Advanced Access – a step in the wrong direction

So Gary Oldman looks set to win the Oscar for best actor for his starring role in ‘The Darkest Hour’.
If that film is anything to go by, Winston Churchill would have liked what I had my eye on as 2017 drew to an end – that is a ‘Drinks by the Dram’ Advent Calendar available last December on Amazon for a shilling short of £10,000. But then who wouldn’t want to start the day with a 60 year old Glenfarclas or a shot of Pappy Van Winkle’s 23 Year Old Family Reserve to accompany their coco pops? Churchill’s penchant for starting the day in the manner he intended to continue may have had us reaching for our CAGE questionnaires and dolling out the health advice but one can’t help admire the man for his leadership. He was a man willing to take a stand.

Locally, advanced access [AA] is up for discussion again. A year ago we extended opening hours until 8pm on two nights a week as a tentative step towards the government’s wish that GP surgeries open 8 till 8, seven days a week. It’s not been a great success. Ours is not a commuter town and, for the most part, patients who have taken the late appointments would have preferred appointments in normal working hours. After all, late appointments are hardly the natural habitat of babes in arms and the frail elderly. So should we continue AA as we are being pressured to – or say enough.

Most fundamentally I think we need to be clear that the problem with the NHS is not the failure of GPs to be open for longer. The suggestion, therefore, that such would solve the problems the NHS is facing is disingenuous. The problems are far greater than that and, I suspect, largely reflect the broken society in which we live. Going along with AA only serves as one small further encouragement to the continued overlooking of the real issues.

I believe that Advanced Access is a step in the wrong direction – I think it is bad for us, bad for our patients, and bad for society as a whole.

Despite being a strong partnership, over the last year AA has fragmented the practice by making us more disconnected – we have seen less of each other and, outside of work, it has impinged negatively on our personal lives. Continuing with AA will perpetuate this still further and all the more if it’s extended as planned. The only real benefit to us personally is a little extra money – money the NHS can ill afford to spend on dubious initiatives like AA. The world tells us that money is the route to greater happiness, and makes the extra work worth while. But if we were to ask ourselves what our intrinsic values are, what it is that is really important to us, few of us would say money. For sure we need enough but AA takes us away from what is really important to us and thus has us being paid to be less happy. This will inevitably increase the risk of burn out, worsen GP recruitment and hasten the exodus of GPs leaving the profession early. Each of these will impinge negatively on patient care.

So what of the patients? More altruistically we might say that one of our intrinsic values is the provision of good quality care to our patients. But I don’t believe AA offers this. Your practice may be different but we have shown from experience that locally there is little call for extended opening. Seeing people late is a less good service for those patients who are being forced into taking less convenient appointments. And even for our working patients AA comes up short since it reduces still further the little leisure time workers can enjoy. AA actually forces those who do work to work longer and harder and denies them the right to take time out of work for genuine health concerns. It’s not our working patients who benefit from AA, rather it’s their employers – employers who, all too often, demand more than their pound of flesh from their staff and who far, too readily it seems, discipline them for even the most legitimate time off work due to ill health. This isn’t good.

AA demands both we and the workforce in general work longer and harder with the promise that that will make you happier due to some scant financial reward. It’s not true. As Lily Tomlin once said, ‘The trouble with the rat race is that, even if you win, you’re still a rat.’ And nobody on their death bed ever said ‘I wish I’d spent more time at the office.’

Neither is AA safe. We already work long, intense hours. Working longer will lead to errors – patients will be harmed. The GMC has advised that we should speak out if we are being asked to do more than we can reasonably be expected. Regardless of what we may currently feel about the GMC, we simply can’t just roll over and do more.

AA is, therefore, bad for us and our patients but it is, I think, another small nail in society’s coffin. The problem the NHS has is that it is being asked to solve the problems of a broken society. But it can’t because society’s problems simply aren’t predominately medical. This needs to be shouted from the roof tops if anything is going to change. Simply capitulating to the notion that ‘improved’ access to health will solve everything is to perpetuate the myth. Of course the powers will be will try to make life difficult for us if we say this (indeed they have, for us, already) but we won’t be wrong just because they don’t like what we say. It is, after all, in their interests to make us out to be the villains since doing so lets them off the hook of really addressing the problem. I’m no conspiracy theorist but isolating individuals and making them the problem rather than acknowledging the system itself is broken seems to be a trend. Blame Hadiza Bara-Garba for the death of a child, blame GPs for the failure of the NHS – it’s all much the same. We need to come together and standup for what we know to be true if we’re not going to be complicit with what is making society worse.

Some seem to think that Advanced Access will just go away if we tow the line for the time being but if we do we may risk it gradually establishing itself as the norm and remaining with us for ever. If we’re happy with that then fine but, if not, shouldn’t we be at least saying so now. I know it’s only a tiny little stand – hardly on a par with Churchill’s – but could we not take some professional satisfaction in coming together and making it our stand?

These are my thoughts but perhaps they are the ramblings of grumpy old man who is trying to justify his selfish desire to lie in at the weekend with some wordy pronouncements which, despite his protestations, have no merit. Or perhaps they are the ramblings of a grumpy old man who selfishly wants to lie in at the weekend but, fortuitously for him, on this occasion at least has a point. Is this a battle worth fighting and if so what price – financial or otherwise – should we be prepared to pay? Or should we save ourselves for bigger battles ahead and hope that it does indeed just go away soon? I’d be genuinely interested to hear your thoughts.

So the motion is: ‘Advance Access should be abandoned and GP practices trusted to be run professional enough to determine opening times according to individual local need and individual practice capacity.’

Do I hear ‘Aye’?


I hope you’ll bear with me for a while but, I wasn’t born yesterday, I know you’ve a lot on and this is a little on the long side.

Recently I watched the BBC adaptation of ‘Little Women’. Despite the fact that it wasn’t the kind of programme I would naturally be drawn to, I enjoyed it and found it genuinely moving. Let’s just say, on a number of occasions I found myself affected by what I can only assume was a speck of dust in my eye. Watching it I was struck by the ability that the characters had to bear great hardship. On several occasions in the story, there were those who spoke of having to simply bear, together, the trials their were experiencing – trials that included the anxiety of having a relative away at war, the pain of experiencing a debilitating illness and the sorrow of having to look on powerlessly as a loved one died. Though only a story, this ability to accept suffering, and bear it together, has a place in real life too.

