

But I heard him exclaim, ‘ere he drove out of sight

HAPPY CHRISTMAS TO ALL AND TO ALL A GOODNIGHT

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To see ‘How the Grinch Stole General Practice’s Christmas’, click here

To read ‘A Primary Care Christmas Carol – Stave One’, click here

A PRIMARY CARE CHRISTMAS CAROL

Stave One – in which Scrooge reveals how burnt out he is

Old Dr Marley was dead. As dead as the NHS would be within a couple of years if things didn’t start to improve soon. And, as far as Dr Ebenezer Scrooge was concerned, Jacob Marley was better off out of it. Scrooge and Marley had been long term partners and Scrooge greatly missed his former colleague who had died several years earlier. This was not the result of any affection he had had for the man, that was not in Scrooge’s nature, but rather on account of the fact that, due to the national shortage of GPs, he had been unable to find a replacement, and his workload had consequently increased beyond the point of being manageable.

It was Christmas Eve and Scrooge was sat at the desk in his consulting room. It was nearly three in the afternoon. Morning surgery had only just finished and this was now what was laughably called his ‘lunch break’. An email flashed up on his computer screen. It was from the CCG wishing him a merry Christmas.

‘Bah!’ muttered Scrooge to himself. ‘Humbug! If they really wanted my Christmas to be merry, then perhaps they and NHS England could have agreed that I didn’t have to make up the Advanced Access hours, lost from not opening the surgery on Christmas Day, later in the week. Every idiot’, he continued, ‘who goes about with ‘Merry Christmas’ on his lips should be submitted to unnecessary colonoscopic examination and be forced to reflect on the experience for the purposes of revalidation.’

Dr Scrooge was not one to enjoy Christmas, and being encouraged to be merry served only to darken his already black mood still further. The situation was not helped by the arrival of a receptionist who announced her presence with a knock on his already open door.

‘Sorry to trouble you Dr Scrooge, but the Salvation Army band are playing Christmas carols in the car park and are asking if you would like to make a donation.’ She handed him a leaflet informing him that this Christmas many people would not have anywhere to sleep due to the lack of hospital beds resulting from years of chronic NHS underfunding. Scrooge sighed – this was nothing he didn’t already know. Only that morning he had been asked to arrange a review over the holiday period of a patient that was about to be discharged, a little earlier than was ideal, from the local, desperately overworked, hospital. Though he regretted being unable to promise that level of care, his refusal then had been unequivocal and he was no more minded now, at his own personal expense, to start financially propping up a system left destitute by the establishment. As far as he was concerned, he was already paying quite enough tax and, given that he had just learnt that the security of his pension was now somewhat precarious, he felt it was unlikely that he would change his mind on the matter. He stood up and slammed the door in his informant’s face. Sensibly, the receptionist interpreted that as a ‘No’ and scuttled back to where her colleagues were celebrating Christmas with a box of mince pies and a tube of Prosecco and pink peppercorn Pringles – the latter, notwithstanding the alliteration, surely an ill advised flavour choice, regardless of the season.

Scrooge had been invited to share in the festivities but he had no desire to do so. Nor did he have time. Instead he returned to his computer screen and started the never ending task of clearing his inbox of lab results, hospital letters, and prescription requests. He’d barely started when there was another knock at the door. Scrooge barked out a ‘What is it?’ and the door swung open to reveal the ST3 who had been with the practice since August. Dr Robert Cratchit was a highly capable doctor though one who lacked confidence in his own ability. To Scooge’s dismay he was wearing a Christmas jumper.

‘What do you want? Can’t you see I’m busy?

These words were not unfamiliar to Dr Cratchit, who, over the previous five months, had heard them frequently from the man who purported to be his trainer. In fact, so frequently had he heard them that, for a time, he had used them to start all consultations with patients, imagining them to be the profession’s approved opening words for all doctor/patient interactions. A failed attempt at the CSA and the associated considerable expense of applying to sit the exam again had indeed taught him much. Familiarity however did not make it any easier for Dr Cratchit to approach a man who never offered advice without showing contempt for the one who asked for it. For although Scrooge had received training on giving feedback, he had, much to the dismay of his appraiser, consistently failed to demonstrate any change in his behaviour as a result of such practice improving activity.

‘I was j-just wondering if it would be convenient if I were to g-go’ Cratchit stammered. ‘I’m only supposed to do one clinical session today and, though the planned patch t-tutorial for this afternoon has been cancelled, I thought that, since you allocated me all the visits, you m-might let me skip off a little early this afternoon. It is Christmas after all and I would so appreciate having the extra time to be with m-my family.’

Scrooge glowered. ‘Of course it’s not convenient. And I don’t suppose you’ll be offering to work a couple of extra Saturday mornings in lieu of the day you’ll no doubt be taking off tomorrow. That’s the trouble with young doctors these days. No commitment’

The ST3 smiled faintly and waited nervously. ‘Go on then, leave’ Scrooge eventually conceded, ‘But if anything goes amiss this afternoon and I’m compelled to reflect on some significant event or another, I know where my reflections will lay the blame. Just make sure you’re in early on Thursday.’ Cratchit thanked Scrooge and slipped away, leaving the burnt out old clinician alone with his thoughts and the prospect of a three hour afternoon surgery.

As things turned out the rest of the day was mercifully quiet with Christmas Eve being the one afternoon of the year which provided the general population with something more interesting to do than seek medical advice regarding their minor health concerns. As a result, Scrooge locked up the practice early and arrived home before nine. He’d stopped on the way to pick up a bite to eat but, having consumed it en route, the only thing he had to look forward to on arriving back was, as most evenings, the prospect of going to bed.

As he got out of his car, a fog hung about the driveway of the old house, that he’d bought some years before. Scrooge approached the front door, the fog seeming to cling to him as he walked. It was then that he noticed, in place of the ancient door knocker, what was clearly the face of his old partner, Dr Marley. The apparition lasted but a moment before Scrooge, unsettled by the sighting, hurried on, unlocking the door and subsequently forcing a pile of unsolicited medical periodicals to one side as he entered the house. He locked the door behind him and climbed the stairs to his bedroom.

Scrooge undressed and put on his night attire. As he sat gazing into the middle distance, contemplating once more the strange appearance of the door knocker, there came an unexpected ringing sound that filled him with inexplicable dread. Scrooge scrambled in his pocket for his phone. However, as the caller’s number was withheld, he, as was his custom, ignored what was almost certainly a nuisance call and continued his preparations for bed. And then he saw it. A sight that caused him to be more horrified than he’d ever been before – even more horrified than that morning when his appointments had included seven heart sink patients and three more complaining of being ‘Tired all the time’. Before him, as unwelcome as critical emails from the head of Medicines Management, stood the ghost of Dr Jacob Marley.

Scrooge, nothing if not a man of reason, rose up and spoke to the spectre in an accusatory tone.

‘I don’t believe in you’ he said.

‘You don’t believe in most NICE guidelines and yet they exist’ countered the phantom.

‘That’s true’, Scrooge was forced to concede and with that he sat back down in his chair. He paused a moment then, looking the ghost full in the face and acknowledging his existence, asked the reason for his visit.

‘I have come to warn you Ebenezer. There is yet a chance that you may escape what has become my fate. I am condemned to walk the earth for all eternity burdened by these chains – chains composed of nonsensical bureaucratic demands imposed on me by those who understand nothing of medicine and seek to use the profession for their own political ends. You have forgotten, Ebenezer, what being a doctor is really all about. You have forgotten the joy that your work once brought you and now you practice as a mere shadow of the clinician you once longed to be. You’re burnt out Ebenezer. Something needs to change.’

‘Blimey!’ said Scrooge, ‘like that’s going to happen’.

‘You will be haunted by three spirits,’ continued the ghost, ignoring Scrooge’s cynicism. ‘They will teach you all that you need to know. Without them you cannot hope to shun the path I now tread. Expect the first when the clock strikes one’.

And with that the ghost of Jacob Marley departed, groaning incoherent sounds of lamentation and dragging the weight of his chains behind him. Scrooge stood motionless for he knew not how long. Then, mindful of his need for rest, he climbed into bed. Picking up a copy of the BJGP, he fell asleep upon an instant.

A PRIMARY CARE CHRISTMAS CAROL

Stave Two – in which Scrooge fondly remembers

Dr Scrooge woke in a cold sweat and sat bolt upright in his bed. This was not unusual for, in recent weeks, the stress associated with an impending visit by the CQC had frequently disturbed his sleep. Moments later, however, his thoughts were diverted from the need to get on and write those mandatory protocols on the secure overnight storage of hand towels and the safe use of the stairs, when, at one o’clock precisely, his bedroom door creaked open and a strange looking fellow crept into the room. Over a woollen cardigan he wore a tweed jacket complete with leather patches on the elbows; on the end of his nose was perched a pair of pince nez glasses; and in his hand he carried a battered black Gladstone bag.

‘Are you the spirit, sir, whose coming was foretold me?” asked Scrooge.

‘Indeed I am’ the apparition replied. ‘I am the Ghost of General Practice Past. I’ve come straight from a meeting of my celestial Balint Group. And my, what catharsis we enjoyed there this evening. Your former partner, Jacob, was in attendance. He’s a good chap, a jolly fine fellow. But enough of that. Come along with me – he has sent me to show you what General Practice once was.’

The spirit held out his hand and Scrooge instinctively took it. As he did so, Scrooge felt himself being lifted, as if weightless, from his bed. The spirit led him to, and then through, the wall of the bedroom and out into the night air. They journeyed until they found themselves in the oak panelled surroundings of what appeared to be a gentleman’s club. A number of elderly men sat together in high backed leather chairs. All were doctors, enjoying a glass of port after a drug sponsored Christmas meal. With them was a medical student who was attached to one of their number.

‘Listen to these chaps’, the spirit said to Ebenezer, ‘Each and every one is a fine fellow – a jolly good chap. You could learn a thing or two from what decent sorts like these have to say.’

The men were taking it in turns in regaling the medical student with tales of their working life.

‘Of course, these days, the youngsters have it easy. They only work a mere seventy two hours a week you know. In my day it was eighty one’

‘Eighty one hours? You had it easy. It was all internal cover when I did my house jobs. In real terms, I did a hundred hours a week’

‘Only a hundred hours a week? Luxury. I was running a GP practice single handedly by the time I was 23.. On call every hour of every day.’

‘That’s right. We had it tough as GPs. One hundred and sixty eight hours a week we worked – and, of course, we had to provide all the obstetric care – home deliveries every day’

‘And most of those were C.Sections – we had do the operations with only kitchen utensils for surgical instruments and a bottle of brandy for an anaesthetic’

‘Aye – and if you tell that to the medical students of today, they’ll not believe you.’

The spirit indicated that it was time to move on and Ebenezer readily agreed. He’d heard it all before. The walls of the room blurred and faded and gradually, as things came back into focus, Scrooge realised that they were now high above rolling hills. Passing over snow covered fields and lanes, they travelled until they came at last to a small town and stopped by a house that Scrooge recognised as his childhood home. Outside the dwelling, a car pulled up. The familiar figure of his family GP clambered out of the vehicle and made her way up the garden path to the front door. A woman was waiting anxiously for her arrival. They exchanged a warm greeting after which the woman led the doctor up the stairs to a room in which a boy lay, pale and in obvious distress.

‘Thank you for coming doctor, I know you’re busy but I didn’t know what to do. Ebenezer’s usually such a healthy child but he seems now to be struggling with his breathing.’

‘It’s no trouble Mrs Scrooge – let’s take a look at him.’

The doctor knelt down by the bedside and smiled at the boy who managed to smile weakly back. Ebenezer liked the doctor. He’d visited her a number of times over the years but this was the first time she’d ever visited him. The doctor asked a few questions and then carefully examined the boy, paying particularly careful attention to his chest. When she was done, she turned back to his mother and gave her the diagnosis.

‘I’m afraid it looks like we’ve a case of pneumonia on our hands. He’s really quite poorly and will be needing the help of my colleagues at the hospital. We best get him there as soon as possible.’

Scrooge looked on and wondered how she could say such a thing without a computer and a pulse oximeter to enable her to assess the risk of sepsis. She hadn’t appeared to even consider a CURB-65 score. None the less, a few phone calls were made and the doctor, placing her hand on Mrs Scrooge’s shoulder as if to say that everything would be alright, made her goodbyes,having given an assurance that an ambulance would soon arrive, an expectation Scrooge thought fanciful in the extreme,

‘Do you remember that day Ebenezer?’ asked the Ghost of General Practice Past.

‘I do,’ Ebenezer whispered, taken aback at how emotional he was now feeling. The spirit smiled to himself as he sensed that Scrooge was close to tears. He loved catharsis – catharsis was good. ‘She was such a lovely doctor’, Scrooge continued. ‘Always so kind and reassuring. She’d become almost a part of the family having visited so frequently during the last days of my father’ final illness. She always seemed to have time. It was because of her that I decided to become a doctor. The way she practiced medicine caused me to realised that being a doctor was a wonderful job to have. She seemed to me to be a fortunate woman.”

‘A fortunate woman indeed’ agreed the spirit. ‘A fortunate women and…’ he paused, thrown for a moment, ‘…a good chap’. The spirit hesitated again and then added, as if to try and reassure himself, ‘She was a jolly fine fellow.’

With that the ghost again took Scrooge’s hand and soon they were once more travelling through the night sky. On and on they flew, until they came to a village hall decorated brightly with all manner of coloured lights. A Christmas tree strewn with tinsel and still more lights stood by the entrance. Inside, Scrooge recognised the staff of his GP training practice. Some talked, others laughed and a number danced enthusiastically to music provided by a band. All were clearly enjoying the opportunity to relax and have fun together. A portly man then stood up and called for a bit of hush. It was Dr Fezziwig, the senior partner of the practice and Ebenezer’s one time trainer.

‘A moment’s silence if you please everybody. If I might say a few words, thank you all so much for coming this evening. I hope you’re having a good time.’ He paused a moment and then, with a feigned suggestion of doubt in his voice, questioned the crowd, ‘You are having a good time, aren’t you?’ Those gathered gave the desired response with cheers and roars that left nobody in any doubt that indeed they were. Fezziwig continued. ‘I want to thank you all for your help this past year. The partners appreciate your hard work, doing what can be a very difficult job. We couldn’t manage without you.’ More cheers followed together with a few calls for a pay rise. Fezziwig then concluded by wishing everyone a very Merry Christmas and insisting that everyone took advantage of the free bar that he and the partners were glad to provide. ‘Only keep an eye on young Dr Scrooge. He’s a fine young doctor but Ebenezer’s not as experienced as we older GPs and I’m not sure he can take his drink! We don’t want a repeat of last months incident when he woke up naked on the delicatessen counter at Sainsbury’s!’

‘Now he does seem like a good chap – a jolly fine fellow’ declared the spirit, beaming as if the natural order had been restored to where chaos had once threatened to reign. ‘He’s a good, fine, decent, jolly chap of a fellowy sort if ever I saw one.’

The Ghost of General Practice Past turned to Scrooge and looked him straight in the eye. ‘But what of him?’ the spirit asked drawing his companion’s attention to a young man who was accepting the gentle ribbing at the hands of the senior colleague he respected so highly. He was sat laughing alongside various members of staff with whom he was sharing a table.