I wonder, however, if today we have lost our ability to bear with suffering, to sometimes simply endure what life throws at us. We have, perhaps, come to assume that we have a right to comfort and ease and, when that dream falters, have become accustomed to the NHS, and others, always being there to rush to our aid. We may even have foolishly developed the notion that there is no limit to the help that can be provided – that no problem needs to be put up with. If we have come to believe this however, we are deluded. If one thing in life is certain, it is that, to a greater or lesser extent, hard times will come to us all. And sometimes there is no earthly solution to the difficulties we face. Sometimes they simply have to be endured – maybe for weeks, maybe for years. Sometimes the pain just has to be borne.

In his book ‘The Uses of Pessimism and the Danger of False Hope’, Roger Scruton warns against what he calls ‘The best case fallacy’, the illusion that we are prone to believe that progress will inevitably bring about a future state of affairs when all will be well. ‘There is’, he writes, ‘a kind of addiction to unreality that informs the most destructive forms of optimism: a desire to cross out reality…and to replace it with a system of compliant illusions.’ Scruton advises that we act as a ‘scrupulous optimist’ might. Alongside other characteristics, Scruton suggests that a scrupulous optimist ‘knows the uses of pessimism’, that conscious awareness that things may well go wrong, and that we ‘live in a world of constraints’. Scrupulous optimists, he says, ‘like all rational beings’ take risks ‘as part of their desire to improve things’ but do so ‘always counting the cost of failure and evaluating the worst case scenario.’ They know that things sometimes go wrong and that they and those around them are limited.

Both those who are ill and those working in the health service to support them in their sickness need to have this healthy dose of pessimism. We aren’t always as tough as we would like to be and we can’t always assume that we’ll be able to cope. Simply demanding that we, or others, be more resilient, is not always either helpful or realistic. Demanding that we be more resilient can even add to our burden. When the problems really are too much, beyond what any of us can cope with, it’s OK to find ourselves broken and awash with tears. On those occasions we may simply have to bear the pain – and it won’t be pleasant.

Sometimes the problems are too many for even the most capable
Sometimes the problems are too complex for even the most wise.
Sometimes the problems are too heavy for even the most strong.

Every now and then a day will inevitably come along which is just too much – when the demands put upon us exceed that with which we are able to cope. Our best efforts to meet the overwhelming need drains us of every ounce of energy we posses. Sometimes we can be so overwhelmed that it can feel that our inability to deliver the impossible reflects negatively on us, that our failure to solve every problem suggests some moral failure on our part. But we need not feel like this. There is no shame in being asked for more than we have and only being able to give all that we’ve got. We are, after all, only human.

We’re not all #NHSsnowHeroes. Some of us didn’t have 4x4s with which to brave the roads, some of us didn’t walk 20 miles to work, and some of us didn’t work additional hours because we simply couldn’t. I am genuinely grateful for those who did but we must not berate ourselves for not doing what we could not. To make the mistake of thinking we can meet every need will only crush us more. We do not help ourselves by being that foolish.

We need to be more realistic, we need to be those ‘scrupulous optimists’. Of course the demands of all our jobs are often overwhelming and the recent flu epidemic and now this bad weather has made things harder still. When the calls for help from those who are sick just keep on coming, those in health care ought not be surprised that there are days when it is all too much. Sometimes that is simply the way that it is, the nature of the job – the nature, even, of existence. Whilst we might bemoan the actions of others, and let’s face it we’re all good at that, it is not always someone else’s fault that our day has been hard. Though their actions have not always helped, and not denying that we should press for change in how the NHS is run, not even the government is wholly responsible for the struggles the NHS is currently facing. We need to accept that sometimes, in the midst of a flu epidemic or in atrocious weather for example, the job of health care professionals will, as a consequence, be significantly harder. And whilst not encouraging a resigned fatalism, we need to accept that when it is, that harder time will have to be borne for a while, not only by those in the NHS but also by society as a whole. Complaining about it today won’t help anyone. On the contrary, what will help today is if we bear the problem together. Blaming others only serves to isolate us at the very time we need others alongside us.

Though it may cost us to do so, we need to support one another especially those who find the struggle hardest. That includes patents but also those with whom we work alongside. We must not demand that they are superhuman. If we aren’t very careful, exalting #NHSsnowheroes will become a new way of our playing an old game – that of playing God. Some of us aren’t always as resilient as we’d like to be, and when we aren’t we may be the ones who struggle the hardest and need help. I am fortunate to work in a practice where that support is found and I am grateful to all those I work with that that is the case. I am grateful that there are those who help me: other doctors, nurses, reception, admin and managerial staff – even patients, who for the most part appreciate the pressures the NHS is under – we’re all in it together. Sometimes I help others, sometimes others help me.

Medicine is a wonderful thing. It can ease many burdens – but not all. Like those who practice it, it has its limitations and will never bring about a world where sickness and death is no more. I am not suggesting that medicine should therefore stop trying to find new ways of alleviating suffering but none the less, it must maintain that healthy dose of pessimism that reflects the reality that not every need can be met, that nobody lives for ever. Doctors also need that healthy dose of pessimism. Sometimes we should go the extra mile but we mustn’t lose sight of our limitations, our inability to meet impossible demand and that even despite our best efforts, some of those who get sick will have bad outcomes..

Furthermore doctors need to be wise enough to know that sometimes the kindest thing that we can do is stop striving for a cure and not burden a patient more by constantly demanding that they get better. Sometimes, when there is no longer any earthly solution to sickness and disease, when medicine has reached its limit, we mustn’t be afraid to acknowledge our weakness and our inability to help as we would like. Even so, as we look on and watch our patients, even our friends and family, suffer and die, we will do well if we can still bear with them in their suffering, if we can share in their sadness and ‘weep with those who weep’.

So when the going gets tough, what about those who don’t feel tough enough to keep going? What about those who lack, for now at least, the necessary resilience? Do we demand they toughen up as we regale them of the superhuman efforts of the strong? No. Instead we pick them up and carry them just as far as we can because those who are overwhelmed by the avalanche of need are no less worth carrying than those who are sick.

I wasn’t born yesterday – but I may need to be borne tomorrow.
And when one day I am too heavy to bear – and that day will surely come – lay me down and, if you can, please bear with me a while longer. And I’ll try to do the same for you.
Because bearing things alone would be truly unbearable.


It’s conference season and, after the warm up acts of the political parties, we have now had the big one, the main event – the conference of the Royal College of General Practitioners. I know you’ve been excited – it’s always good to hear GPs bemoaning their lot and calling the government to account. But the problems are genuine and GP practices really are closing at an alarming rate with more and more GPs abandoning the profession as workload rises exponentially and recruitment continues to struggle to keep up with the number of doctors leaving.

Reflecting on the assertion, given some support at the conference by RCGP chair Dr Helen Stokes-Lampard, that the causes of ill health are largely social, Dr Phil Hammond has said: ‘For 90% of symptoms you’re better of with a dog than a doctor’. He points out that ‘Dogs are an antidote to loneliness and a lack of exercise. And they give encouraging licks, which generally GPs are reluctant to do’. He’s probably right but life as a GP does feel more challenging than a job that can be discharged with a pair of appealing eyes, a shiny coat and a tail that wags. The reason for this is, in part, that medicine continues to be asked questions to which, largely, it doesn’t have the answers. That’s why we need GPs and, especially, GPs with a special interest in being a generalist. We need super generalists every bit as much as we need super specialists. If GPs are ‘ideally positioned’ to do anything, then it is to navigate the uncertain waters of discerning the cause of a patient’s symptom and distinguishing the minority which are medically important and warrant hospital attention from the rest that are medically less worrying and can be safely managed, medically or otherwise, in primary care. GPs have long been considered to be the gate keepers to secondary care who, by assessing and managing risk, protect hospitals from unnecessary patient attendance even as they protect patients form unnecessary, and potentially harmful, hospital intervention. It is a key role within the NHS, one which, with all due respect to our canine friends, is beyond the ability of even the most diligent of hounds. Primary and secondary care compliment each other – both are vital and each need the other.

Though, like a tickle on the tummy, offering money for a state-backed indemnity scheme for general practice is welcome, something more has to happen if things are going to improve. Insisting on the continuation of such harmful activities as over regulation and the slavish pursuit of all that can be measured won’t solve the problems the profession faces. Neither will having yet another tick box to complete as has been suggested this last week with the proposal that we now ask every patient the nature of their sexuality. It’ll take more than a doggie choc to get me to do that! As, perhaps, in much of life, we would do well to listen to Pete Doherty singing ‘You’ll never fumigate the demons, no matter how much you smoke’.

So what needs to change? Much has been suggested previously but not least is a need to realise that doctors, like patients, are people, They are not robots, programmed to infallibly do the right thing. Like patients they need to be allowed to acknowledge their limitations and work within them. It is simply unrealistic to expect GPs to comprehend the intricacies of, for example, cardiological problems at the level of a cardiologist. Furthermore, an expert, judging, from a distance, that a particular referral isn’t warranted doesn’t mean that it was inappropriate from the point of view of the GP. Far less when the inappropriateness of that referral is the opinion of a medically untrained person following a protocol. Despite having less specialist expertise in a particular field, GPs have a good deal more understanding of the patient sat in front of them. Quite apart from the obvious negative impact on patient care, demanding GP’s function at levels higher than they feel competent, and dismissing their genuine concerns, will increase levels of stress within the workforce still more significantly and consequently accelerate the exodus from the profession. General Practice continues to deal with the overwhelming majority of medical concerns presented across the country each day – remarkably few are beyond the competency of GPs. This should be appreciated more highly and the fact accepted that a small proportion of those concerns, as deemed appropriate by the, on ground and in the firing line GP, will need to be passed on to those with the requisite additional knowledge and skill.

Equally doctors need to be given time to grow into their roles. All good things take time to mature – it’s not just fine wines that get better with a few years behind them. The government have pledged more GPs. This is good but, even if these doctors can be found and this promise can be kept, it will take a long time for it to make a real difference – longer even than the 10 years or so that it requires to train a GP since it takes more than just having the letters after your name to be a family doctor. As a young GP I was fortunate to work in a supportive practice that was nurturing rather than critical of what I did. Without question I sometimes referred what I need not have, investigated more than was strictly necessary and admitted patients who more experienced eyes may have managed at home. No doubt sometimes I still do. But this is, in part, how one learns. If I am any better now than I was then it will be because I have been allowed to mature over the subsequent twenty years in a practice whose more experienced doctors were wise enough and kind enough to consistently encourage and support me rather than question me on every decision I made and criticise me for every less than perfect action I took. We must not insist that less experienced doctors behave in the same way as those who have years of on the job learning behind them anymore than we should expect GPs to manage specific conditions at the level of those with specialist knowledge. I am fortunate to work with a bunch of young GPs who are, not that it’s a competition, far better doctors than me. And without a doubt, in 20 years time, if they are allowed to grow into their roles, they will be better doctors still. We all need that time to develop. My progress may not have been as great as I would have liked but demanding perfection, at any point in ones career, is both unrealistic and damaging.

But despite all this I am not planning on leaving General Practice anytime soon – and no, I’m not barking! I’ll stick with it a while longer because, quite simply, despite everything, being a GP is one of the best jobs in the world. Each week I have the very great pleasure of being consulted by patients who are people of whom I am genuinely fond and who I find it an absolute privilege to see. We often laugh together – and occasionally cry. Daily I share in the joy of patents who are pregnant or who are venturing out on the adventure of parenthood; I try to offer reassurance and help to those who are unwell and to those who, in innumerable ways, are struggling; and I share in the sadness of terminal illness and bereavement. And occasionally maybe I may make some small difference. It is an inherently rewarding way to spend ones working hours. Perhaps on occasions, patients feel they need to see me – but what is more certain is that my day is enriched for seeing them.

And its not just the patients who make each day worth getting out of bed for. What also makes the job so good, despite the difficulties, is the people I work with, who allow me to be the doctor I am rather than insist I am the doctor some faceless authority demands me to be. The flexible and supportive nature of the team in which I work is fundamental to what makes our practice, and the NHS as a whole, work so remarkably well. And I’m not just referring to my partners who notice when I’m running behind and help out by seeing a patient of two. In addition, there are nurses (both practice and district) who, on top of their already busy workload, are always happy to help with one more dressing and HCAs who don’t complain when I ask them to squeeze in an extra ECG; there are reception staff, manning the front line with good humour and still managing a smile when they bring round coffee and cleaners who stop for a chat at either end of the day; there are admin staff, who cope with my garbled dictations and smooth my way through the machinations of the NHS with good grace, and pharmacy staff who are ready with advice on prescribing issues and information on the availability of yet another difficult to source drug. And there is a manager who manages with the understanding that General Practice is a team effort that works for the benefit, not only of those who rely on the practice for medical help, but also for those who work within it, a manager who realises, as does everybody else who makes up the team, that the bottom line is not the bottom line, that people matter more than targets and financial reward.

Primary care needs to remain locally responsive to individuals – both its patients and staff. General Practice needs to remain small enough to see the big picture. Larger, regional primary care centres, obsessed with chasing targets, ticking boxes, and slavishly adhering to protocols, may appeal to those holding the purse strings but there will be a high price to pay for such economies of scale,

General Practice can sometimes feel like a battleground – like the NHS as a whole, it certainly has a fight on its hands. But it a fight that is overwhelming worth fighting.

Now who’ll take me for a walk?