‘I was so happy then’ Scrooge told the ghost. ‘He was such a wise man and so willing to share what he had learnt. And we were such a great team, all so eager to support one another. Back then, there seemed to be so much more time. Why did everything change? And how did I become so resentful of the job I used to love?’

‘Something certainly changed – something that shouldn’t have’ replied the ghost. ‘At least, not in the way it has. Perhaps something needs to change again. Perhaps something needs to be recovered. But it is for you to decide what and how. As for me, my time is up. We must return. You have other guests to welcome tonight.’

And in less time than it takes for EMIS to crash on a busy Monday morning, Scrooge was back in his room, alone with his thoughts. It was nearly two in the morning.

A PRIMARY CARE CHRISTMAS CAROL

Stave Three – in which our tale takes (trigger warning) a darker turn

In the few minutes he had to think before the next ghostly visitor was due to arrive, Scrooge reflected on the events of the evening so far and wondered if he should try to claim a few hours of CPD. However, anxious as to how his appraiser might respond to such revelations and fearful that his reflections may be used against him, he concluded, as many before him, that it would be best not to put his thoughts down in writing.

He then realised that it was almost half past two. Was he not to be visited again tonight after all? But within a moment of his beginning to wonder this, he was woken from his reverie by the sound of his bedroom door bursting open and the arrival of a rather flustered looking figure entering the room. She was carrying a pile of papers in one hand whilst tapping into the mobile phone she held with the other.

‘I’m sorry to keep you waiting’, the spectre began. ‘I’ve been so busy tonight and the last chap I visited had several issues that he wanted me to provide spiritual insight on. Blow me if he didn’t have a list! Now what seems to be the problem? I am the Ghost of General Practice Present. Did you have any ideas, concerns or expectations as to how I might haunt you?’

Scrooge looked back at the apparition somewhat non-plussed. He hadn’t asked for the visit and, other than his previous encounters that night, had no experience of consulting with individuals from beyond the grave. Though highly concerned by the present turn of events and expecting to find the whole thing highly disagreeable, he had very little idea as to quite how the encounter should progress. Consequently, Scrooge said nothing.

‘Oh dear,’ said the ghost, unnerved by Scrooge’s silence, ‘This is awkward. I told Marley that there was little point in my visiting you without you being willing to see me. You see it’s so hard to help somebody unless they realise they have a problem and want to be helped.’ Still Scrooge found himself lost for words.

Rather than using the silence as a technique for therapeutic communication, the ghost laid the papers that she had been carrying down upon Scrooge’s bed and started flipping through the pages. ‘I’m sure there is a guideline for this situation somewhere. Give me a minute and I’ll be with you as soon as I find it. I don’t want to get this wrong.’ A few minutes passed, at the end of which the ghost seemed to have found what it was that she was looking for. ‘Ah yes, that’s it – come with me. I’m to show you how Christmas is being spent by others this year. Only I’m running short of time so we’ll have to make it quick’.

Once again, Scrooge was taken by the hand but, somewhat to his disappointment, she led him down the stairs in the conventional fashion before continuing through the front door and out into the night. ‘I’m afraid that these days we don’t employ the use of magic flight’, the spirit explained, ‘There’s no evidence for it, you see. It’s all evidence based hauntings these days’.

The fog had thickened making it difficult to see where they were going but the ghost still had hold of her phone and had entered the post code of their destination into Google maps. Before long they reached a block of flats and proceeded to climb the communal stairs. On the second floor, they passed through the wall into the home of a young family, the spirit assuring Scrooge as they did so, that the Celestial Institute for Ethereal Excellence had approved, in highly selected cases, what was known in the profession as quantum tunnelling, provided said cases met stringent eligibility criteria.

The flat bore witness to the fact that it was Christmas Day. The mantelpiece and sideboard were covered with Christmas cards and coloured paper chains were hanging from the ceiling. In the corner was a Christmas tree under which a three year old boy was happily making good use of the colouring set he had recently unwrapped. He stood up and walked into the kitchen where his parents were preparing dinner. They turned to him and noticed that he was covered in red spots. Immediately his mother emptied the pint glass of Prosecco she was drinking and used it to perform the ‘tumbler test’, her anxiety being heightened all the more when the rash failed to disappear. She pressed the speed dial button on her phone and called ‘111’.

‘I’m worried about my son – he’s covered in spots’ she exclaimed to the call handler. ‘No – he seems well in himself…No – no vomiting or fever…No – no headache or tummy pain…No – no catastrophic loss of blood and No – he has just the one head’. The list of negatives continued until the questioner focused in on the rash. ‘Well it’s almost as if he’s been marking himself with a red felt tip pen!’ The women listened to the call handler for a few moments longer before ending the call.

‘What did they say?’ her partner asked.

‘Something about a non-blanching rash being possible meningitis and that it’s better to be safe than sorry. They’re sending an ambulance.’

‘Bloomin’ right too. Now let me refill your glass, we can’t have you sober when it arrives!’

The Ghost of Christmas Present indicated to Scrooge that it was time to move on. Their next stop was just across the stairwell. Passing once more through the walls of the property, Scrooge recognised Mrs Gray, the frail elderly lady who lived there, as one of his patients. She was nearing the end of her life due to her having advanced metastatic disease. A single Christmas card lay face down on the dining room table, alongside of which was a box of chocolates she had bought for herself in an attempt to make Christmas Day, the fifth she’d have spent alone since the death of her husband, at least a little special. She knew it would probably be her last. As Scrooge looked on, the woman picked up the chocolates and shuffled slowly across the room and then, for want of anyone else to give them to, placed them in the kitchen bin.

‘What’s she doing?’ Scrooge asked the spirit.

‘She doesn’t think you’d approve if she ate them’ replied the ghost, who then proceeded to point to a letter held to the fridge door by a magnet commemorating the Queen’s Silver Jubilee. It was from Scrooge’s medical practice informing her that her recent routine blood tests had revealed that she had a slightly elevated HBA1c and that she was therefore classified as ‘pre diabetic’. Included with the letter was a leaflet giving helpful advice on healthy eating.

Scrooge stood staring at the woman. He realised that, though if asked to relay the ins and outs of all her most recent blood tests he would have been up to the task, in recent years at least, he’d not really known her at all.

The spirit had left the flat and Scrooge hurried to catch her up. They walked together without talking until they came to a house that Scrooge had never visited before. Here they stopped and stood outside the window of a dimly lit room. Peering in through the poorly drawn curtains they could see the figure of Bob Cratchit. He was sat, his head in his hands, surrounded by various medical text books. To his left was a half empty bottle of scotch and a packet of antidepressants. He was writing a note.

Scrooge turned to the Ghost of General Practice. ‘What’s he doing?’ he asked.

‘Struggling’ she replied.

‘But why? He’s such a good doctor’.

‘He is indeed. But he doesn’t know it. He has come to believe that he has to be perfect – that every guideline must be followed and a failure to do so will result in legal action being taken against him. He’s taken on the burden that comes from believing that medicine has the answer to every problem experienced by a broken society. He thinks it’s all down to him. He has been worn down by the constant demand from both society and the profession that he must perform better – that good enough is not good enough. He’s exhausted by the never ending assessment of his performance and crushed by the weight of the responsibility he feels. He lives in the constant fear that it’ll all be his fault if anything bad ever happens. He too feels all alone this Christmas.’

‘But this afternoon? He asked to leave early to spend some time with his family’

‘Indeed he did but the truth is that he hasn’t much in the way of a family – just a couple of friends he thinks of as family. In reality he had hoped to meet those friends for a drink but things didn’t quite work out the way they were planned. When he left the surgery late yesterday he went back to check on one of the patients he’d visited. Their condition had deteriorated and he arranged an admission but he was left feeling guilty and anxious. As a result he didn’t think he’d make very good company. And besides, he was worried about his CSA exam and thought the time would be better spent preparing for that.’

‘But he’ll pass the exam easily’ Scrooge exclaimed. ‘He’s come on leaps and bounds since that unfortunate misunderstanding the first time round. The patients love him – and the staff. He’ll make a great GP’.

‘Have you ever told him that?’

Scrooge fell silent. Perhaps he could have been a bit more supportive, encouraged a little more. Perhaps he could have helped him steer a course through the mass of expectation and enabled him to distinguish between what was genuinely important and what could appropriately be ignored. Perhaps he could have been the kind of trainer Fezziwig had been to him – one who, despite the changes enforced on the profession, could still see the joy of working in general practice and convey a little of that to the next generation – one who would fight for what was worth fighting for rather than retreating into cynicism, bitterness, and resentment.

‘I never knew he felt so alone. I never knew he was finding it so hard.’

‘Did you ever ask?’

Scrooge’s head fell. ‘Can I speak to him now?’

‘I’m afraid not. He won’t be able hear you, and what’s more our time is up. We must go.’

‘But I must do something’

‘That’s as maybe – but you have another appointment to keep. You must meet the Ghost of General Practice Yet To Come.’

The ghost started back towards Scrooge’s home. Scrooge himself lingered a little longer at the window in the hope that Cratchit would see him and appreciate his concern. Finally he turned his back on the scene and trudged slowly after the ghost who was now some yards ahead of him. Behind him, Cratchit slipped silently into the deepest of deep sleeps.

The spirit accompanied Scrooge back to his room but, before she left, she had one small request.

‘I’d be most grateful if you could fill in this form by way of giving feedback on my performance this evening. And it would be very helpful if you could indicate whether you’d feel able to recommend me to your friends and family…’

Regretting the choice of words even as she spoke them, an awkward silence arose between them. The spirit looked at Scrooge – Scrooge looked back

‘…or perhaps just an acquaintance…a passer by even?’

Sensing that now was clearly not the time, the Spirit said a hurried goodbye and left, leaving Scrooge alone with his thoughts. He couldn’t stop thinking about what he’d seen. He tried to convince himself it was all a dream, that none of it was real. Had things really become this bad? And could the future be worse? He had a feeling he was about to find out.

A PRIMARY CARE CHRISTMAS CAROL

Stave Four – in which the future appears far from bright.

Alone again, Scrooge, out of force of habit, checked his phone for notifications. No red circle had appeared in the corner of the Facebook icon to indicate that someone, somewhere cared about what was on his mind. This was not unexpected as it had been a long time since anyone had ‘liked’ him – still longer since he’d been loved. It was a surprise to him, therefore, when the phone vibrated alerting him to the arrival of a text message.

‘This is to remind you that your appointment with the Ghost of General Practice Yet To Come is scheduled for now. Please access your Babylon Wealth account and prepare to speak to somebody with no soul’

Scrooge noticed a new app had appeared on his phone’s home screen. It glowed menacingly, demanding to be tapped. Scrooge couldn’t help thinking that ‘Babylon’ was a curious name for a company to chose to call itself, recalling, as he did from his days in Sunday School, how Babylon represented all that was evil, ‘the mother of earth’s abominations’ and a ‘dwelling place for demons’. Perhaps, he concluded, it was strangely fitting after all.

Against his better judgement, Scrooge opened the application and was greeted by a disclaimer making it clear that any advice given was only valid for minor, self limiting medical conditions and any harm that resulted from Babylon clinicians failing to appreciate a more serious underlying problem was not their responsibility. Those experiencing more complex health concerns were directed to approach less forward thinking health providers. Scrooge was requested to indicate his acceptance of these conditions and, having complied, the screen gave out a burst of light and there then appeared what looked for all the world to be a businessman dressed in an executive suit.

‘Welcome to Babylon Wealth,’ the man announced. ‘where your health needs are our business opportunity’. He smiled a self-satisfied smile, which Scrooge did not find reassuring.

‘Are you the Spirit of General Practice Yet To Come?’ Scrooge enquired.

The spirit’s smile wavered a little. ‘Is that what The Ghost of Christmas Present called me? She is so yesterday. I’ve been rebranded and, from now on, I am to be known simply as ‘The Future’. Exciting isn’t it? Now, how can I profit from you?’

‘I believe you’re supposed to show me my future’

‘Yes of course, but I don’t have time to talk to you about that in any depth. So, in the interests of efficiency, I’d like to request that you utilise this corporate video feed. If you’ve any further questions you’ll be required to make a further appointment. You will receive an invoice for the services I have provided today and your account will be automatically debited the requisite amount. Thank you for using Babylon Wealth. Have a nice day.’

Lost for words, Scrooge tapped the link that had appeared on his phone and continued to gaze at the screen at what seemed to be, if such a thing was possible, a broadcast from the future. It began with an aerial view of a huge featureless building over which an audio commentary played. “Welcome to the world’s first fast health outlet. – Where health is cheap and time is short”. A notice board at the entrance of the building came into focus revealing that ‘The National Wellbeing Centre’ was open 24 hours a day, 365 days of the year. Two enormous panels straddled the entrance bearing images of the Secretary of State for Health and the President of the National Pharmaceutical Board. They were pictured smiling benignly down upon the multitude who were milling around a large reception area.

As the camera roamed around, the audio commentary explained how no appointment was necessary but that, on arrival, patients were required to utilise electronic panels positioned in the foyer to answer a series of questions by way of ‘Yes’ or ‘No’ answers only. As a result of the responses that were given, each individual would then be assigned to a wellbeing advisor. If, and only if, it was deemed necessary that face to face contact should ensue, they would then wait outside one of the 666 consulting rooms housed within the complex until their allocated interaction was scheduled. Patients were advised that only objective quantifiable, symptoms could be dealt with and that treatment options would be determined solely on the basis of the medico-economic considerations pertinent to each individual case. Reassurances were offered that a number of payment options were available.

Around the foyer, electronic panels displayed information for consumers alongside a number of company disclaimers:

“Due to many drugs now being of limited availability, if medication is advised, the sourcing of that medication is entirely the responsibility of the customer.”

“Please be assured that we respect your anonymity and consider it of paramount importance to maintain the highest levels of confidentiality. In order to guarantee this, no wellbeing advisor will consult with the same client on more than one occasion and no personal communication is permitted between clinicians. At all times, to minimise any humanising of the clinical interaction, a mask must be worn over the face.”

“The National Wellbeing Centre cannot accept responsibility”

“Strict quality control measures are in place to guarantee the optimal outcome of each clinical interaction. Each consultation is electronically monitored and any deviation from company protocols will result in disciplinary action being taken against the clinician concerned.”

The announcements seemed endless, each, it appeared to Scrooge, alienating the individual in need still further from the connection they craved with somebody who just might care enough to show a little concern. Patients were managed without any warmth or compassion – processed by a system that existed solely for the benefit the state that had created it.

As Scrooge continued to watch, the announcements kept flashing across the screens, hypnotising those whose eyes were drawn lifelessly to their incessant messages. Dehumanised, everyone became the same – And that same was nothing more than a reservoir of data.

“Please be aware that displays of emotion are not encouraged in consultations and tissues are therefore not provided in the consultation rooms.”

“Customers will not be permitted to leave the centre until the requisite post interaction forms are completed. Not only does the filling of these forms provide the essential feedback necessary to identify suboptimal clinician performance, the personal data requested allows us to identify those agencies from whom we will profit most by our facilitating their communication with you.”

“Everybody here at the National Welfare Centre wishes you, and your purchases, a very merry Consumertide.”

And then, finally, before the cycle of messages started once more, one last announcement:

“Turmeric is available from the kiosk in the foyer”

The camera returned to a view of the outside of the building and Scrooge caught a glimpse of a small panel attached to the wall next to the main entrance. He paused the video and expanded the image to take a closer look. He could just make out the words that were inscribed on the ill maintained copper plate.

‘This facility was erected on the derelict site of what was once known as a GP medical centre. Drs J. Marley and E. Scrooge worked here for many years providing a form of medical provision which today is only of historical interest. The medical centre operated with the quaint intent to provide medical care that was responsive to patient needs. Dr Marley’s untimely death left Dr Scrooge struggling as he found it impossible to replace his former partner. He continued for a time supported by a series of doctors in training, but, after a personal tragedy struck the medical centre, it was no longer considered fit to remain a training practice. Dr Scrooge continued alone for a brief time, but the pressure of working in such an inefficient manner soon proved too much and he himself succumbed to a stress related illness. Happily, his demise proved the catalyst for the development of the progressive wellbeing centre that we benefit from today.’

Scrooge could not believe what he had witnessed. It struck him that there had at no point been any mention of there being any doctors present in the running of the well-being centre. It was almost as if there was now nobody providing a professional opinion, nobody making a judgement, nobody applying a bit of wisdom and that clinical algorithms were being used to make each and every decision. Were there, he wondered, any doctors still in existence at all? Perhaps, in the future, nobody wanted to be one. The questions kept coming. Was this really the future of the health service that once, years previously, he had been so proud to be a part? What about Cratchit? What did the ‘personal tragedy’ refer to? And what of his own future? Could any of this be changed?

Scrooge tapped frantically on his phone seeking a further appointment with the Ghost of General Practice Yet To Come. Fortunately, for all the faults of Babylon Wealth, having made the appropriate additional payment, an appointment was easy to come by, and soon, the business-like figure of the spectre, who had been so brusque with him earlier, appeared on the screen once more.

‘Good Spirit’ Scrooge implored, ‘Assure me that I may yet change these shadows you have shown me by an altered life’

The spirit laughed. ‘It’ll take more than one doctor changing to alter the future of the health service. That’s the trouble with you people. Too often you think it’s all down to you’. The spirit made a poor attempt at a Clint Eastwood impersonation, ‘A doctor’s got to know his limitations.’

‘And besides, what’s your problem? What we’re doing merely reflects the ideology of the nation – that everything comes down to money. We measure and record data because data sells. What we understand at Babylon Wealth is that people are commodities. For example, we record an elevated cholesterol solely because we know there is somebody out there who is selling a product to reduce lipid levels and is willing to pay for the information we collect. We don’t care about people, only the wealth that they generate for us.’

‘But it’s not all about money’, Scrooge insisted.

‘Isn’t it?’ countered the spirit. ‘It seems to me that everyone has a price Dr Scrooge. Are you really the exception?’

‘Well maybe I do have a price, but if I have, it’s at least partly because, in recent years, with so much of the joy having been sucked out of the job, the only way that I’ve been in any way rewarded for my efforts is financially. There’s no appreciation from those who call the tune, no recognition of how difficult the job has become and nothing but constant demands that I must do better. Take appraisal – if a requirement to show year on year improvement doesn’t amount to saying that we’re not good enough as we are, I don’t know what is. Something has to change’.

‘Well good luck to you with that, Scrooge. I concede that, as a profession, challenging the status quo rather than capitulating to the spirit of the age whilst all the while laudably endeavouring to deliver its impossible demands would be a step in the right direction. But I can’t see it ever happening – you’re all too busy just trying to keep your head above water to organise a concerted campaign for change.’

‘But let me try, spirit. Let us try. I have learned my lesson well this night. Perhaps things need not turn out the way you have shown me”.

And with that, Scrooge deleted the Babylon Wealth app from his phone, never to be installed again. He got back into bed. He’d seen and heard quite enough.

A PRIMARY CARE CHRISTMAS CAROL

Stave Five – in which we are given cause for hope

It was early morning when Scrooge woke. He sat up in bed and looked around the room. Everything appeared as normal and yet, within himself, he felt changed. Perhaps he was being naive but he felt a sense of optimism that he hadn’t known for years, daring to hope that things could get better.

It was then he remembered it was Christmas Day. ‘At least I think it is,’ he said to himself excitedly, ‘assuming that all three Spirits did indeed visit me last night and that I haven’t missed the great day completely’. He ran to the window and looked out. A light layer of snow coated the ground which heightened his excitement still further. And yes, a young lad was trying out a brand new bicycle, no doubt a freshly unwrapped Christmas present. Add to that the fact that one or two folk were making their way towards a church whose bells were ringing joyfully in the distance, it was, with the utmost certainty, Christmas morning.

But there was no time to lose. He had to check on Bob Cratchit. He dressed hurriedly and ran down the stairs and out into the crisp morning sunlight which reflected off the snow-covered ground. Scrooge got into his car and within a few minutes he was outside the house of his trainee. He knocked loudly on the door but there was no answer. He knocked again and, when there was no response, shouted through the letter box. Still there was only silence. Scrooge moved round to the side of the house and looked through the same window he had the previous evening, its curtains still only partly drawn. Cratchit was sat there, just as he had been when Scrooge and the Ghost of Christmas Present had left him earlier. Scrooge hammered on the window until, at last, he saw movement and a wave of relief surged through him. Slowly Cratchit stood up.

‘Open up Bob. Open up this instant. Do you hear?’ Scrooge shouted at him though the glass. ‘Open up. It’s Christmas Day!’

Cratchit, clearly half asleep and still the worse for the half bottle of whisky he’d drunk the night before, gradually stood up and made his way to the front door. Scrooge had never been one for outward displays of affection, but now, as Cratchit opened the door, Scrooge greeted him with a hug that was as welcome as it was unexpected.

‘How are you Bob? Are you alright?’

‘I’ve a bit of a headache if I’m honest. And not one that’s improved any by all your hollering. But why are you here? Has something happened? Have I done something wrong?’

‘On the contrary. If anyone is at fault it’s me, for not appreciating you more. And to show you that I mean it, what do you say to a partnership come August when you’ve completed your training? I’d be proud to call you my partner’

‘You must be desperate!’

‘Desperate? Of course I’m desperate! Have you seen the state of the health service? But that’s not the reason for my offering you a partnership. I would like you to help me change the way we do General Practice. It’s a conditional offer of course – conditional that is on you seeing some change. There’s no way I’d want you to commit to a lifetime of working the way we have of late.’

‘Well I guess I’ll have to think about it. But thank you. I didn’t realise that you thought I was up to the job’.

‘Of courses you’re up to the job. We all worry sometimes that we’re not though, so don’t be surprised if you find yourself questioning the fact – that’s normal! The trouble is that we’re all so anxious imaging that we have to be perfect. We’re not God you know – even though both the government and our patients sometimes expect us to act as though we were.’

‘Well I guess you’re right there’

‘Of course I’m right, I’m your trainer! Now, what’s with the whisky and the packet of antidepressants?’

Cratchit looked down at the ground. ‘I didn’t take any, just thought about it. I guess I was just feeling a little overwhelmed. I was being stupid”

‘It’s not stupid to feel overwhelmed. There’s no shame in being asked to do more than you can cope with. The only foolish thing is to not realise you need to say ‘No’ sometimes – that sometimes you need help and have to ask for it. I’ll try and make that easier for you from now on. Promise me though that you’ll not let your thoughts travel in such a dark direction again without letting me know.’

‘I’ll try not to – I promise.’

‘Excellent. Remember, we’re in this together.

Cratchit couldn’t quite believe what he was hearing and couldn’t stop himself voicing the question that was on his mind.’

‘Dr Scrooge,’ Cratchit began

‘It’s Ebenezer. Call me Ebenezer’.

Cratchit hesitated and then tried again. ‘Ebenezer.’ It seemed strange to hear the name spoken aloud, ‘I hope you don’t mind me saying this, but something seems different about you today. Has something happened?’

‘I rather think it has,’ said Scrooge. ‘As a profession we’re convinced everything’s wrong. A lot is of course, but I see now that if we can see what the problems are, then surely we stand a chance of making changes.’

‘But how?’

‘To be honest, I’m not quite sure. One thing would be our need to challenge the idea that medicine has all the answers. We need to say ‘No’ to the over medicalisation of life and be honest with both ourselves and our patients as to what we can and can’t do. Another thing would be that we have to be allowed to behave as the professionals we were trained to be. Once we were seen as people who could be trusted to make judgments in the best interests of patients. Now it seems we are seen as mere service providers, required to unquestionably follow guidelines regardless of how appropriate or otherwise that might be. It’s as if we’re not considered competent to try to decide what is best for our own individual patients. But one size doesn’t fit all. And so we need to fight to retain the doctor patient relationship that underpins good general practice and not allow it to be lost in the rush to conveyer belt medicine. We have to take back control over our work, make our own decisions as to how to apply medical knowledge to each individual situation and have the courage to resist the inappropriate demand to behave in ways that are imposed on us by government, pharmaceutical companies and society as a whole. That would mean better health for our patients and happier working lives for ourselves. That’s something I can aspire too, and knowing what it is I’m aiming for might just give me a chance of fathoming out how I might go about working towards it. At least, that’s my hope.”

Scrooge, in his excitement, had been pacing around the room. Now, pausing for breath, he sat down.

‘But that’s enough of all that for now. We can get together tomorrow and plan then just how exactly we’re going to do things differently. We’ll call it a practice away day. Just think of all the CPD hours we can claim! So, what are your plans for today?’

‘Well I had planned on a spot of revising for the CSA.’

‘Revising for the CSA. What nonsense – you’d pass that tomorrow with your eyes closed. Like it or not, you’re spending the day with me! We’ll have dinner at my house. I ordered a lorry load of food from Waitrose last week and there’s no way I can manage it all on my own. In fact there’s more than enough for two. Quick, go and get yourself sorted out. I’ve got an idea – one that might, for the first time in my career, satisfy my appraiser that my reflections have altered my practice!”

It wasn’t long before Cratchit was sat in the passenger seat of Scrooge’s car wondering where Scrooge might be taking him. A few minutes later they pulled up outside a block of flats and Scrooge led the way up the steps to the second floor. He knocked on a door.

“Who lives here?” asked Cratchit.

“Mrs Gray. She’s lived here alone since her husband, Timothy, died a few years ago. He was a short man. He had some kind of growth hormone deficiency I believe.’

Eventually, the door opened, and Mrs Gray stood there, evidently astonished to see her GP.

‘Good morning Mrs Gray. And a very merry Christmas to you.’

‘Well a very merry Christmas to you too Dr Scrooge. But what brings you here? Is it about the chocolates?’

‘Certainly not. We, that’s Dr Cratchit and I, have come to pick you up and take you off to my house for Christmas Day. What do you say? Will you come?’ Mrs Gray hesitated, uncertain if she should.

‘Please come, Mrs Gray. It would mean a lot to me’

‘But I’ve nothing to bring’.

Scrooge looked over her shoulder and saw the box of chocolates on the kitchen table. ‘What about those?’ Scrooge asked, ‘You don’t have to bring anything, but if you’d like to make a contribution…’

‘But I’m pre diabetic Dr Scrooge, I need to be careful what I eat’

‘Who told you that?’ said Scrooge, a broad grin forming on his face. ‘Not a doctor I hope. Believe me Mrs Gray, you shouldn’t believe everything we doctors tell you!’

With that, Mrs Gray tottered to the kitchen, picked up the chocolates and made her way back to the front door. Then, together with Scrooge and Cratchit, she made her way slowly down the stairs. Half way down, Scrooge stopped.

‘You go on Bob, I’ll catch you up in a moment. It’s just that I have a feeling that, as a GP, I am, for once, ideally positioned to reduce hospital admissions’

He ran back up the stairs and knocked on the door of the flat opposite that of Mrs Gray. A man opened the door.

‘I don’t want to appear interfering,’ Scrooge began, ‘but your son will develop a rash later this morning. When he does, try wiping it off with a damp cloth. Trust me, I’m a doctor!’

With that Scrooge turned and headed off back down the stairs leaving the man speechless behind him.

…………………………………

A couple of hours later, the two doctors and their elderly patient sat around a dining table enjoying Waitrose’s finest. As the meal drew to a close, Cratchit turned to Scrooge

‘I think I’ve made my decision’ he said.

‘What decision is that?’

‘I’d like to accept your offer of a partnership, if I pass the CSA that is’

‘That’s wonderful Bob, simply wonderful!’ Scrooge stood up and shook Crachit warmly by the hand and then, for the second time in the day, embraced him warmly. ‘This is excellent news – for me and for the practice. We should organise a party!’

Scrooge dashed out of the room and returned with a sheet of paper on which were listed all the practice staff, their names and telephone numbers.

‘And a party we shall have,’ declared Scrooge handing the list to Cratchit. ‘Start ringing round and invite anyone who’s free to join us here this evening. Perhaps someone will bring some of those Prosecco and pink peppercorn Pringles – are they really a thing? Only don’t let me drink too much. The last time I did that there was an incident at a local supermarket, the details of which you don’t want to know!’

‘Can I say something Dr Scrooge?’ Scrooge turned around and saw that Mrs Gray had got to her feet. With one hand she steadied herself by holding onto the table and with the other she was holding a glass of wine. ‘I’ve had a lovely time today and I want to thank you for all your kindness. I’d like to propose a toast, to both of you, the practice, and the NHS as a whole. It’s something my late husband used to say.’ She raised her glass higher. ‘God bless us, every one’, she said.

‘God bless us, every one’, repeated Scrooge and Cratchit, smiling as they raised and carefully tapped their glasses together.

…………………………………

In time, Cratchit passed his CSA and joined Scrooge in partnership. And for a while the practice prospered. Though their processes and procedures didn’t always meet with the full approval of the CQC, Scrooge and Cratchit always enjoyed the strong support of their patients. Scrooge’s experiences that night may not have changed the state of the NHS as a whole, but they did change how the NHS was manifested in one small corner of that great organisation. Scrooge became known as a doctor who cared for his patients more than he cared how he was thought of by those in power. He knew how to support others and recognised too how he himself needed the support of others. May that be truly said of us all.

And so, as Mr Gray observed, ‘God bless us, Every One!’

---

SCROOGE WILL BE BACK – IN ‘SCROOGE IN THE TIME OF CORONAVIRUS’

TO READ THE COMPLETE FOUR PART STORY, CLICK HERE.

---

Other medically related Christmas themed blogs:

To read ‘How the Grinch and Covid stole General Practices Christmas’, click here

To read ‘Twas the night before Christmas – 2020’, click here

To read ‘A Merry, and Resilient, Christmas’, click here

Other GP related stories:

To read ‘A Grimm Tale’, click here

To read ‘The Happy Practice – A Cautionary Tale’, click here

To read ‘The Three Little GPs and the Big Bad Secretary of State for Health’, click here

To read ‘A Mission Impossible’, click here

To read ‘A Bear called Paddington’, click here

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

To read ‘Jeeves and the Hormone Deficiency’, click here

For Part 1, click here

For Part 2, click here

For Part 3, click here

For Part 4, click here

Stave Five – in which we are given cause for hope

It was early morning when Scrooge woke. He sat up in bed and looked around the room. Everything appeared as normal and yet, within himself, he felt changed. Perhaps he was being naive but he felt a sense of optimism that he hadn’t known for years, daring to hope that things could get better.

It was then he remembered it was Christmas Day. ‘At least I think it is,’ he said to himself excitedly, ‘assuming that all three Spirits did indeed visit me last night and that I haven’t missed the great day completely’. He ran to the window and looked out. A light layer of snow coated the ground which heightened his excitement still further. And yes, a young lad was trying out a brand new bicycle, no doubt a freshly unwrapped Christmas present. Add to that the fact that one or two folk were making their way towards a church whose bells were ringing joyfully in the distance, it was, with the utmost certainty, Christmas morning.