I won’t keep you. I know you’re busy, crazy busy – possibly busier than you’ve ever been before. Certainly the NHS and its 1.7 million employees are. There were 24.8 million attendances at A&E departments last year and more than 312 million visits to general practices. Demand is increasing faster than the chronically underfunded NHS can cope with and waiting times for some services have increased way beyond what is remotely acceptable. With up to 40% of GP consultations now being related to mental health, the local wait for NHS counselling services is too long to be useful and it seems likely to lengthen as society fractures further. Attention needs to be given to the causes of both physical and emotional ill health and the extra funding needed to provide the necessary resources to attend to all these very real needs must be forthcoming if we, as a nation, want to be considered a caring society. But, rather than just charging the NHS to solve our problems and demanding our politicians provide the funds for it to do so, what else, if anything, can be done to ease the load?

As I say, we’re all busy – it’s not just the NHS – and none of us are happy about it. It’s hardly a surprising statement and neither is it a new problem. Back in 1660 Blaise Pascal wrote:

‘I have often said that the sole cause of man’s unhappiness is that he does not know how to stay quietly in his room’.

We are too busy to be happy. But interestingly Pascal asked the question as to why we are busy and came up with the answer that we keep ourselves busy to distract ourselves from the fact that we are ultimately going to die. He writes:

‘Despite [his] afflictions man wants to be happy…But how shall he go about it? The best thing would be to make himself immortal, but as he cannot do that, he has decided to stop thinking about it.’

Now what I find interesting is that the world of medicine is inordinately busy pursuing that same illusion of immortality – trying to deny what we do not want to think about, namely that we will all one day die. And it has got itself into all kinds of trouble.

Atul Gawande, in the first of his 2014 Reith Lectures, asked the question as to why Doctor’s fail. In it he spoke eloquently of how, as the body of medical knowledge increases, the ability to be aware of it all, or apply it all in every situation, becomes increasingly difficult. Furthermore, he explained that, because science cannot tell us everything, since each of us is unique, we cannot have omniscience.

The medical profession fails therefore, not only because of its underfunding, not only because of its ignorance and occasional ineptness but also because of its necessary fallibility. Medicine, you see, is not the answer to the problem of our mortality. Though this may be hard for us to face, one thing at least seems certain – because of it we will continue to suffer and die.

Society has bought into the lie that perhaps in years past we doctors have been guilty of encouraging – that we have godlike capabilities, that medicine can solve every problem. Hence the increasing demand that the NHS is all too evidently experiencing. And because that expectation has taken too firm a root in the minds of some patients, health care professionals can find themselves charged with being infallible and, as a result, increasingly find themselves being criticised for failing to be so. No wonder the recent reports of decreased satisfaction in GP services.

Putting ones ultimate faith in doctors is never wise because, despite our best efforts, suffering in life is, sadly, inevitable. And yet too often, our patients, and we doctors, busy ourselves trying to deny the fact. Denying the reality of death, too many have become intolerant of even the slightest suffering and we have become unable to accept our inability to relieve it. As a consequence of becoming too busy chasing absolute health, too many make it increasingly difficult for themselves to enjoy being mortal – and we make it harder four ourselves to enjoy being doctors.

Pursuing immortality, we have become dissatisfied with mortality.

Attempting to avoid death, we have forgotten what it to live.

And busy chasing a happiness defined by the absence of imperfection, we are rendered more unhappy than ever before.

So what is the answer to our busyness? Could it be that, rather than pretending we have the answers, we need to acknowledge our ‘necessary fallibility’ – rather than frantically attempting to deny the inevitable, we need to face up to the reality of suffering and death and become more realistic in our attempts to avoid it? Counterintuitive though it may seem, might we be happier if we accepted suffering, and even death, as part of life?

We live in a world which constantly massages the truth, portraying real life as more ideal than it is – take advertisements, the ‘beauty’ industry and our own Facebook profiles. Medicine must stop airbrushing reality and be honest enough with society to acknowledge what some of us know all too well – that suffering, though an unwelcome aspect of day to day existence is, none the less, one that cannot be avoided. If we stopped demanding that medicine correct every spot or blemish, remove every ache and pain and curtail every cough and sneeze, might we not be freed up to enjoy life more and, at the same time, free up NHS time and resources for the care of those with more pressing concerns?

The NHS still won’t be able to make all things well – we’ll have to put our faith elsewhere for that – but we will have helped an overburdened NHS cope with the demands placed upon it rather than having added still further to its load.

And we all might be a little less busy – and a little more happy.

[Updated 30th November 2019]

Pascal B. Pensées. 1660.
Gawande A. Why do doctors fail? BBC Reith Lecture – 25th November 2014

Increasing anxiety – a relative certainty.

This last year I have mainly been dealing with anxiety. Anxiety, with its lonely companion, it’s accomplished accomplice, depression, seems, in all its forms so pervasive these days that it’s easily the most common problem that presents to me on a day to day basis.

Firstly there are those patients who present with frank anxiety – by which I do not mean to suggest they have an irrational fear of Frank’s be that Sinatra, Zappa or D. Roosevelt. Rather I mean those patients that present with anxiety symptoms up front – panic attacks and the like. Then there are those patients who present with symptoms that they are anxious represent serious underlying disease. They are often hard to reassure, so twitched are they by the twitches they experience. And then there are the patients whose symptoms generate anxiety in we doctors who are left concerned that we may be missing something serious and fear what that might mean for the patient and, indeed, our own reputation that we cherish more highly than perhaps we ought. Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

I wonder how much of this is tied up with the current postmodern notion of relative truth. Many have remarked that 2016 was a particularly bad year and perhaps, with all the terrorist outrages, natural disasters and political upheaval the year bought, not to mention all those celebrity deaths, we all have good reason to be uneasy. But, over and above all these events, might it not be that the most concerning thing of all in 2016, was the fact that the Oxford English Dictionary made ‘post-truth’ its word of the year – a decision that reflects that public policy is being decided based on appeals to personal emotions rather than objective facts. Paul Weller and ‘The Jam’ sang, ‘The public gets what the public wants’ and it seems today the public is at least promised what it feels it wants, independently of what it needs, because it is politically expedient so to do. I am left wondering if all the anxiety we see, and feel, stems from the fact that, with the throwing out of the still clean, clear bathwater of objective truth, we have thrown out the baby of any sense of assurance.