But there was no time to lose. He had to check on Bob Cratchit. He dressed hurriedly and ran down the stairs and out into the crisp morning sunlight which reflected off the snow-covered ground. Scrooge got into his car and within a few minutes he was outside the house of his trainee. He knocked loudly on the door but there was no answer. He knocked again and, when there was no response, shouted through the letter box. Still there was only silence. Scrooge moved round to the side of the house and looked through the same window he had the previous evening, its curtains still only partly drawn. Cratchit was sat there, just as he had been when Scrooge and the Ghost of Christmas Present had left him earlier. Scrooge hammered on the window until, at last, he saw movement and a wave of relief surged through him. Slowly Cratchit stood up.

‘Open up Bob. Open up this instant. Do you hear?’ Scrooge shouted at him though the glass. ‘Open up. It’s Christmas Day!’

Cratchit, clearly half asleep and still the worse for the half bottle of whisky he’d drunk the night before, gradually stood up and made his way to the front door. Scrooge had never been one for outward displays of affection, but now, as Cratchit opened the door, Scrooge greeted him with a hug that was as welcome as it was unexpected.

‘How are you Bob? Are you alright?’

‘I’ve a bit of a headache if I’m honest. And not one that’s improved any by all your hollering. But why are you here? Has something happened? Have I done something wrong?’

‘On the contrary. If anyone is at fault it’s me, for not appreciating you more. And to show you that I mean it, what do you say to a partnership come August when you’ve completed your training? I’d be proud to call you my partner’

‘You must be desperate!’

‘Desperate? Of course I’m desperate! Have you seen the state of the health service? But that’s not the reason for my offering you a partnership. I would like you to help me change the way we do General Practice. It’s a conditional offer of course – conditional that is on you seeing some change. There’s no way I’d want you to commit to a lifetime of working the way we have of late.’

‘Well I guess I’ll have to think about it. But thank you. I didn’t realise that you thought I was up to the job’.

‘Of courses you’re up to the job. We all worry sometimes that we’re not though, so don’t be surprised if you find yourself questioning the fact – that’s normal! The trouble is that we’re all so anxious imaging that we have to be perfect. We’re not God you know – even though both the government and our patients sometimes expect us to act as though we were.’

‘Well I guess you’re right there’

‘Of course I’m right, I’m your trainer! Now, what’s with the whisky and the packet of antidepressants?’

Cratchit looked down at the ground. ‘I didn’t take any, just thought about it. I guess I was just feeling a little overwhelmed. I was being stupid”

‘It’s not stupid to feel overwhelmed. There’s no shame in being asked to do more than you can cope with. The only foolish thing is to not realise you need to say ‘No’ sometimes – that sometimes you need help and have to ask for it. I’ll try and make that easier for you from now on. Promise me though that you’ll not let your thoughts travel in such a dark direction again without letting me know.’

‘I’ll try not to – I promise.’

‘Excellent. Remember, we’re in this together.

Cratchit couldn’t quite believe what he was hearing and couldn’t stop himself voicing the question that was on his mind.’

‘Dr Scrooge,’ Cratchit began

‘It’s Ebenezer. Call me Ebenezer’.

Cratchit hesitated and then tried again. ‘Ebenezer.’ It seemed strange to hear the name spoken aloud, ‘I hope you don’t mind me saying this, but something seems different about you today. Has something happened?’

‘I rather think it has,’ said Scrooge. ‘As a profession we’re convinced everything’s wrong. A lot is of course, but I see now that if we can see what the problems are, then surely we stand a chance of making changes.’

‘But how?’

‘To be honest, I’m not quite sure. One thing would be our need to challenge the idea that medicine has all the answers. We need to say ‘No’ to the over medicalisation of life and be honest with both ourselves and our patients as to what we can and can’t do. Another thing would be that we have to be allowed to behave as the professionals we were trained to be. Once we were seen as people who could be trusted to make judgments in the best interests of patients. Now it seems we are seen as mere service providers, required to unquestionably follow guidelines regardless of how appropriate or otherwise that might be. It’s as if we’re not considered competent to try to decide what is best for our own individual patients. But one size doesn’t fit all. And so we need to fight to retain the doctor patient relationship that underpins good general practice and not allow it to be lost in the rush to conveyer belt medicine. We have to take back control over our work, make our own decisions as to how to apply medical knowledge to each individual situation and have the courage to resist the inappropriate demand to behave in ways that are imposed on us by government, pharmaceutical companies and society as a whole. That would mean better health for our patients and happier working lives for ourselves. That’s something I can aspire too, and knowing what it is I’m aiming for might just give me a chance of fathoming out how I might go about working towards it. At least, that’s my hope.”

Scrooge, in his excitement, had been pacing around the room. Now, pausing for breath, he sat down.

‘But that’s enough of all that for now. We can get together tomorrow and plan then just how exactly we’re going to do things differently. We’ll call it a practice away day. Just think of all the CPD hours we can claim! So, what are your plans for today?’

‘Well I had planned on a spot of revising for the CSA.’

‘Revising for the CSA. What nonsense – you’d pass that tomorrow with your eyes closed. Like it or not, you’re spending the day with me! We’ll have dinner at my house. I ordered a lorry load of food from Waitrose last week and there’s no way I can manage it all on my own. In fact there’s more than enough for two. Quick, go and get yourself sorted out. I’ve got an idea – one that might, for the first time in my career, satisfy my appraiser that my reflections have altered my practice!”

It wasn’t long before Cratchit was sat in the passenger seat of Scrooge’s car wondering where Scrooge might be taking him. A few minutes later they pulled up outside a block of flats and Scrooge led the way up the steps to the second floor. He knocked on a door.

“Who lives here?” asked Cratchit.

“Mrs Gray. She’s lived here alone since her husband, Timothy, died a few years ago. He was a short man. He had some kind of growth hormone deficiency I believe.’

Eventually, the door opened, and Mrs Gray stood there, evidently astonished to see her GP.

‘Good morning Mrs Gray. And a very merry Christmas to you.’

‘Well a very merry Christmas to you too Dr Scrooge. But what brings you here? Is it about the chocolates?’

‘Certainly not. We, that’s Dr Cratchit and I, have come to pick you up and take you off to my house for Christmas Day. What do you say? Will you come?’ Mrs Gray hesitated, uncertain if she should.

‘Please come, Mrs Gray. It would mean a lot to me’

‘But I’ve nothing to bring’.

Scrooge looked over her shoulder and saw the box of chocolates on the kitchen table. ‘What about those?’ Scrooge asked, ‘You don’t have to bring anything, but if you’d like to make a contribution…’

‘But I’m pre diabetic Dr Scrooge, I need to be careful what I eat’

‘Who told you that?’ said Scrooge, a broad grin forming on his face. ‘Not a doctor I hope. Believe me Mrs Gray, you shouldn’t believe everything we doctors tell you!’

With that, Mrs Gray tottered to the kitchen, picked up the chocolates and made her way back to the front door. Then, together with Scrooge and Cratchit, she made her way slowly down the stairs. Half way down, Scrooge stopped.

‘You go on Bob, I’ll catch you up in a moment. It’s just that I have a feeling that, as a GP, I am, for once, ideally positioned to reduce hospital admissions’

He ran back up the stairs and knocked on the door of the flat opposite that of Mrs Gray. A man opened the door.

‘I don’t want to appear interfering,’ Scrooge began, ‘but your son will develop a rash later this morning. When he does, try wiping it off with a damp cloth. Trust me, I’m a doctor!’

With that Scrooge turned and headed off back down the stairs leaving the man speechless behind him.

…………………………………

A couple of hours later, the two doctors and their elderly patient sat around a dining table enjoying Waitrose’s finest. As the meal drew to a close, Cratchit turned to Scrooge

‘I think I’ve made my decision’ he said.

‘What decision is that?’

‘I’d like to accept your offer of a partnership, if I pass the CSA that is’

‘That’s wonderful Bob, simply wonderful!’ Scrooge stood up and shook Crachit warmly by the hand and then, for the second time in the day, embraced him warmly. ‘This is excellent news – for me and for the practice. We should organise a party!’

Scrooge dashed out of the room and returned with a sheet of paper on which were listed all the practice staff, their names and telephone numbers.

‘And a party we shall have,’ declared Scrooge handing the list to Cratchit. ‘Start ringing round and invite anyone who’s free to join us here this evening. Perhaps someone will bring some of those Prosecco and pink peppercorn Pringles – are they really a thing? Only don’t let me drink too much. The last time I did that there was an incident at a local supermarket, the details of which you don’t want to know!’

‘Can I say something Dr Scrooge?’ Scrooge turned around and saw that Mrs Gray had got to her feet. With one hand she steadied herself by holding onto the table and with the other she was holding a glass of wine. ‘I’ve had a lovely time today and I want to thank you for all your kindness. I’d like to propose a toast, to both of you, the practice, and the NHS as a whole. It’s something my late husband used to say.’ She raised her glass higher. ‘God bless us, every one’, she said.

‘God bless us, every one’, repeated Scrooge and Cratchit, smiling as they raised and carefully tapped together their glasses.

…………………………………

In time, Cratchit passed his CSA and joined Scrooge in partnership. And for a while the practice prospered. Though their processes and procedures didn’t always meet with the full approval of the CQC, Scrooge and Cratchit always enjoyed the strong support of their patients. Scrooge’s experiences that night may not have changed the state of the NHS as a whole, but they did change how the NHS was manifested in one small corner of that great organisation. Scrooge became known as a doctor who cared for his patients more than he cared how he was thought of by those in power. He knew how to support others and recognised too how he himself needed the support of others. May that be truly said of us all.

And so, as Mr Gray observed, ‘God bless us, Every One!’

---

SCROOGE WILL BE BACK – IN ‘SCROOGE IN THE TIME OF CORONAVIRUS’

To read ‘A Tale of Two Patients’, Part 1 of that story, click here

---

For a complete version ‘A Primary Care Christmas Carol’, click here

Other medically related Christmas themed blogs:

To read ‘How the Grinch and Covid stole General Practices Christmas’, click here

To read ‘Twas the night before Christmas – 2020’, click here

To read ‘A Merry, and Resilient, Christmas’, click here

Other GP related stories:

To read ‘A Grimm Tale’, click here

To read ‘The Happy Practice – A Cautionary Tale’, click here

To read ‘The Three Little GPs and the Big Bad Secretary of State for Health’, click here

To read ‘A Mission Impossible’, click here

To read ‘A Bear called Paddington’, click here

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

To read ‘Jeeves and the Hormone Deficiency’, click here

For Part 1, click here

For Part 2, click here

For Part 3, click here

Stave Four – in which the future appears far from bright.

Alone again, Scrooge, out of force of habit, checked his phone for notifications. No red circle had appeared in the corner of the Facebook icon to indicate that someone, somewhere cared about what was on his mind. This was not unexpected as it had been a long time since anyone had ‘liked’ him – still longer since he’d been loved. It was a surprise to him, therefore, when the phone vibrated alerting him to the arrival of a text message.

‘This is to remind you that your appointment with the Ghost of General Practice Yet To Come is scheduled for now. Please access your Babylon Wealth account and prepare to speak to somebody with no soul’

Scrooge noticed a new app had appeared on his phone’s home screen. It glowed menacingly, demanding to be tapped. Scrooge couldn’t help thinking that ‘Babylon’ was a curious name for a company to chose to call itself, recalling, as he did from his days in Sunday School, how Babylon represented all that was evil, ‘the mother of earth’s abominations’ and a ‘dwelling place for demons’. Perhaps, he concluded, it was strangely fitting after all.

Against his better judgement, Scrooge opened the application and was greeted by a disclaimer making it clear that any advice given was only valid for minor, self limiting medical conditions and any harm that resulted from Babylon clinicians failing to appreciate a more serious underlying problem was not their responsibility. Those experiencing more complex health concerns were directed to approach less forward thinking health providers. Scrooge was requested to indicate his acceptance of these conditions and, having complied, the screen gave out a burst of light and there then appeared what looked for all the world to be a businessman dressed in an executive suit.

‘Welcome to Babylon Wealth,’ the man announced. ‘where your health needs are our business opportunity’. He smiled a self-satisfied smile, which Scrooge did not find reassuring.

‘Are you the Spirit of General Practice Yet To Come?’ Scrooge enquired.

The spirit’s smile wavered a little. ‘Is that what The Ghost of Christmas Present called me? She is so yesterday. I’ve been rebranded and, from now on, I am to be known simply as ‘The Future’. Exciting isn’t it? Now, how can I profit from you?’

‘I believe you’re supposed to show me my future’

‘Yes of course, but I don’t have time to talk to you about that in any depth. So, in the interests of efficiency, I’d like to request that you utilise this corporate video feed. If you’ve any further questions you’ll be required to make a further appointment. You will receive an invoice for the services I have provided today and your account will be automatically debited the requisite amount. Thank you for using Babylon Wealth. Have a nice day.’

Lost for words, Scrooge tapped the link that had appeared on his phone and continued to gaze at the screen at what seemed to be, if such a thing was possible, a broadcast from the future. It began with an aerial view of a huge featureless building over which an audio commentary played. “Welcome to the world’s first fast health outlet. – Where health is cheap and time is short”. A notice board at the entrance of the building came into focus revealing that ‘The National Wellbeing Centre’ was open 24 hours a day, 365 days of the year. Two enormous panels straddled the entrance bearing images of the Secretary of State for Health and the President of the National Pharmaceutical Board. They were pictured smiling benignly down upon the multitude who were milling around a large reception area.

As the camera roamed around, the audio commentary explained how no appointment was necessary but that, on arrival, patients were required to utilise electronic panels positioned in the foyer to answer a series of questions by way of ‘Yes’ or ‘No’ answers only. As a result of the responses that were given, each individual would then be assigned to a wellbeing advisor. If, and only if, it was deemed necessary that face to face contact should ensue, they would then wait outside one of the 666 consulting rooms housed within the complex until their allocated interaction was scheduled. Patients were advised that only objective quantifiable, symptoms could be dealt with and that treatment options would be determined solely on the basis of the medico-economic considerations pertinent to each individual case. Reassurances were offered that a number of payment options were available.

Around the foyer, electronic panels displayed information for consumers alongside a number of company disclaimers:

“Due to many drugs now being of limited availability, if medication is advised, the sourcing of that medication is entirely the responsibility of the customer.”

“Please be assured that we respect your anonymity and consider it of paramount importance to maintain the highest levels of confidentiality. In order to guarantee this, no wellbeing advisor will consult with the same client on more than one occasion and no personal communication is permitted between clinicians. At all times, to minimise any humanising of the clinical interaction, a mask must be worn over the face.”

“The National Wellbeing Centre cannot accept responsibility”

“Strict quality control measures are in place to guarantee the optimal outcome of each clinical interaction. Each consultation is electronically monitored and any deviation from company protocols will result in disciplinary action being taken against the clinician concerned.”

The announcements seemed endless, each, it appeared to Scrooge, alienating the individual in need still further from the connection they craved with somebody who just might care enough to show a little concern. Patients were managed without any warmth or compassion – processed by a system that existed solely for the benefit the state that had created it.

As Scrooge continued to watch, the announcements kept flashing across the screens, hypnotising those whose eyes were drawn lifelessly to their incessant messages. Dehumanised, everyone became the same – And that same was nothing more than a reservoir of data.

“Please be aware that displays of emotion are not encouraged in consultations and tissues are therefore not provided in the consultation rooms.”

“Customers will not be permitted to leave the centre until the requisite post interaction forms are completed. Not only does the filling of these forms provide the essential feedback necessary to identify suboptimal clinician performance, the personal data requested allows us to identify those agencies from whom we will profit most by our facilitating their communication with you.”

“Everybody here at the National Welfare Centre wishes you, and your purchases, a very merry Consumertide.”

And then, finally, before the cycle of messages started once more, one last announcement:

“Turmeric is available from the kiosk in the foyer”

The camera returned to a view of the outside of the building and Scrooge caught a glimpse of a small panel attached to the wall next to the main entrance. He paused the video and expanded the image to take a closer look. He could just make out the words that were inscribed on the ill maintained copper plate.

‘This facility was erected on the derelict site of what was once known as a GP medical centre. Drs J. Marley and E. Scrooge worked here for many years providing a form of medical provision which today is only of historical interest. The medical centre operated with the quaint intent to provide medical care that was responsive to patient needs. Dr Marley’s untimely death left Dr Scrooge struggling as he found it impossible to replace his former partner. He continued for a time supported by a series of doctors in training, but, after a personal tragedy struck the medical centre, it was no longer considered fit to remain a training practice. Dr Scrooge continued alone for a brief time, but the pressure of working in such an inefficient manner soon proved too much and he himself succumbed to a stress related illness. Happily, his demise proved the catalyst for the development of the progressive wellbeing centre that we benefit from today.’

Scrooge could not believe what he had witnessed. It struck him that there had at no point been any mention of there being any doctors present in the running of the well-being centre. It was almost as if there was now nobody providing a professional opinion, nobody making a judgement, nobody applying a bit of wisdom and that clinical algorithms were being used to make each and every decision. Were there, he wondered, any doctors still in existence at all? Perhaps, in the future, nobody wanted to be one. The questions kept coming. Was this really the future of the health service that once, years previously, he had been so proud to be a part? What about Cratchit? What did the ‘personal tragedy’ refer to? And what of his own future? Could any of this be changed?

Scrooge tapped frantically on his phone seeking a further appointment with the Ghost of General Practice Yet To Come. Fortunately, for all the faults of Babylon Wealth, having made the appropriate additional payment, an appointment was easy to come by, and soon, the business-like figure of the spectre, who had been so brusque with him earlier, appeared on the screen once more.

‘Good Spirit’ Scrooge implored, ‘Assure me that I may yet change these shadows you have shown me by an altered life’

The spirit laughed. ‘It’ll take more than one doctor changing to alter the future of the health service. That’s the trouble with you people. Too often you think it’s all down to you’. The spirit made a poor attempt at a Clint Eastwood impersonation, ‘A doctor’s got to know his limitations.’

‘And besides, what’s your problem? What we’re doing merely reflects the ideology of the nation – that everything comes down to money. We measure and record data because data sells. What we understand at Babylon Wealth is that people are commodities. For example, we record an elevated cholesterol solely because we know there is somebody out there who is selling a product to reduce lipid levels and is willing to pay for the information we collect. We don’t care about people, only the wealth that they generate for us.’

‘But it’s not all about money’, Scrooge insisted.

‘Isn’t it?’ countered the spirit. ‘It seems to me that everyone has a price Dr Scrooge. Are you really the exception?’

‘Well maybe I do have a price, but if I have, it’s at least partly because, in recent years, with so much of the joy having been sucked out of the job, the only way that I’ve been in any way rewarded for my efforts is financially. There’s no appreciation from those who call the tune, no recognition of how difficult the job has become and nothing but constant demands that I must do better. Take appraisal – if a requirement to show year on year improvement doesn’t amount to saying that we’re not good enough as we are, I don’t know what is. Something has to change’.

‘Well good luck to you with that, Scrooge. I concede that, as a profession, challenging the status quo rather than capitulating to the spirit of the age whilst all the while laudably endeavouring to deliver its impossible demands would be a step in the right direction. But I can’t see it ever happening – you’re all too busy just trying to keep your head above water to organise a concerted campaign for change.’

‘But let me try, spirit. Let us try. I have learned my lesson well this night. Perhaps things need not turn out the way you have shown me”.

And with that, Scrooge deleted the Babylon Wealth app from his phone, never to be installed again. He got back into bed. He’d seen and heard quite enough.

For Part 5, click here

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Other medically related Christmas themed blogs:

To read ‘How the Grinch and Covid stole General Practices Christmas’, click here

To read ‘Twas the night before Christmas – 2020’, click here

To read ‘A Merry, and Resilient, Christmas’, click here

Other GP related stories:

To read ‘A Grimm Tale’, click here

To read ‘The Happy Practice – A Cautionary Tale’, click here

To read ‘The Three Little GPs and the Big Bad Secretary of State for Health’, click here

To read ‘A Mission Impossible’, click here

To read ‘A Bear called Paddington’, click here

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

To read ‘Jeeves and the Hormone Deficiency’, click here

For Part 1, click here

For Part 2, click here

Stave Three – in which our tale takes (trigger warning) a darker turn

In the few minutes he had to think before the next ghostly visitor was due to arrive, Scrooge reflected on the events of the evening so far and wondered if he should try to claim a few hours of CPD. However, anxious as to how his appraiser might respond to such revelations and fearful that his reflections may be used against him, he concluded, as many before him, that it would be best not to put his thoughts down in writing.

He then realised that it was almost half past two. Was he not to be visited again tonight after all? But within a moment of his beginning to wonder this, he was woken from his reverie by the sound of his bedroom door bursting open and the arrival of a rather flustered looking figure entering the room. She was carrying a pile of papers in one hand whilst tapping into the mobile phone she held with the other.

‘I’m sorry to keep you waiting’, the spectre began. ‘I’ve been so busy tonight and the last chap I visited had several issues that he wanted me to provide spiritual insight on. Blow me if he didn’t have a list! Now what seems to be the problem? I am the Ghost of General Practice Present. Did you have any ideas, concerns or expectations as to how I might haunt you?’

Scrooge looked back at the apparition somewhat non-plussed. He hadn’t asked for the visit and, other than his previous encounters that night, had no experience of consulting with individuals from beyond the grave. Though highly concerned by the present turn of events and expecting to find the whole thing highly disagreeable, he had very little idea as to quite how the encounter should progress. Consequently, Scrooge said nothing.

‘Oh dear,’ said the ghost, unnerved by Scrooge’s silence, ‘This is awkward. I told Marley that there was little point in my visiting you without you being willing to see me. You see it’s so hard to help somebody unless they realise they have a problem and want to be helped.’ Still Scrooge found himself lost for words.

Rather than using the silence as a technique for therapeutic communication, the ghost laid the papers that she had been carrying down upon Scrooge’s bed and started flipping through the pages. ‘I’m sure there is a guideline for this situation somewhere. Give me a minute and I’ll be with you as soon as I find it. I don’t want to get this wrong.’ A few minutes passed, at the end of which the ghost seemed to have found what it was that she was looking for. ‘Ah yes, that’s it – come with me. I’m to show you how Christmas is being spent by others this year. Only I’m running short of time so we’ll have to make it quick’.

Once again, Scrooge was taken by the hand but, somewhat to his disappointment, she led him down the stairs in the conventional fashion before continuing through the front door and out into the night. ‘I’m afraid that these days we don’t employ the use of magic flight’, the spirit explained, ‘There’s no evidence for it, you see. It’s all evidence based hauntings these days’.

The fog had thickened making it difficult to see where they were going but the ghost still had hold of her phone and had entered the post code of their destination into Google maps. Before long they reached a block of flats and proceeded to climb the communal stairs. On the second floor, they passed through the wall into the home of a young family, the spirit assuring Scrooge as they did so, that the Celestial Institute for Ethereal Excellence had approved, in highly selected cases, what was known in the profession as quantum tunnelling, provided said cases met stringent eligibility criteria.

The flat bore witness to the fact that it was Christmas Day. The mantelpiece and sideboard were covered with Christmas cards and coloured paper chains were hanging from the ceiling. In the corner was a Christmas tree under which a three year old boy was happily making good use of the colouring set he had recently unwrapped. He stood up and walked into the kitchen where his parents were preparing dinner. They turned to him and noticed that he was covered in red spots. Immediately his mother emptied the pint glass of Prosecco she was drinking and used it to perform the ‘tumbler test’, her anxiety being heightened all the more when the rash failed to disappear. She pressed the speed dial button on her phone and called ‘111’.

‘I’m worried about my son – he’s covered in spots’ she exclaimed to the call handler. ‘No – he seems well in himself…No – no vomiting or fever…No – no headache or tummy pain…No – no catastrophic loss of blood and No – he has just the one head’. The list of negatives continued until the questioner focused in on the rash. ‘Well it’s almost as if he’s been marking himself with a red felt tip pen!’ The women listened to the call handler for a few moments longer before ending the call.

‘What did they say?’ her partner asked.

‘Something about a non-blanching rash being possible meningitis and that it’s better to be safe than sorry. They’re sending an ambulance.’

‘Bloomin’ right too. Now let me refill your glass, we can’t have you sober when it arrives!’

The Ghost of Christmas Present indicated to Scrooge that it was time to move on. Their next stop was just across the stairwell. Passing once more through the walls of the property, Scrooge recognised Mrs Gray, the frail elderly lady who lived there, as one of his patients. She was nearing the end of her life due to her having advanced metastatic disease. A single Christmas card lay face down on the dining room table, alongside of which was a box of chocolates she had bought for herself in an attempt to make Christmas Day, the fifth she’d have spent alone since the death of her husband, at least a little special. She knew it would be her last. As Scrooge looked on, the woman picked up the chocolates and shuffled slowly across the room and then, for want of anyone else to give them to, placed them in the kitchen bin.

‘What’s she doing?’ Scrooge asked the spirit.

‘She doesn’t think you’d approve if she ate them’ replied the ghost, who then proceeded to point to a letter held to the fridge door by a magnet commemorating the Queen’s Silver Jubilee. It was from Scrooge’s medical practice informing her that her recent routine blood tests had revealed that she had a slightly elevated HBA1c and that she was therefore classified as ‘pre diabetic’. Included with the letter was a leaflet giving helpful advice on healthy eating.

Scrooge stood staring at the woman. He realised that, though if asked to relay the ins and outs of all her most recent blood tests he would have been up to the task, in recent years at least, he’d not really known her at all.

The spirit had left the flat and Scrooge hurried to catch her up. They walked together without talking until they came to a house that Scrooge had never visited before. Here they stopped and stood outside the window of a dimly lit room. Peering in through the poorly drawn curtains they could see the figure of Bob Cratchit. He was sat, his head in his hands, surrounded by various medical text books. To his left was a half empty bottle of scotch and a packet of antidepressants. He was writing a note.

Scrooge turned to the Ghost of General Practice. ‘What’s he doing?’ he asked.

‘Struggling’ she replied.

‘But why? He’s such a good doctor’.

‘He is indeed. But he doesn’t know it. He has come to believe that he has to be perfect – that every guideline must be followed and a failure to do so will result in legal action being taken against him. He’s taken on the burden that comes from believing that medicine has the answer to every problem experienced by a broken society. He thinks it’s all down to him. He has been worn down by the constant demand from both society and the profession that he must perform better – that good enough is not good enough. He’s exhausted by the never ending assessment of his performance and crushed by the weight of the responsibility he feels. He lives in the constant fear that it’ll all be his fault if anything bad ever happens. He too feels all alone this Christmas.’

‘But this afternoon? He asked to leave early to spend some time with his family’

‘Indeed he did but the truth is that he hasn’t much in the way of a family – just a couple of friends he thinks of as family. In reality he had hoped to meet those friends for a drink but things didn’t quite work out the way they were planned. When he left the surgery late yesterday he went back to check on one of the patients he’d visited. Their condition had deteriorated and he arranged an admission but he was left feeling guilty and anxious. As a result he didn’t think he’d make very good company. And besides, he was worried about his CSA exam and thought the time would be better spent preparing for that.’

‘But he’ll pass the exam easily’ Scrooge exclaimed. ‘He’s come on leaps and bounds since that unfortunate misunderstanding the first time round. The patients love him – and the staff. He’ll make a great GP’.

‘Have you ever told him that?’

Scrooge fell silent. Perhaps he could have been a bit more supportive, encouraged a little more. Perhaps he could have helped him steer a course through the mass of expectation and enabled him to distinguish between what was genuinely important and what could appropriately be ignored. Perhaps he could have been the kind of trainer Fezziwig had been to him – one who, despite the changes enforced on the profession, could still see the joy of working in general practice and convey a little of that to the next generation – one who would fight for what was worth fighting for rather than retreating into cynicism, bitterness, and resentment.

‘I never knew he felt so alone. I never knew he was finding it so hard.’

‘Did you ever ask?’

Scrooge’s head fell. ‘Can I speak to him now?’

‘I’m afraid not. He won’t be able hear you, and what’s more our time is up. We must go.’

‘But I must do something’

‘That’s as maybe – but you have another appointment to keep. You must meet the Ghost of General Practice Yet To Come.’

The ghost started back towards Scrooge’s home. Scrooge himself lingered a little longer at the window in the hope that Cratchit would see him and appreciate his concern. Finally he turned his back on the scene and trudged slowly after the ghost who was now some yards ahead of him. Behind him, Cratchit slipped silently into the deepest of deep sleeps.

The spirit accompanied Scrooge back to his room but, before she left, she had one small request.

‘I’d be most grateful if you could fill in this form by way of giving feedback on my performance this evening. And it would be very helpful if you could indicate whether you’d feel able to recommend me to your friends and family…’

Regretting the choice of words even as she spoke them, an awkward silence arose between them. The spirit looked at Scrooge – Scrooge looked back

‘…or perhaps just an acquaintance…a passer by even?’

Sensing that now was clearly not the time, the Spirit said a hurried goodbye and left, leaving Scrooge alone with his thoughts. He couldn’t stop thinking about what he’d seen. He tried to convince himself it was all a dream, that none of it was real. Had things really become this bad? And could the future be worse? He had a feeling he was about to find out.

For Part 4, click here

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Other medically related Christmas themed blogs:

To read ‘How the Grinch and Covid stole General Practices Christmas’, click here

To read ‘Twas the night before Christmas – 2020’, click here

To read ‘A Merry, and Resilient, Christmas’, click here

Other GP related stories:

To read ‘A Grimm Tale’, click here

To read ‘The Happy Practice – A Cautionary Tale’, click here

To read ‘The Three Little GPs and the Big Bad Secretary of State for Health’, click here

To read ‘A Mission Impossible’, click here

To read ‘A Bear called Paddington’, click here

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

To read ‘Jeeves and the Hormone Deficiency’, click here

For Part 1, click here

Stave Two – in which Scrooge fondly remembers

Dr Scrooge woke in a cold sweat and sat bolt upright in his bed. This was not unusual for, in recent weeks, the stress associated with an impending visit by the CQC had frequently disturbed his sleep. Moments later, however, his thoughts were diverted from the need to get on and write those mandatory protocols on the secure overnight storage of hand towels and the safe use of the stairs, when, at one o’clock precisely, his bedroom door creaked open and a strange looking fellow crept into the room. Over a woollen cardigan he wore a tweed jacket complete with leather patches on the elbows; on the end of his nose was perched a pair of pince nez glasses; and in his hand he carried a battered black Gladstone bag.