If nothing is certain, how can our patients be anything but anxious about everything? How can they be reassured that their symptoms are not concerning when the opinion we hold can never be more than what we feel to be true? Our feeling, that their symptoms are not worrying, can never counter their feeling that they are, since their feelings are no more valid than ours. I was surprised once when my assurances, that a lesion on a patient’s scalp was a harmless seborrheic wart, were not accepted by the patient because her hairdresser had thought it was a skin cancer. But then, if truth is relative, an expert’s opinion (and I use the term lightly) has no more authority over that of a non specialist. Another patient once challenged a consultant cardiologist’s opinion that her ECG was normal as she felt her symptoms were consistent with what she had read of Wolf-Parkinson-White syndrome. The objectively normal ECG, and the expert opinion of the consultant on that ECG, was contrary to the patients feelings. And so a second opinion was requested and, when this was declined, the patient chose to write directly to the consultant expressing her belief that her concerns were being ignored.

This notion extends to the anxieties we experience as doctors. If truth is relative, how can we have any confidence in what we feel to be true, and, if the patient feels differently to us, how can we say that we are right and they are wrong? I am aware, of course, that there are, inevitably, times when a diagnosis is in doubt, when the truth is uncertain, but it sometimes seems we are no longer confident that we know anything for sure. In a society suspicious of intellectualism, the learned are themselves suspicious of their learning. Too concerned that our patients be happy with our opinion, our clinical diagnoses have to be malleable, tempered to acknowledge the validity of the patients’ opinion regardless of how lacking in objectivity that opinion might be. Is it only me who, knelt at a patients feet and examining their sylph like ankles has reluctantly murmured; ‘They are a little swollen I suppose’? Of course it is no wonder we sometimes behave like this since we have had it driven into us that we be patient centred when all along we really should have been urged to be truth centred. But it’s arrogant to claim to be right about anything these days – facts prove nothing. In a consumer society, the customer is always right. Is it any wonder then that, as medicine was opened up to market forces, the result would be that the patient is always right too?

And if feelings are what are important, then what others feel about me are every bit as much an indicator of who I am as what I feel about myself. After all, a satisfactory satisfaction survey is sacrosanct – I’m OK, if you’re OK with me. But if everybody’s feelings are different, how can I be OK, since how can I be OK with everyone? How can I make everybody feel positively toward me when they all have different criteria for what it is that would cause them to feel in such a way?

Anxiety is, I think, largely, a fear of unhappiness in the future which leads inevitably to us being unhappy in the here and now. That’s why anxiety and depression are such common bedfellows. With, to a great extent, the loss of religious belief, and with it the hope of a better time and place to come, society no longer is prepared to accept that we must sometimes wait for happiness. In an age when everything is instant, waiting is not an option – we must be happy now. But in a materialistic, consumerist society which daily advertises to us our discontentment by displaying what it insists we need, but do not have, to be happy, it is no surprise that we are anxious that life is passing us by, that we are missing out on being fulfilled today. And of course it’s not just material goods that our society consumes. We consume health – it is the ‘must have’ we assume and insist upon. No suffering, however small, ought to be tolerated. We must have health and we must have it now – not next month, nor next week or tomorrow – we must have that appointment now be it Tuesday morning or Sunday afternoon. And so the National Health Service has become the National Health Slave, even as the NHS itself, colluding with the society that it can meet its greatest need if it would just do as it was told, slavishly insists patients behave in ways current medical opinion deems appropriate. Don’t smoke, don’t drink, don’t fail to exercise, don’t eat just four of your five a day, and whatever you do, don’t forget your Vitamin D. Don’t, don’t, don’t, don’t, don’t – and you might just live forever.

And so it seems to me that what this all ultimately boils down to the existential question of death. It is the one thing certain about life but we, increasingly perhaps, try to pretend that this too is uncertain as we pursue, and push, eternal life through medicine, lifestyle adaptations and sentimental and fanciful notions of how those who undeniably have died, somehow live on. In a world where nothing is certain, the certainty of death is above all to be doubted.

But we need to face facts, and so must our patients. Despite how much money is pumped into the NHS to fund all that medicine increasingly can do, despite how long GP surgeries are open or how short waiting times in A&E departments become, and despite how much we heed medical advice and adjust our lifestyles accordingly, we and our patients will all one day die. Regardless of what we may or may not believe about life after death, if we are to find any happiness in this life, we need to stop pretending otherwise. We must stop believing that our interventions could ever prevent the inevitable. Rather than doing more for longer, if we want a population that is healthy in the fullest sense of the word, we need to do less. Yes the NHS must be funded adequately but it must be funded adequately to do what a long hard look determines is objectively thought to be important rather than subjectively felt to be urgent. We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship and we must stop suggesting to our patients that life is all about cholesterol, BP and vitamin D levels, that they are somehow the route to eternal life. Such a view is all too often an expensive and time consuming distraction that compels us to look down at the temporary and trivial and leaves us neglecting to look up at the significant and satisfying. We need to learn to ignore the mundane and consider instead the transcendent. Only then will we, instead of enduring an existence weighed down with anxiety and depression, enjoy a life buoyed by contentment and joy.


It’s been another bad week at the end of what has been a bad year, a year that some are suggesting has been the worst of all years. Events in Berlin should shock us but I wonder if they do to the extent that they really ought. With all the bad news this year, the terrorist attacks in Nice and Brussels, the conflict in Syria and the appalling destruction in Aleppo, earthquakes in Ecuador, Italy, and Taiwan, plane crashes, hurricanes and flooding not to mention the deaths of so many celebrities, might we be becoming too familiar with tragedy, numbed to the horror, unable to process the awfulness? Do we distance ourselves from the news, holding on to the lie that it couldn’t happen to us, imagining that it doesn’t really having anything to do with our lives? In the week before Christmas, do we simply pay lip service to how dreadful it all is before continuing on our merry way – unchanged, unmoved, unaffected. After all – what’s it got to do with Christmas?

And that’s the problem with Christmas, or rather the problem with the Christmas that we have created. As with life, we struggle to conceive that the realities of hate, pain and suffering sit alongside those of love, joy and peace – that these things, to a greater or lesser extent, are present in all our lives – present indeed, even in ourselves. We have marginalised the horror of the Christmas story, preferring the sanitised version that fits better with our over optimistic outlook on life, our over optimistic view of who we are. ‘It’s all good’ we try to tell ourselves but the truth is rather different – we exist in a world of good and evil.

Life can be filled with overwhelming joy.
And yet, life can be hard, very hard. For some, impossibly hard.
And for many the sadness is just too much.

The Christmas story reflects this – the joy of the birth of Jesus and the hope that the arrival of a saviour brought with it, is mixed with the abject poverty into which he was born, the rejection experienced by his parents and the murder of the innocents at the hands of Herod. And, of course, what began in ‘O little town of Bethlehem’ led to ‘…a green hill far away, outside a city wall’ – ‘the little Lord Jesus asleep in the hay’ grew up and suffered the horror of crucifixion. The Roman orator Cicero described crucifixion 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.’ That is the world we live in, joy and sadness, pleasure and pain – we cannot have one without the other. Indeed the two are mutually dependent on each other – the existence of suffering is why we need a redeemer and redemption is secured through the suffering that redeemer endured – suffering that we all still share in.