‘Are you the spirit, sir, whose coming was foretold me?” asked Scrooge.

‘Indeed I am’ the apparition replied. ‘I am the Ghost of General Practice Past. I’ve come straight from a meeting of my celestial Balint Group. And my, what catharsis we enjoyed there this evening. Your former partner, Jacob, was in attendance. He’s a good chap, a jolly fine fellow. But enough of that. Come along with me – he has sent me to show you what General Practice once was.’

The spirit held out his hand and Scrooge instinctively took it. As he did so, Scrooge felt himself being lifted, as if weightless, from his bed. The spirit led him to, and then through, the wall of the bedroom and out into the night air. They journeyed until they found themselves in the oak panelled surroundings of what appeared to be a gentleman’s club. A number of elderly men sat together in high backed leather chairs. All were doctors, enjoying a glass of port after a drug sponsored Christmas meal. With them was a medical student who was attached to one of their number.

‘Listen to these chaps’, the spirit said to Ebenezer, ‘Each and every one is a fine fellow – a jolly good chap. You could learn a thing or two from what decent sorts like these have to say.’

The men were taking it in turns in regaling the medical student with tales of their working life.

‘Of course, these days, the youngsters have it easy. They only work a mere seventy two hours a week you know. In my day it was eighty one’

‘Eighty one hours? You had it easy. It was all internal cover when I did my house jobs. In real terms, I did a hundred hours a week’

‘Only a hundred hours a week? Luxury. I was running a GP practice single handedly by the time I was 23.. On call every hour of every day.’

‘That’s right. We had it tough as GPs. One hundred and sixty eight hours a week we worked – and, of course, we had to provide all the obstetric care – home deliveries every day’

‘And most of those were C.Sections – we had do the operations with only kitchen utensils for surgical instruments and a bottle of brandy for an anaesthetic’

‘Aye – and if you tell that to the medical students of today, they’ll not believe you.’

The spirit indicated that it was time to move on and Ebenezer readily agreed. He’d heard it all before. The walls of the room blurred and faded and gradually, as things came back into focus, Scrooge realised that they were now high above rolling hills. Passing over snow covered fields and lanes, they travelled until they came at last to a small town and stopped by a house that Scrooge recognised as his childhood home. Outside the dwelling, a car pulled up. The familiar figure of his family GP clambered out of the vehicle and made her way up the garden path to the front door. A woman was waiting anxiously for her arrival. They exchanged a warm greeting after which the woman led the doctor up the stairs to a room in which a boy lay, pale and in obvious distress.

‘Thank you for coming doctor, I know you’re busy but I didn’t know what to do. Ebenezer’s usually such a healthy child but he seems now to be struggling with his breathing.’

‘It’s no trouble Mrs Scrooge – let’s take a look at him.’

The doctor knelt down by the bedside and smiled at the boy who managed to smile weakly back. Ebenezer liked the doctor. He’d visited her a number of times over the years but this was the first time she’d ever visited him. The doctor asked a few questions and then carefully examined the boy, paying particularly careful attention to his chest. When she was done, she turned back to his mother and gave her the diagnosis.

‘I’m afraid it looks like we’ve a case of pneumonia on our hands. He’s really quite poorly and will be needing the help of my colleagues at the hospital. We best get him there as soon as possible.’

Scrooge looked on and wondered how she could say such a thing without a computer and a pulse oximeter to enable her to assess the risk of sepsis. She hadn’t appeared to even consider a CURB-65 score. None the less, a few phone calls were made and the doctor, placing her hand on Mrs Scrooge’s shoulder as if to say that everything would be alright, made her goodbyes,having given an assurance that an ambulance would soon arrive, an expectation Scrooge thought fanciful in the extreme,

‘Do you remember that day Ebenezer?’ asked the Ghost of General Practice Past.

‘I do,’ Ebenezer whispered, taken aback at how emotional he was now feeling. The spirit smiled to himself as he sensed that Scrooge was close to tears. He loved catharsis – catharsis was good. ‘She was such a lovely doctor’, Scrooge continued. ‘Always so kind and reassuring. She’d become almost a part of the family having visited so frequently during the last days of my father’ final illness. She always seemed to have time. It was because of her that I decided to become a doctor. The way she practiced medicine caused me to realised that being a doctor was a wonderful job to have. She seemed to me to be a fortunate woman.”

‘A fortunate woman indeed’ agreed the spirit. ‘A fortunate women and…’ he paused, thrown for a moment, ‘…a good chap’. The spirit hesitated again and then added, as if to try and reassure himself, ‘She was a jolly fine fellow.’

With that the ghost again took Scrooge’s hand and soon they were once more travelling through the night sky. On and on they flew, until they came to a village hall decorated brightly with all manner of coloured lights. A Christmas tree strewn with tinsel and still more lights stood by the entrance. Inside, Scrooge recognised the staff of his GP training practice. Some talked, others laughed and a number danced enthusiastically to music provided by a band. All were clearly enjoying the opportunity to relax and have fun together. A portly man then stood up and called for a bit of hush. It was Dr Fezziwig, the senior partner of the practice and Ebenezer’s one time trainer.

‘A moment’s silence if you please everybody. If I might say a few words, thank you all so much for coming this evening. I hope you’re having a good time.’ He paused a moment and then, with a feigned suggestion of doubt in his voice, questioned the crowd, ‘You are having a good time, aren’t you?’ Those gathered gave the desired response with cheers and roars that left nobody in any doubt that indeed they were. Fezziwig continued. ‘I want to thank you all for your help this past year. The partners appreciate your hard work, doing what can be a very difficult job. We couldn’t manage without you.’ More cheers followed together with a few calls for a pay rise. Fezziwig then concluded by wishing everyone a very Merry Christmas and insisting that everyone took advantage of the free bar that he and the partners were glad to provide. ‘Only keep an eye on young Dr Scrooge. He’s a fine young doctor but Ebenezer’s not as experienced as we older GPs and I’m not sure he can take his drink! We don’t want a repeat of last months incident when he woke up naked on the delicatessen counter at Sainsbury’s!’

‘Now HE does seem like a good chap – a jolly fine fellow’ declared the spirit, beaming as if the natural order had been restored to where chaos had once threatened to reign. ‘He’s a good, fine, decent, jolly chap of a fellowy sort if ever I saw one.’

The Ghost of General Practice Past turned to Scrooge and looked him straight in the eye. ‘But what of him?’ the spirit asked drawing his companion’s attention to a young man who was accepting the gentle ribbing at the hands of the senior colleague he respected so highly. He was sat laughing alongside various members of staff with whom he was sharing a table.

‘I was so happy then’ Scrooge told the ghost. ‘He was such a wise man and so willing to share what he had learnt. And we were such a great team, all so eager to support one another. Back then, there seemed to be so much more time. Why did everything change? And how did I become so resentful of the job I used to love?’

‘Something certainly changed – something that shouldn’t have’ replied the ghost. ‘At least, not in the way it has. Perhaps something needs to change again. Perhaps something needs to be recovered. But it is for you to decide what and how. As for me, my time is up. We must return. You have other guests to welcome tonight.’

And in less time than it takes for EMIS to crash on a busy Monday morning, Scrooge was back in his room, alone with his thoughts. It was nearly two in the morning.

TO BE CONTINUED…

To read Part 3, click here

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Other medically related Christmas themed blogs:

To read ‘How the Grinch and Covid stole General Practices Christmas’, click here

To read ‘Twas the night before Christmas – 2020’, click here

To read ‘A Merry, and Resilient, Christmas’, click here

Other GP related stories:

To read ‘A Grimm Tale’, click here

To read ‘The Happy Practice – A Cautionary Tale’, click here

To read ‘The Three Little GPs and the Big Bad Secretary of State for Health’, click here

To read ‘A Mission Impossible’, click here

To read ‘A Bear called Paddington’, click here

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

To read ‘Jeeves and the Hormone Deficiency’, click here

Stave One – in which Scrooge reveals just how burnt out he really is.

Old Dr Marley was dead. As dead as the NHS would be within a couple of years if things didn’t start to improve soon. And, as far as Dr Ebenezer Scrooge was concerned, Jacob Marley was better off out of it. Scrooge and Marley had been long term partners and Scrooge greatly missed his former colleague who had died several years earlier. This was not the result of any affection he had had for the man, that was not in Scrooge’s nature, but rather on account of the fact that, due to the national shortage of GPs, he had been unable to find a replacement, and his workload had consequently increased beyond the point of being manageable.

It was Christmas Eve and Scrooge was sat at the desk in his consulting room. It was nearly three in the afternoon. Morning surgery had only just finished and this was now what was laughably called his ‘lunch break’. An email flashed up on his computer screen. It was from the CCG wishing him a merry Christmas.

‘Bah!’ muttered Scrooge to himself. ‘Humbug! If they really wanted my Christmas to be merry, then perhaps they and NHS England could have agreed that I didn’t have to make up the Advanced Access hours, lost from not opening the surgery on Christmas Day, later in the week. Every idiot’, he continued, ‘who goes about with ‘Merry Christmas’ on his lips should be submitted to unnecessary colonoscopic examination and be forced to reflect on the experience for the purposes of revalidation.’

Dr Scrooge was not one to enjoy Christmas, and being encouraged to be merry served only to darken his already black mood still further. The situation was not helped by the arrival of a receptionist who announced her presence with a knock on his already open door.

‘Sorry to trouble you Dr Scrooge, but the Salvation Army band are playing Christmas carols in the car park and are asking if you would like to make a donation.’ She handed him a leaflet informing him that this Christmas many people would not have anywhere to sleep due to the lack of hospital beds resulting from years of chronic NHS underfunding. Scrooge sighed – this was nothing he didn’t already know. Only that morning he had been asked to arrange a review over the holiday period of a patient that was about to be discharged, a little earlier than was ideal, from the local, desperately overworked, hospital. Though he regretted being unable to promise that level of care, his refusal then had been unequivocal and he was no more minded now, at his own personal expense, to start financially propping up a system left destitute by the establishment. As far as he was concerned, he was already paying quite enough tax and, given that he had just learnt that the security of his pension was now somewhat precarious, he felt it was unlikely that he would change his mind on the matter. He stood up and slammed the door in his informant’s face. Sensibly, the receptionist interpreted that as a ‘No’ and scuttled back to where her colleagues were celebrating Christmas with a box of mince pies and a tube of Prosecco and pink peppercorn Pringles – the latter, notwithstanding the alliteration, surely an ill advised flavour choice, regardless of the season.

Scrooge had been invited to share in the festivities but he had no desire to do so. Nor did he have time. Instead he returned to his computer screen and started the never ending task of clearing his inbox of lab results, hospital letters, and prescription requests. He’d barely started when there was another knock at the door. Scrooge barked out a ‘What is it?’ and the door swung open to reveal the ST3 who had been with the practice since August. Dr Robert Cratchit was a highly capable doctor though one who lacked confidence in his own ability. To Scooge’s dismay he was wearing a Christmas jumper.

‘What do you want? Can’t you see I’m busy?

These words were not unfamiliar to Dr Cratchit, who, over the previous five months, had heard them frequently from the man who purported to be his trainer. In fact, so frequently had he heard them that, for a time, he had used them to start all consultations with patients, imagining them to be the profession’s approved opening words for all doctor/patient interactions. A failed attempt at the CSA and the associated considerable expense of applying to sit the exam again had indeed taught him much. Familiarity however did not make it any easier for Dr Cratchit to approach a man who never offered advice without showing contempt for the one who asked for it. For although Scrooge had received training on giving feedback, he had, much to the dismay of his appraiser, consistently failed to demonstrate any change in his behaviour as a result of such practice improving activity.

‘I was j-just wondering if it would be convenient if I were to g-go’ Cratchit stammered. ‘I’m only supposed to do one clinical session today and, though the planned patch t-tutorial for this afternoon has been cancelled, I thought that, since you allocated me all the visits, you m-might let me skip off a little early this afternoon. It is Christmas after all and I would so appreciate having the extra time to be with m-my family.’

Scrooge glowered. ‘Of course it’s not convenient. And I don’t suppose you’ll be offering to work a couple of extra Saturday mornings in lieu of the day you’ll no doubt be taking off tomorrow. That’s the trouble with young doctors these days. No commitment’

The ST3 smiled faintly and waited nervously. ‘Go on then, leave’ Scrooge eventually conceded, ‘But if anything goes amiss this afternoon and I’m compelled to reflect on some significant event or another, I know where my reflections will lay the blame. Just make sure you’re in early on Thursday.’ Cratchit thanked Scrooge and slipped away, leaving the burnt out old clinician alone with his thoughts and the prospect of a three hour afternoon surgery.

As things turned out the rest of the day was mercifully quiet with Christmas Eve being the one afternoon of the year which provided the general population with something more interesting to do than seek medical advice regarding their minor health concerns. As a result, Scrooge locked up the practice early and arrived home before nine. He’d stopped on the way to pick up a bite to eat but, having consumed it en route, the only thing he had to look forward to on arriving back was, as most evenings, the prospect of going to bed.

As he got out of his car, a fog hung about the driveway of the old house, that he’d bought some years before. Scrooge approached the front door, the fog seeming to cling to him as he walked. It was then that he noticed, in place of the ancient door knocker, what was clearly the face of his old partner, Dr Marley. The apparition lasted but a moment before Scrooge, unsettled by the sighting, hurried on, unlocking the door and subsequently forcing a pile of unsolicited medical periodicals to one side as he entered the house. He locked the door behind him and climbed the stairs to his bedroom.

Scrooge undressed and put on his night attire. As he sat gazing into the middle distance, contemplating once more the strange appearance of the door knocker, there came an unexpected ringing sound that filled him with inexplicable dread. Scrooge scrambled in his pocket for his phone. However, as the caller’s number was withheld, he, as was his custom, ignored what was almost certainly a nuisance call and continued his preparations for bed. And then he saw it. A sight that caused him to be more horrified than he’d ever been before – even more horrified than that morning when his appointments had included seven heart sink patients and three more complaining of being ‘Tired all the time’. Before him, as unwelcome as critical emails from the head of Medicines Management, stood the ghost of Dr Jacob Marley.

Scrooge, nothing if not a man of reason, rose up and spoke to the spectre in an accusatory tone.

‘I don’t believe in you’ he said.

‘You don’t believe in most NICE guidelines and yet they exist’ countered the phantom.

‘That’s true’, Scrooge was forced to concede and with that he sat back down in his chair. He paused a moment then, looking the ghost full in the face and acknowledging his existence, asked the reason for his visit.

‘I have come to warn you Ebenezer. There is yet a chance that you may escape what has become my fate. I am condemned to walk the earth for all eternity burdened by these chains – chains composed of nonsensical bureaucratic demands imposed on me by those who understand nothing of medicine and seek to use the profession for their own political ends. You have forgotten, Ebenezer, what being a doctor is really all about. You have forgotten the joy that your work once brought you and now you practice as a mere shadow of the clinician you once longed to be. You’re burnt out Ebenezer. Something needs to change.’

‘Blimey!’ said Scrooge, ‘like that’s going to happen’.

‘You will be haunted by three spirits,’ continued the ghost, ignoring Scrooge’s cynicism. ‘They will teach you all that you need to know. Without them you cannot hope to shun the path I now tread. Expect the first when the clock strikes one’.