Sorrowful yet always rejoicing. These were words of the apostle of Paul in his second letter to the church at Corinth and we would would do well to ponder them, to reflect on the fact that we cannot expect to live trouble free lives. Hardships and calamities will befall us and they will bring with them great sorrow. Yet despite those hardships, despite the awful suffering, there is, in Christ, still hope and a cause for rejoicing. Leonard Cohen says it well:

There’s a lover in the story but the story’s still the same
There’s a lullaby for suffering and a paradox to blame
But it’s written in the scriptures, and it’s not some idle claim

We live in the tension of the already and the not yet. Because of Jesus life death and resurrection and the redemption that he as secured, the future is assured – it is so certain that we can count it as already here. We we can live rejoicing in the confidence of its inevitability whilst at the same time, honestly acknowledging that it is ‘not yet’. We live in the very real pain of today, the heart breaking awfulness of now. Even as we rejoice in the joy of Christmas, we dare not tell ourselves, or indeed our children, differently. To do so is to delude ourselves, and them, and ensure disillusionment and despair when eventually the truth can be denied no longer.


Up and down the country on each December 1st the first doors are opened on a million ‘Sleeps till Santa’ calendars. The choice this year is huge. Believe it or not, you could be opening drawers or pulling back cardboard squares to reveal nail varnish, Play-doh, or components to build an FM radio. My favourite though has to be the ‘Drinks by the Dram’ Calendar available on Amazon for a shilling short of £10,000 – who wouldn’t want to start the day with a 60 year old Glenfarclas to accompany their coco pops? But don’t worry if you’re a traditionalist, there are still plenty of calendars out there that retain the true meaning of the holiday season and counting down the days with chocolate impressions of characters from Star Wars remains an option. There’s no doubt about it, ‘It’s beginning to look a lot like Winterval’.

The word Advent is derived from the Latin ‘adventis’ which is itself a translation of the Greek word ‘parousia’ which was often used to speak of the second coming of Christ. Traditionally, therefore, the advent season is that time of year when the church not only looks forward to remembering Jesus’ birth at Christmas but also anticipates his return at the end of history. In many households, as Christmas approaches, the excitement is, no doubt, beginning to build but, when all is said and done, for many Christmas is a huge anticlimax, a deeply unsatisfying time. I wonder why that might be.

For some, Christmas is just too busy, there is simply too much that has to be done. Perhaps we long for the Christmases of our childhood, fondly remembered as magical times when we believed in someone who was better and kinder than ourselves, who insisted on bestowing upon us one kindness after another without us doing anything whatsoever to deserve it. Now though, as adults, we have lost sight of any transcendence that Christmas once held and, rather than resting in the generosity of one greater than ourselves, find ourselves burdened with a list of a thousand things we must do if we are to be deemed acceptable celebrants of what a consumerist society has made of Christmas. Wouldn’t it be lovely if we could experience Christmas, indeed experience life as a whole, as we did when we were little, with a childlike faith that someone other than ourselves would be kind to us in ways we don’t come close to deserving and would see to it that everything worked out just fine in the end. If that sounds appealing to you, if that sounds like heaven, then be encouraged by the words of one wiser than me who once said ‘Truly, I say to you, unless you turn and become like children, you will never enter the kingdom of heaven’ [Matthew 18:3]. You can’t work your way in, but you are offered a free pass – because the one who said these words has paid the entry fee for us, undeserving though we are, and seen to it that everything will indeed work out just fine in the end. We enter the kingdom of heaven by grace, not works.

For others, of course, the forced jollity is unwelcome – when life is characterised by sorrow and despair few of us are up for a party, regardless of how many amusing Christmas jumpers are on display. Some have said that we should no longer wish others a ‘Merry Christmas’ as to do so risks being insensitive to those who are experiencing difficult times. But to suggest as much is to misunderstand Christmas, to consider it nothing more than an excuse for overindulgence as we try to deny the vicissitudes of life. One of my favourite carols is ‘God rest ye merry, gentleman’ – note the position of the comma. For many years I misunderstood this carol imagining that the words were expressing the hope that God would give a bunch of already merry gentlemen a well earned rest! This is not the point at all, as the position of the comma makes clear. What is being hoped for is that God would cause these souls, of undisclosed happiness, to be rendered merry. And the reason that they should be left in such a state of merriment, the reason that, as the carol goes on, nothing should cause them to dismay, is that ‘Jesus Christ our Saviour was born on Christmas Day’. And why was he born? ‘To save us all from Satan’s power when we had gone astray’. This is news worth hearing, very good news in fact, tidings, no less, of comfort and joy, even for those whose lives may have taken the most precipitous of down turns.

Once I asked a group of youngsters which of the following had the most to do with Christmas: a Christmas tree, a mince pie or a fire engine. The answer I was looking for was the fire engine, my point being that Christmas was all about rescue or at least the arrival of a rescuer – the birth of a saviour. Forget this and Christmas loses all of its significance. But even if we are minded to remember what Christmas is really all about, even if we piously pronounce ‘Jesus is the reason for the season’, might we still be missing the point? Could it be that even religious types sometimes get too excited about Christmas?

Imagine this. It’s night time and you wake up to discover your house is on fire. You’re trapped upstairs in your bedroom and the flames are getting higher and higher. The heat is intense and the smoke is getting thicker and thicker. All hope seems lost. The morning was to have brought with it a shot of Pappy Van Winkle’s 23 Year Old Family Reserve but now, at best, it is going to be a little on the warm side to appreciate at its finest. And then, in the distance, you hear the sound of sirens telling you that help is on its way. You run to the window and in the distance you can see the flash of blue light that confirms that the fire brigade is close by. What a relief. Moments later the fire engine comes round the corner and stops outside your house and the neighbours all gather around the crew celebrating their arrival. Everyone is happy. But then you realise, to your horror, that the firemen aren’t doing anything to rescue you – and none of your neighbours seem concerned by the fact. They’re just happy that the rescuers have arrived. What a tragedy that would be. Christmas is about the birth of Jesus but his arrival is only the start – he came with a job description, work to do. The angel had it right – you remember what he told the shepherds? [Luke 2:10-11].