And with that the ghost of Jacob Marley departed, groaning incoherent sounds of lamentation and dragging the weight of his chains behind him. Scrooge stood motionless for he knew not how long. Then, mindful of his need for rest, he climbed into bed. Picking up a copy of the BJGP, he fell asleep upon an instant.

TO BE CONTINUED…

To read Part 2, click here

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Other medically related Christmas themed blogs:

To read ‘How the Grinch and Covid stole General Practices Christmas’, click here

To read ‘Twas the night before Christmas – 2020’, click here

To read ‘A Merry, and Resilient, Christmas’, click here

Other GP related stories:

To read ‘A Grimm Tale’, click here

To read ‘The Happy Practice – A Cautionary Tale’, click here

To read ‘The Three Little GPs and the Big Bad Secretary of State for Health’, click here

To read ‘A Mission Impossible’, click here

To read ‘A Bear called Paddington’, click here

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

To read ‘Jeeves and the Hormone Deficiency’, click here

Three reflections on observations made on dark early morning journeys into work:

Firstly – Sat Navs can cause confusion.

One morning, not too long ago, I was confused when my Sat Nav, suddenly added 18 minutes to my expected journey time to work. I couldn’t discern why and so concluded that I must have entered a time warp and that my understanding of the space-time continuum would need rethinking. Later I realised it was simply that I had set the Sat Nav for home. My confusion had resulted from setting an inappropriate goal and then paying too much attention to what the IT was saying.

It seems to me we are in danger of doing the same in medicine. It’s been remarked on before that computers were once our servants but that we have now become their slaves. We have set our destination as ‘perfect health’, believing that medical knowledge and technological advance could deliver just that. Though an unrealistic goal, it is one our political masters, and much of society, continue to demand.  The result is that too many of us in the NHS are confused – feeling overwhelmed, disillusioned and unhappy. Burdened with striving for the perfection the system demands and forgetting that not everything deemed urgent is important, we find ourselves constantly responding to messages that tell us we are deviating from our course and that somehow we are not up to scratch. And worst of all, as we chase the measurable targets that are demanded of us we are in danger of missing the unmeasurable, but immeasurably more important, needs of the patient in front of us. Sickness and suffering are, regrettably, part of life. Though we should try to alleviate it, believing it can be eradicated, we lose our capacity to tolerate any form of difficulty. And so, every day normal inconveniences become worthy of an urgent consultation – ‘Acne? The duty doctor will see you now’.

Medicine harms – not only by way of drug side effects and surgical complications but also by creating health anxiety and promoting dissatisfaction with one’s lot by colluding with the idea that what is normal is unacceptable. Furthermore the constant pressure to deliver perfect medical practice is harmful for us as doctors – an insistence that all must be done perfectly – every guideline followed, every problem solved, every demand met – will lead to a generation of guilt ridden doctors who are paralysed by the fear of doing it ‘wrong’. No wonder it has been reported that about 50% of doctors presenting in difficulty to support services are GPs and 50% of those are aged 29-32. We need to continue to look after each other.

So how to solve the problems of the NHS?  Easy. We just need to reset the Sat Nav – and decide on some other place to go than ‘perfect health’. I’m absolutely certain there are better places to visit – I just doubt whether society will be able to agree on where that place might be.

Second observation – Mobile phones are presumptuous.

Not long after getting my new phone, it thoughtfully informed me, as I climbed into my car one morning, that the journey to my practice would take 29 minutes. At first I found it a little unnerving to think it knew where I was going. But later I realised it was simply being presumptuous. I say presumptuous because travelling around in my pocket for a few weeks did not give it the right to think it knew me. OK it got lucky that particular morning – and a number of mornings since if I’m honest – but, believe it or not, it takes more than a few weeks to know who I am.

I am closing in on 23 years as a partner at my practice  and one of the great things about working in one place for as long as that is that you get to know people – and people get to know you – rather better than a jumped up piece of electronics can over a couple of weeks. This is true in relation to the patients on one’s list – and is why we must continue to resist any pressure to give up the concept of personal lists. Patients are all extraordinary complex and if we are to be in any position to be remotely helpful to them then we need to understand them better than is possible from a cursory acquaintance. But just as significant perhaps as how well we know, and are known by, our patients is how well we know, and are known, by those with whom we work. We too are all extraordinary complex – unfathomable even. I truly value the constancy that I have known at my practice over these past many years. To feel one has a place and that one is accepted – despite ones many limitations – is immensely reassuring – particularly in a job such as ours where we deal with so much uncertainty – both in terms of the problems that are presented to us and the insecurities that we feel within ourselves – or at least I feel within myself. Of the eight partner practice I became a part of, though three partners joined, only one retired in the first 18 years I was with the practice. Our practice manager started at the same time as me and some of the members of nursing and admin teams predate me. More recently, four partners have retired in the last four year. They were such a part of the practice that they are still genuinely missed – somehow something seems to be missing.

Now that’s not to make the seven excellent new doctors we have appointed in recent years feel uncomfortable. The practice has been a place of constancy for a big chunk of my life but, at the same time, never unchanging. I am absolutely delighted to have each of the new partners with me – all are already friends as well as colleagues – and I look forward over the next 8-10 years (maybe) continuing to get to know and be known by them better. I very much hope they will feel as supported and at home as I have these past couple of decades.

GP Practices are important. Because resilience doesn’t just come from within. It comes from without too – from the support and encouragement provided by those one can lean on when times are hard and who, in the event of you falling, can be relied upon to pick you back up again when you haven’t the strength to do it yourself.

On a personal level, recent years have not always been easy. Frequently it’s all felt too much. Now I’m fully aware that others – both within those who will read this and amongst our patients – have far worse difficulties to face than I do – but inevitably my own problems often dominate my thoughts. I’ve lived long enough now to realise that, as I’ve already suggested, nobody escapes suffering – it’s true for our patients, it’s true for our families and, of course, it’s true for each one of us. It is part of what makes up a life. But at such times it’s good to be amongst a bunch of people with whom one can be weak and know that, even if they can’t fix it for you, they none the less care. Which is, I suppose, a large part of what being a doctor – indeed a large part of what being human – is about. I am hugely grateful to those I have blubbed down the phone to on a Sunday evening, to those who have offered to cover if I ever wanted to leave work and take some time, and those who have simply known and shown concern over the years. I have often thought that happiness has got less to do with what you do in life, and rather more to do with who you do it with. I’m glad to have done whatever I have done with the people I have. I don’t see that changing.

And lastly and ever so quickly – the third thing I’ve noticed on my way to work. The sunrise is sometimes staggeringly beautiful. There have been a few glorious ones. It is good to get a little perspective by looking outward at something more impressive than oneself. Not only is it more satisfying to admire the admirable than to be admired, it’s good to be reminded that, after a period of darkness, the sun eventually rises. ‘Weeping may tarry for the night, but joy comes with the morning’.

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To read ‘Reflections in the Darkness’, a more theological version of this blog, click here

Why have so many of us become so dissatisfied with our working lives?

Why have so many of us become so dissatisfied with our lives in general?

Hannah Arendt (1906-1975) was a German born philosopher best known for ‘The Human Condition’ (1958). In it, if I understand her correctly, she explains her view that the way out of living a meaningless life is to bring about change through our ability to act and thus create something new. She distinguishes our ‘actions’ from our ‘labour’ and our ‘work’. ‘Labour’, to Arendt, is simply those activities of living by which we meet our biological needs whereas ‘work’ she defines as that which we do within the world that imparts a ‘measure of permanence and durability upon the futility of mortal life and the fleeting character of human time’. ‘Work’ produces something abiding and is of a higher level than ‘labour’ which merely perpetuates. Our ‘actions’, however, are what really count. It is not so much ‘what’ we are that matters but rather ‘who‘ we are and who we are is best revealed through our words and deeds – when we go beyond our inherent selfish survival instincts and ‘act’ to bring something new and unexpected into existence.

Two key behaviours that Arendt identifies as bringing about this change are those of forgiveness and the making and keeping of promises. Forgiveness is the behaviour by which it is possible to nullify past actions, releasing others from what they have done and enabling them to change their minds and start again. ‘Forgiveness‘, she writes, ‘is the key to action and freedom‘ and ‘the only way to reverse the irreversible flow of history‘. In contrast, our ability to make and keep promises marks us out as being able to make the future different from the past. ‘Promises are the uniquely human way of ordering the future, making it predictable and reliable to the extent that this is humanly possible‘.

Arendt believes that, to be fulfilled, we need to be able to act in ways that advance or better society as a whole. And herein lies the clue as to why some of us may have lost satisfaction in our working lives and, perhaps, our lives as a whole.

Though we continue to seek happiness, so restricted have we become in public life, by the guidelines that we have to adhere to and the hoops through which we have to jump, that we have become like slaves who have no prospect of having genuine influence. In Arendt’s terms, we can ‘labour’ and ‘work’ – but we can not ‘act’. Furthermore, having given up the prospect of doing something that might bring about real change and produce genuine benefit, we have retreated from the public sphere and been reduced to consumers who are content to amuse ourselves in private – with yet another bottle of prosecco, perhaps, and an evening spent bingeing on the latest Netflix box set.

Arendt suggests that ‘under conditions of tyranny, it is far easier to act than to think‘. Such then is the consequence of a too heavy, top down, approach to medicine when conformity to guidelines is all. In such circumstances, we seek only to unquestioningly comply with what we are told we must do and, from fear of reprisal, we anxiously seek to do so perfectly. But, says Arendt, ‘In order to go on living one must try to escape the death involved in perfectionism‘. By giving up the hope of genuine autonomous action we have given up our hope of fulfilment and with it our hope of happiness.

Thoughtlessly striving for perfect compliance, we therefore die.

This links into another idea of Arendt – that whilst we can know much about the objective world, we fail to understand what lies beneath the surface – that which is most important. ‘What’ we are is our body, but ‘who’ we are is disclosed by our words and deeds. As doctors we may know a lot about ‘what’ our patients are – the details of their individual biological parameters – but we struggle to know ‘who’ they are – their true nature as revealed by what they say and what they do. We can only know ‘who’ our patients are by devoting more time to watching them, listening to them and learning what makes them who they are. We need to spend more time with people, both our patients and those friends and relations whom we love the most, not only for the emotional and material support they provide but also, Arendt believes, for the joy of seeing them reveal their true character.

Failure to know our patients therefore diminishes our working lives. We all risk burning out if we are concerned only about ‘what’ our patients are rather than ‘who’ they are and who they may become. But this becomes harder as workload increases, remote consulting increases and personal lists become fractured. These and a million other concerns press in on us and prevent us from taking the time necessary for us to know our patients.

Finally then, what of ourselves. Arendt suggests that we may never really know who we are ourselves because that is something that can only really be observed by others, those who see us act in ways that we can not see ourselves. This is most true when we love – for love, she says, reveals ‘who’ we are like nothing else simply because it is unconcerned with the ‘what’ of the one we love. ‘Love, by reason of its passion, destroys the in-between which relates us to and separates us from others’

To regain our satisfaction with work, therefore, we need to change. We need to stop behaving in the way that we have been encouraged to practice, stop seeing the ‘what’ of patients and, instead, notice the ‘who’ that they are. In short we need to care for our patients.

We need to stop judging them for their past mistakes, forgiving their unhealthy habits, and thereby giving them the opportunity to start again. We need to give them the hope they need in order to begin again and so create something new in their lives. And we need to believe that patients really can change and promise them the help and support they need to avoid remaining stuck as they are.

If we act in these considered, creative and unexpected ways we really will make a difference – a difference that will also restore our own satisfaction in practicing. We must be more than simply service providers, performing our jobs according to protocol. We need to tackle head on the problems of life and think for ourselves. Because to live is not to merely survive, mindlessly comply and contentedly be entertained. The provision of ‘bread and circuses‘ is not enough for us to be happy. Rather, to truly live is to be somebody who acts and brings about the change, the new start, we all so hope for and so very much need if we are to keep on keeping on.

Eleanor Oliphant, the eponymous hero in Gail Honeyman’s novel captures the sense of this well.

“I suppose one of the reasons we’re all able to exist for our allotted span in this green and blue vale of tears is that there is always, however remote it seems, the possibility of change”.

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Related blogs begin with one on the dangers of perfectionism:

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

To read ‘On Not Remotely Caring’, click here

To read ‘Contactless’, click here

To read ‘Vaccinating to remain susceptible’, click here

To read ‘On Approaching One’s Sell By Date’, click here

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

To read ‘General Practice – still a sweet sorrow’, click here

To read ‘We had the experience but missed the meaning’, click here

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

To read ‘When good enough isn’t good enough’ click here

To read ‘It’s alright ma (I’m on GPing)’, click here

To read ‘My back pages’, click here

To read ‘Vanity Fair’, click here

And now one on the dangers of perfectionism:

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

And finally 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

Not so long ago, a school uniform committee was set up at the local educational establishment frequented by my children. Predictably enough, though nobody seemed to have a problem with the previously requisite attire, before long, presumably to justify their own existence, changes started being made and additional expense was forced on parents who had to spend money they would rather not, simply to satisfy the desire of those imposing the new requirements.

Immanuel Kant, the great German philosopher of the seventeenth century, once said, ‘The possession of power invariably debases the free judgement of reason’ or as William Pitt the Elder put it in a speech in 1770, ‘Unlimited power is apt to corrupt the minds of those who possess it.’ Those with power think differently because of that power and do so in a way that tends to favour their own ends rather than those of others.

This is a problem – and not only because of the cost I incurred kitting out my children. There are those who have power over us in the world of medicine, the government, the CQC and various regulatory bodies to name but three. If Kant is right, inevitably that power will serve them more than it serves us. But before we join the revolution and line our masters up against the wall, there are some things we should consider. Firstly we should think about the nature of the authority held by those who make the rules. We make a mistake if we think we should necessarily be the final arbiters of what should be done and how. It would be arrogant to think we know everything and do not need guidance from those with greater expertise. But equally we should be slow to comply with the instructions of those who impose their will but have yet to demonstrate that they have the requisite wisdom and knowledge for their authority to be accepted. Stanley Milgram’s carried out experiments in the 1960’s, in which he found subjects were, contrary to their conscience, prepared to administer potentially life threatening electric shocks to people when instructed to do so by someone in authority, even when those they were shocking had supposed heart conditions and were begging for them to stop. Such experiments demonstrate how prone we are to obey authority figures.

So we need to keep our minds switched on and think critically about what we are being asked to do. The way we practice should not be as a consequence of a mindless desire to satisfy the guidance with which we have been issued. If we are nothing more than protocol following service providers it will make us bitter and complaining, resistant but not resilient – there is a difference. Bob Dylan had it right when he sang of how ‘the masters make the rules, for the wise men and the fools’ and that those ‘who must obey authority that they do not respect in any degree…despise their jobs, their destinies’ and end up doing ‘just to be nothing more than something they invest in’

We need to be different. We need to be professionals who enjoy their work despite the stress because we know that the work is meaningful. We will be humble enough to follow advice and guidance from those we trust but when we do it will not be simply so we can be suitably compliant but because we see it as the best way to achieve the desired end – the best for our patients.