‘Fear not, for behold, I bring you good news of great joy that will be for all the people. For unto you is born this day in the city of David a saviour, who is Christ the Lord’

The Angel brings good news ‘for all the people’ which gives the lie to the assertion so often heard at this time of the year that ‘Christmas is for the children’. And the good news of great joy is that a saviour has been born. Jesus, so called as he would ‘save his people from their sins’ [Matthew 1:21], came as a saviour but, remarkable though the fact that God should become a man is, in and of itself, Jesus’ birth achieved nothing. Yes he came as a saviour but, more importantly still, Jesus went on to secure the salvation he came to achieve. By living a perfect life, a life which God graciously credits us as having lived and thereby enabling him to count us righteous, and then dying in our place, bearing the punishment we deserve for our sinfulness, Jesus saves us from the wrath of God by satisfying God’s need for justice. At Christmas, forgetting the rescue that Jesus was sent by God to secure for us is as tragic, and foolish, as our delighting at the arrival of the fire brigade at our burning home and having no interest in them putting out the fire!

But there’s more. It is not the arrival of the rescuer at Christmas that is the main thing. Nor is it our rescue itself that is the main thing. The main thing is what we are rescued for. And the thing that we are rescued for, mans chief end, is to glorify God and enjoy him for ever.

This life cannot satisfy – not ultimately. Sometimes it might seem to for a while but, sooner or later, its inability to do so is all too obvious – when life is hard and bad things happen to us, as they surely will to a greater or lesser extent, there is no pretending otherwise. Not even the very best of times can ultimately satisfy as even the most pleasant of days, when everything goes well for us, even those days come to an end. A year or three ago, Kaye and I had a great day out in London – we went on the London Eye and took a boat trip down the Thames, we visited the Houses of Parliament and took tea on the terrace there. And lastly, we went to the theatre and saw ‘The Lion King’ – you know the one, ‘Hakuna Matata’ and all that (It means, as you are probably aware ‘No worries’ – great little song but a facile philosophy for this life if it’s not grounded in anything that can relieve us of our anxieties). It was a genuinely lovely day but eventually, of course, it ended. In twenty four days I hope we will all have a really lovely day celebrating Christmas with those we love most – but it will end. All good things do, inevitably so – it’s the nature of our human condition. Memento mori.

C.S. Lewis, author of the Chronicles of Narnia, wrote :

‘If I find in myself a desire which no earthly experience in this world can satisfy, the most probable explanation is that I was made for another world’.

But where might that other world be – where might our longing for infinite joy be eternally satisfied. David gives us the answer in Psalm 16 where he writes

‘[O God,] You make known to me the path of life, in your presence there is fullness of joy; at your right hand there are pleasures forevermore.’

You want infinite joy? It’s found in the presence of God
You want everlasting pleasure? It’s found at his right hand.

The rescue that was heralded by the prophets of the Old Testament, that began with the arrival of Jesus at the first Christmas and was secured by the death and resurrection of Jesus at the first Easter prior to his ascension into heaven, will find its fulfilment when Jesus comes back. Advent is that season of the year when we look forward to the coming of Jesus. It’s good to remember Jesus’ first coming at Christmas but it’s better still to remember he’s coming back. If we’re looking for infinite and everlasting joy, let’s not put our hope in a few fun-filled days at the end of December each year, pleasant though those days may be. Let’s not put our hope in our perhaps seventy or eighty years of life for those years are soon gone and we will ultimately ‘bring our years to an end with a sigh’ [Psalm 90]. Instead let’s hope in God and the new heavens and new earth that he will establish when Jesus returns. It is going to happen! It’s not wrong to long for infinite and everlasting joy, indeed we only truly honour God when we find our joy in him. Delighting in God certainly honours him more than our dutiful religious observance. So let’s rejoice in God – we have every reason to do so as God has promised that he will dwell with us and we will be his people.

Another name for Jesus often heard at Christmas is Emmanuel which means ‘God with us’. Jesus came at the first Christmas as God in human form ‘The word became flesh and dwelt among us’ [John 1:14]. And he has promised that he’s coming back again one day. And when he does he will wipe away every tear from our eyes, death will be no more, and there will be no mourning or crying or pain. Only then will ‘Hakuna Matata’ be a philosophy that will hold true. Today we can only know this by faith – faith in the God who has told us that this is how it will be and who has done everything necessary to see that it works out just fine in the end. Now we see by faith, but when Jesus comes back, then we will see it in all its glorious reality!

This certain hope for the future has the power to change our present, to lift our hearts today, no matter how downcast they might be, as we consider the tomorrow that awaits us. As the psalmist wrote:

“Why are you cast down, O my soul, and why are you in turmoil within me? Hope in God; for I shall again praise him, my salvation and my God. My soul is cast down within me; therefore I remember you” [Psalm 42:5-6]

Merry Christmas.

Reflections on the death of Leonard Cohen

I have a confession to make. I like the music of Leonard Cohen and was saddened to hear the announcement of his death at the age of 82 just three weeks after the release of what until recently was his last album. 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.’

Born and raised in a Jewish family, Leonard Cohen evidently explored religious ideas throughout his life even spending several years at a Buddhist retreat in California where he eventually became a Buddhist monk in 1996. Many of his songs convey religious ideas and his own struggle to understand the nature of existence and though some of what he wrote, to my mind at least, falls very wide of the mark, sometimes his lyrics, often rich in Christian imagery, get things absolutely right.

One of my favourite songs is one called ‘Amen’ which includes the line: ‘Tell me again when the filth of butcher is washed by the blood of the lamb’. This powerfully brings home to me the idea of how the sacrifice of Christ’s death by crucifixion is enough to secure redemption even for the very people who nailed him to the cross. Elsewhere he sings: ‘There is no God in heaven, and there is no hell below, so says the great professor of all there is to know. But I’ve had the invitation, that a sinner can’t refuse, and it’s almost like salvation, it’s almost like the blues.’

I was interested to read in the coverage of his death, an answer Cohen gave some years previously in response to a question regarding the fact that much of his music is melancholic in tone. 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 dramas in centre stage and inevitably life moves us out of centre stage, defeats the hero, overturns the plot and the strategy and we’re left on the side-lines wondering why we no longer have a part – or want a part – in the whole…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 as I think that it gets to a truth that is rarely expressed in these days of perpetual self-promotion. It confronts us with the view that making ourselves the hero of our life is sure to end in defeat, and that to make life all about us, is foolishness.

This is something that those of us who are Christians have known, or at least ought to have known, for a long time. And yet it is a truth that I all too often forget. Are we not all, perhaps, tempted to make our triumphs, or even our disasters, front page news imagining that what happens to us is of huge importance rather than realising that we are but minor characters in His story, the story in which he, Christ, is the hero. As John the Baptist said: ‘He must increase, but I must decrease’ [John 3:30].

There is in all of us, admittedly stronger in some than others, a desire to be important, to be newsworthy. The truth, though, is that few of us will ever make the headlines. Though occasionally someone of the stature of a William Wilberforce may live a life of historical significance, most of us will live ordinary lives each with its everyday ups and downs. This is, I believe, to be expected. A constant searching for the so called ‘wonderful plan’ God has for our lives can be, if we are not very careful, little more than a seeking to make a name for ourselves and risks leaving us thinking that when our lives are merely ‘ordinary’ that somehow we have missed out on what God had planned for us.

As Mike Horton writes:

‘Facing another day, with ordinary callings to ordinary people all around us is much more difficult than chasing my own dreams that I have envisioned for the grand story of my life’.

The truth is that God has told us what his ‘wonderful plan’ for each of our lives is and it is this – that we be transformed into the likeness of his son Jesus Christ ‘who, though he was in the form of God, did not count equality with God a thing to be grasped, but emptied himself, by taking the form of a servant, being born in the likeness of men. And being found in human form, he humbled himself by becoming obedient to the point of death, even death on a cross.’ [Philippians 2:6-8].

This is quite a calling and one that will see us having to give up being ‘the hero in our own drama’ that will surely end in our defeat. It will, of course, be a struggle, a struggle in which we will all too often fail. But before we get too introspective and constantly bewail our inadequacies, let’s remember that even our inadequacies fade into insignificance when we recall that the story of our lives has a hero who will never be defeated. Even our sinfulness, great though that sinfulness is, is far eclipsed by the greatness of the one who really is newsworthy. It is He, not us, who guarantees our salvation since we are promised that ‘he who began a good work in [us] will bring it to completion at the day of Jesus Christ.’

The lyrics of his final album clearly reflect Leonard Cohen’s awareness that he was approaching death. ‘Magnified, sanctified, be thy holy name. Vilified, crucified, in the human frame’ he sings and then adds ‘Hineni (a Hebrew word meaning ‘Here I am’) I’m ready my Lord’. The album also contains a song called ‘Treaty’ and it is a reprise of this track with which the album ends. Cohen’s last recorded words were therefore those that the song ends with:

‘I wish there was a treaty between your love and mine’.

These are heart achingly sad final words. I said I’d liked to have met Leonard Cohen, I said I’d like to have heard him sing live, but most of all I’d loved to have been able to tell him that there is a treaty, a covenant between God and his people, not signed by us, but secured by the blood of Christ.

Jesus, at the institution of the Lord’s supper, and referring to his imminent death on the cross said ‘this is my blood of the covenant, which is poured out for many for the forgiveness of sins’ [Matthew 26:28]. I really hope that Leonard Cohen understood and rejoiced in that when he died, I really hope he was one of the many. I really hope he was ready – if so I may yet have the pleasure of meeting him one day.

ADDENDUM – added November 7th 2020

Leonard Cohen died four years ago today. I wrote then on some of the words he had written during the course of his life and, in particular, those contained in what I imagined would be his final album, released as it was a few weeks before his death.

But last November a posthumous collection of new songs was released, one of which is called ‘The Goal’. It opens with words which seem particularly relevant today.

‘I can’t leave the house’.

But in penning that line, rather than foreseeing our heading into another lockdown, Cohen, was referring to his own failing health. The song continues to reflect on his frailty and failures and includes the lines

‘I sit in my chair

I look at the street

The neighbor returns

My smile of defeat.’

Some may think these lyrics as depressingly typical of Leonard Cohen but the song ends, perhaps, more optimistically. Echoing words from the final track on the album in which he urges us to listen, not to himself but to ‘the mind of God’, he leaves us with this final thought

‘No one to follow

And nothing to teach

Except that the goal

Falls short of the reach.’

What did he mean by that enigmatic last couplet. We must all of course decide for ourselves but I wonder if he is suggesting that too often we strive for something impossible and miss what we actually have, something we have been given which is more precious than we give ourselves time to realise.

This lockdown, despite our feelings of powerlessness, I hope we all may have the opportunity to uncover that ‘pearl of great price’. [Matthew 13:45-46]

An Inappropriate Blog? – I Hope You Like It

It can be difficult to decide whether to write a blog. Most blogs aren’t appropriate and can have adverse effects. Too many blogs can mean the benefits of genuinely necessary and helpful blogs are lessened. But, knowing all that, I’ve decided to blog anyway – just in case. After all you’ve come to the blog page, you presumably expect a blog, and you might not be happy if one isn’t offered – I don’t want to disappoint you.

So here goes. This week I’ve received some good news! I’ve been ‘liked’ by the GMC! 🙂 Well I say liked, I mean of course ‘revalidated’ but it comes to the same thing. I posted a few comments of dubious value on an appraisal website and, lo and behold, I’ve been 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 experience 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 approval 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. It is a requirement that we be approved of by various groups – 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. One wonders if scientific explanation of the facts will ever be effective in a society that increasingly has dismissed scientific fact in favour of what we feel is right. Aren’t we all a little like Stewart Lee’s taxi driver who dismisses what he doesn’t want to believe with, ‘Well you can prove anything with facts!’? Leaving aside that particular question though, one thing is certain – it is impossible to satisfy the competing desire of patients who want antibiotics and the ‘powers that be’ who want us to reduce their being prescribed.

Similarly we are being asked to avoid unnecessary admissions to hospital whilst being increasingly criticised for delays in diagnosis and referral. Some have called for a doubling of our referrals to cancer services and starting primary prevention for heart disease at ever lower levels of risk, and yet our referral rates and prescribing practices are under ever more scrutiny.

Who are we going to choose to please?

I wonder if we doctors are particularly vulnerable to the need to bring liked. How many of us were the good boys and girls at school, driven by the desire to please our teachers, who didn’t like to disappoint the careers advisor who suggested we tried our hand at medicine, and jumped at the chance of entering a profession which made our parents proud. Not that there’s anything wrong with any of this – it’s just that we may not be the best people to say an appropriate ‘No’ to our patients and risk disappointing them. After all didn’t we go into medicine, first and foremost to help patients – to please them, and not our bureaucratic taskmasters?

The truth is that one can’t please everybody all 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. We may not be proud of it, but haven’t we all issued an antibiotic or renewed a sick note, not entirely appropriately, as we simply did not have the time or energy to do otherwise and out of a desire to please the patient – after all, the customer is always right, aren’t they, the doctor-patient relationship is at least partly built on the doctor being seen as helpful rather than obstructive isn’t it, and we need a positive patient satisfaction rating and some thank you letters to show our appraiser, don’t we?

But none the less, 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 do, to the best of our ability, what is right. And we are going to have 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 last month 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. Our patients, our politicians, and we ourselves are going to have to accept this – whether they, or we, ‘like’ it or not.

Well that’s the blog written – I’ll leave you to decide if it was appropriate or not.
But I hope you ‘like’ it!