Because as Kant also said, rational human beings should be treated as an end in themselves and not as a means to something else. Which brings us to another important consideration. We have power over our patients. Milgram’s experiments also demonstrated how carefully power must be wielded . And so we must ask how often do we use our power in such a way to serve our best interests rather than the best interests of our patients? How often do we steer our patients to make decisions that make our life easier? How often do we use them as a way to make us feel good about ourselves?

Of course GPs are human and therefore subject to the same limitations that this brings on everybody else, but we should be mindful of how we may be prone to act and take steps to counter this unhelpful tendency. For me this is one reason why personally I want to remain a GP and not be called something that some might consider more honourable. I acknowledge that there may be benefits in our being known as a Consultant in Family Medicine in terms of patients recognising the degree of our training and expertise, it certainly sounds more lofty, but, for me, it distances me from the patient I am seeking to help. I don’t want to be in this job for status – I need to stay grounded, maintain a little humility. The title GP is certainly a more down to earth title, but it is, as a consequence, one which, as well as making us more approachable to patients, helpful, I think, in limiting the power we may be tempted to feel and which is liable to be used, at least by me, a little too much to my own ends.

In short, and I know this may be controversial, I’m happy to be ‘just a GP’.

If there is one thing that is common to all patients that consult us, it is that they want things to be better for them than they currently are. They would like us to do or say something that would ease their pain, relieve their anxiety, alleviate their distress. They want us to change their future because their present is not to their liking. If on leaving our rooms they already feel better, it is simply because they have been given some hope that things will improve.

Hope. Patients need it – doctors and nurses need it – I need it. Hope keeps us going in the face of problems which seem insurmountable. Like Seligman’s dogs, who in his experiments on ‘learned helplessness’ were put in adverse situations they couldn’t change, without hope we become resigned to never ending difficulty and tend towards depression and passivity.

Jurgen Moltmann writes, “Present and future, experience and hope, stand in contradiction to each other”. He suggests that “hope is directed to what is not yet visible… and brands the visible realm of present experience…as a transient reality that is to be left behind”.

Some are uncomfortable with our constantly living in the hope of a better tomorrow. They suggest we spend either too much time living in the past, remembering what was, but is no longer; or too much time living in the future, hoping for that which is not yet. Bemoaning such behaviour, Blaise Pascal wrote “We do not rest satisfied with the present. We anticipate the future as too slow coming, as if in order to hasten its course; or recall the past, to stop its too rapid flight…We scarcely ever think of the present; and if we think of it, it is only to take light from it to arrange the future…So we never live, but we hope to live; and as we are always preparing to be happy, it is inevitable we should never be so.”

Pascal would, I think, have approved of mindfulness, the psychological process of bringing ones attention to experiences occurring in the present moment. Now, whilst mindfulness may have its place when we are overwhelmed by unnecessary anxiety concerning the future, grounding us, as it does, in the here and now and helping us appreciate what we have and can currently enjoy, if we imagine we can sort our patients’ very real problems by advising that they consider the intricacies of a tree, then surely we are mistaken. T.S.Eliot penned, “The knowledge derived from experience…imposes a pattern, and falsifies”. What we know from what we encounter is not enough to understand fully. We need to draw from outside of ourselves if we are not to be misled. The present requires the context given it by the past and is tempered by what is expected in the future. A powerful illustration of this is provided by John Piper. He asks us to imagine that, whilst walking through a hospital, we hear the screams of somebody in pain. He suggests that how we feel about what we hear will differ greatly depending on whether we are on an oncology ward or a labour ward. The future matters – it changes our present.

As health care professionals, we are in the business of changing the future for our patients – offering a promise of a better tomorrow for those with whom we consult. We seek to envisage what currently can’t be seen and then endeavour to bring it into reality for them. Moltmann again: “Hope’s statements of promise…stand in contradiction to the reality which can at present be experienced. They do not result from experiences, but are the condition for the possibility of new experiences. They do not seek to illuminate the reality which exists, but the reality that is coming.” So, for example, when we issue a prescription for pivmecillinam, it is the proffering of a hope, that the cystitis will come to an end. It’s a promise that what is not true now, will shortly be so.

But changing the future is an act worthy of the divine. Nonetheless, having too often in the past arrogantly acted as if we were God, increasingly, it seems, it’s now being demanded of us. And our attempts to satisfy that overwhelming demand is dragging us under because, of course, not all hopes can be so simply realised by the prescribing of a course of antibiotics. Furthermore, we can strive all we like to live in the moment but, as temporal creatures, we cannot escape the future. Not least, we cannot deny that we are cognisant of our own mortality. Death is a problem we all have to face and one which medicine, despite its best efforts, still can’t solve. To quote Moltmann once more, “The pain of despair surely lies in the fact that a hope is there – but no way opens up towards its fulfilment”. What then can we do when faced with the problem of death. Must we, if we are to carry on at all, agree with L.M. Montgomery that ‘life is a perfect graveyard of buried hopes’? Should we, with Dylan Thomas, “rage, rage against the dying of the light” or comfort ourselves with mere mindfulness as we “go gentle into that good night”.

Death is the one thing we can be certain of and yet, desperate that that were not so, too often we mindfully focus our attention on the detail of the here and now of our patients’ clinical parameters in an attempt to pursue and push eternal life. Not only is this unhelpful for patients weighed down by a medical profession too scared to address its own limitations, it’s also bad for doctors who are burdened with the Sisyphean task of delivering the undeliverable.

Regardless of what we may or may not believe about what happens after death, what is certain is that everlasting life is not a gift that is ours to give. We, and our patients, need to stop pretending otherwise.. If we’re not to make an almighty mistake, we need to stop playing God and acknowledge our remarkable ordinariness, the ocean of our ignorance and, what Atul Gawande calls, our ‘necessary fallibility’. We may not be the answer our patients are looking for.

But death is not the only future problem our patients face that medicine cannot solve. Many of our patients have lost hope of things ever being better – the future is something only to be feared. We live in an increasingly anxiety ridden society. Henry Thoreau wrote “The mass of men lead lives of quiet desperation, and go to the grave with the song still in them.” But Thoreau was wrong – the desperation is deafening.

Many of us will also know what it is to have a difficulty which appears beyond us, which wears us down and threatens both our present happiness and the happiness we desire for tomorrow. If then we are to solve the problem of the future, we must either limit its’ importance and be content to be satisfied by the joy of the present, or struggle to find the antidote to despair that is the hope of something better. There is much that medicine can do but we must not imagine that it is the only thing in which we or our patients should hope. Often that hope would be better placed elsewhere – after all, a misplaced hope is a false hope, and a false hope is no hope at all. We, and our patients, need to be directed towards a real hope that can lift us above the suffering of the here and now, something we can look forward to and which, despite everything, will keep us going; something which, even if it can’t get us to the top of the mountain we face, manages to draw us up a little higher and puts us in a place where we are able to at least imagine what the view from the top might look like.

When life is hard, whether at work or elsewhere, we all want things to be better – it’s then, more than ever, that we need a hope for the future to keep us keeping on, The exact nature of that hope will be different for each one of us. For some, the hope will sometimes be but modest – indeed when life is at its hardest, modest may be all we can muster. For others, or at other times, the hope may be more extravagant – transcendent even. But big or small, dependent on us or others, we need a hope that sustains us.

Despite our difficulties, we must make room for hope

We need to search it out knowing that, though we may not find it medicine or ourselves, there is always hope to be found.

And when it seems there isn’t, we need to hope against hope, that hope somehow finds us. Because, even then, though not, perhaps, in a form we once expected, a hope that does not give up still remains.

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Related blogs:

To read ‘Hope comes from believing the promises of God’, click here.

As a boy, I spent my early years playing. I did not seek to please anyone as I played, though my parents no doubt were pleased to see me doing what all children ought. I did not seek to play better than those I played with – what would be the point? I simply played, and was glad to do so.

Then came school and, though I did not seek to impress, I was, from time to time, rewarded. Stars for pleasing the teacher. And I saw that the number of stars others received was compared with those that were bestowed on me. I was, I realised, in competition with my peers.

School continued and the tasks set me became more complex – the rewards more contingent on my reaching a certain standard. ‘Work hard’, they said, ‘and you might do well – you might progress’. There was always a next stage, never a point beyond which one could stop and rest. And so to university – where those who strived hardest won the best jobs.

And so at last came work. And the rewards dried up, replaced now by the threat of sanctions. Instead of rewards for achieving, now there were punishments – even for those who were simply standing still. Good enough was no longer good enough. ‘Be better, Do more’, they said, ‘You must do better. You must do more’.

So harder and harder i worked until I stopped – exhausted – defeated..

‘Ah, but I was so much older then, I’m younger than that now.’

I remembered my years as a boy. When I just did what I wanted, did what was right for me to do.

Competing in a misguided attempt to prove our perfection makes losers of us all.

And so I became a child again – became wise again – just enjoying doing what I was meant to do.

Perhaps there are those who are glad to see me now – doing what I do. But if not, so be it.

The doing is reward enough.

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To read an updated version of this blog entitled ‘My Back Pages’, click here

How about impressing your appraiser with this as one of your goals for personal development in the coming year. ‘Be drunk’.

Charles Baudelaire (1821 – 1867) wrote:

“You have to be always drunk. That’s all there is to it – it’s the only way. So as not to feel the horrible burden of time that breaks your back and bends you to the earth, you have to be continually drunk.

But on what? Wine, poetry or virtue, as you wish. But be drunk”

I know this because yesterday morning, having dealt with his chronic cough, a patient quoted the above to me – in the original French. He also plays jazz professionally and in the past has, on occasions, performed with Acker Bilk. How cool is that?

The poem goes on:

And if sometimes, on the steps of a palace or the green grass of a ditch, in the mournful solitude of your room, you wake again, drunkenness already diminishing or gone, ask the wind, the wave, the star, the bird, the clock, everything that is flying, everything that is groaning, everything that is rolling, everything that is singing, everything that is speaking. . .ask what time it is and wind, wave, star, bird, clock will answer you: “It is time to be drunk! So as not to be the martyred slaves of time, be drunk, be continually drunk! On wine, on poetry or on virtue as you wish.”

I suspect many of us have woken again this week, ‘in the mournful solitude’ of our consulting rooms, stone cold sober as a consequence of having had the cold water of another day on the front line thrown in our face. Baudelaire tells us that to avoid being the ‘martyred slaves of time’ the only way is to be intoxicated by something good that consumes us. Many of us will have an interest outside of work that does this for us but what if, in addition, it were possible to be continually drunk on our practice of medicine?

Currently this is far from easy, given the way we are forced to practice. Rather than losing ourselves in our work, delighting in it, we are forced to be too self aware – having as we are to constantly justify ourselves. Have you ever thought how the system inherently criticises us.? Our constant need to demonstrate improvements in our practice implies that we are never considered to be good enough whilst our endless need to gather feedback is a system of policing employed by those who can not bring themselves to trust us.

Medicine, like life itself, is a team game in which we all play our part. Highlighting individual weaknesses rather than emphasising team strengths is like a lion isolating the injured in a herd of antelope and going in for the kill. Together we can survive, leaning on our colleagues in both primary and secondary care even as we allow them to lean on us.

How does the poem go? ‘If a child lives with criticism, he learns to condemn’. Is it any different for doctors? Is it any wonder that sometimes we are a little condemning, a little bitter, a little negative? But if instead we lived with encouragement, might we not learn to be a little more confident, if we lived with approval, might we not learn to like ourselves a bit more, (something too many of us struggle with), and if we lived with acceptance, might we not learn again to love what we do. And wouldn’t that make us better, more caring, doctors?

So let’s get drunk this weekend on whatever it is that does it for us but don’t forget that, leaving aside the nonsense, being a GP remains a worthwhile endeavour. Yes it could be better but it still has the capacity to be both wonderfully enjoyable and genuinely satisfying. Of course we’re not perfect, it’s an impossible job, but regardless of what some might say, remember that, as we frequently say to our patients by way of encouragement, together we are ‘good enough’.

Stick that knowledge in your hip flask and sip from it frequently this coming week.

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Charles Baudelaire got something very right in his poem ‘Be drunk’. He felt the need for something to which one can give one’s life, something by which one can transcend the ‘horrible burden of time’. But he also got something very wrong. His suggestions as to what that thing might be, wine, poetry or even virtue, can never satisfy for more than a moment. He should have looked elsewhere for that. And so must we.

It is not wrong though to want to be happy – nor is it wrong to want that happiness to last for eternity.

C.S. Lewis has it right when he said,

“Creatures are not born with desires unless satisfaction for those desires exists. A baby feels hunger: well, there is such a thing as food. A duckling wants to swim: well, there is such a thing as water. Men feel sexual desire: well, there is such a thing as sex. If I find in myself a desire which no experience in this world can satisfy, the most probable explanation is that I was made for another world. If none of my earthly pleasures satisfy it, that does not prove that the universe is a fraud. Probably earthly pleasures were never meant to satisfy it, but only to arouse it, to suggest the real thing. If that is so, I must take care, on the one hand, never to despise, or be unthankful for, these earthly blessings, and on the other, never to mistake them for the something else of which they are only a kind of copy, or echo, or mirage. I must keep alive in myself the desire for my true country, which I shall not find until after death; I must never let it get snowed under or turned aside; I must make it the main object of life to press on to that other country and to help others do the same.”

We were, then, created to be happy – our desire for happiness proves that this is the case. The psalmist knew it too and what is more he knew where to find the happiness he was created to enjoy. And so he cries out to God.

‘You make known to me the path of life; in your presence there is fullness of joy; at your right hand are pleasures forevermore.’ (Psalm 16:11)

You want infinite happiness? You’ll find it in the presence of God – there you will find ‘fullness of joy’. You want eternal happiness? That too is found in God – at his right hand are ‘pleasures forevermore’.

To delight in God is to honour him and it is, therefore, far from wrong to want to be eternally happy.The evil comes from seeking our happiness in the wrong places.

‘Be appalled, O heavens, at this; be shocked, be utterly desolate, declares the LORD, for my people have committed two evils: they have forsaken me, the fountain of living waters, and hewed out cisterns for themselves, broken cisterns that can hold no water.’ (Jeremiah 2:12-13)

God is the fountain of living water, the source of all our satisfaction. It is evil not to go to him for this all encompassing joy. And it is evil, as well as utterly foolish, to seek our satisfaction in anything else since everything else is but a broken cistern in comparison to the fountain of living water that is God.

Baudelaire once wrote:

“I can barely conceive of a type of beauty in which there is no melancholy”

For this life he was right – nothing in this life is not in some way or another tarnished by the fall and even the most perfect of experiences are tempered by the knowledge that they will end. Therein lies the melancholy. But Baudelaire neglected to look beyond this world, to the God that transcends all that we see and experience – the God who is both good and everlasting. We can never fully know happiness until we fully know God. As C.S. Lewis put it:

“God cannot give us a happiness and peace apart from Himself, because it is not there. There is no such thing”

The gospel assures us though that to know God is to have eternal life and that through the redemption that has been, is being, and will be attained through the life death and resurrection of Jesus Christ we will one day have this experience for ourselves. Not yet though,

‘For now we see in a mirror dimly, but then face to face. Now I know in part; then I shall know fully, even as I have been fully known.’ (1 Corinthians 13:12)

On that day, however, we will know a joy that at present we do not have the capacity to fully conceive. Then, as Baudelaire might have put it we will be drunk on God. Then there will be no ‘horrible burden of time’, no melancholy, but rather all of eternity to rejoice in the glory of the one whom we will eternally delight to praise.