11 GOOD INTENTIONS
In its fervour to put right imperfections in the world, society has ensnared its members in a web of regulations which create new problems and diminish life.
Throughout this book, I have used my experience of general practice as an analogy for life in a technological world. I have tried to show how personal relationships between individual people provide us with the ‘why’ of life whereas technology can only ever provide us with the ‘how’. And I have given, I hope, some explanations for our common experience that we can cope with the complexity of modern life far better than either instinct or formal logic would lead us to expect. It remains to summarise the symptoms of our ailing technological society. Then I can make a diagnosis, and finally write my prescription.
I have puzzled over how to encapsulate the problem in a useful way. Most people will acknowledge that the great bell of Progress which rang throughout the post-war years has developed a cracked sound. I could fill chapters with examples which nobody would have time or inclination to read. So, once again, I think it will be best to give just a little of the flavour. Something that happened last week is fresh in my memory…
I’m on a call-out to a new block of sheltered flats. In spite of the sales office flags the place has a slightly desolate air as quite a few of the units are still unsold. This is due to the slump in the housing market, not to a shortage of elderly people. Plenty of spaces for cars, anyway, and I draw up right outside the front door. I find number 25 on the bank of call buttons, press once and peer expectantly at the little grill, watching for a voice. Sure enough, before long the grill crackles and says, ‘Hello’.
‘It’s Dr Willis…’
‘Oh. OK, Doctor. I’ll release the door for you.’
I turn to look at the door catch and listen for the click. Nothing happens. I try the door. Firm as a rock. I wait. I sigh. I press the bell again.
A head pops out of a second floor window fifty yards behind me. ‘Hasn’t it worked, Doctor?’
‘No’, I shout.
‘OK, I’ll come down.’
I wait again. Looking idly at the bank of buttons, neatly machined out of an metal plate. As it has just the right number of buttons it must have been designed and made specially. Then I notice that one of the buttons is different. Instead of having a room number, it has a letter ‘T’ on it. I have the amusing idea that it might be a ‘Test’ button which would bypass all the security arrangements and open the door straight away. My finger is drawn towards it mischievously. Then I decide that such a thing would be ridiculous and I’d be much more likely to trigger some sort of embarrassing security alert. Better wait.
Through the glass front door I watch the lights on the lift control panel across the hall until they tell me that my patient has successfully negotiated the second floor corridor and is on his way down. The call was for a giddy turn, so this is useful diagnostic information. The lights change as they follow the slow descent of the lift and at last the doors open. I watch with relief as he steadily crosses the hall towards me, smiling in his familiar, apologetic way. Most of the nastier explanations of the giddiness melt away. This is going to be a pleasant, mainly social call. Very different from six months before when he had been waiting for me at the entrance, anxious to hurry me up to where his wife lay on her bed, desperately ill after a sudden stroke and never to regain consciousness.
‘I’m sorry you had to come down but it didn’t seem to work at all.’
We look resentfully at the mechanism and I mention my discovery, ‘There’s a button here marked ‘T’. It couldn’t mean ‘Test’, could it?’.
‘Oh, no. I think that’s the one for Tradesmen.’
‘I don’t believe it! Let’s try.’ I pop outside again, close the door and press the ‘T’. The latch clicks back instantly and I walk back in. Silly of me not to have tried… On the way up to the flat we agree that it is a good thing you can trust tradesmen.
When I have checked him over I reassure him about the giddy turn. He seems fine. ‘I didn’t want to call you myself, but the warden said she had to. It’s in the rules, apparently.’
I look up from writing in the notes, ‘Sorry, I don’t understand. What do you mean, she had to?’
‘She says, any call she gets she has to fill in a form and say she has called the doctor.’
‘But that’s crazy. What does she do with the form? Who reads it? How are they to know what was the right thing to do? They are just people, like you and me. Why can’t they just let her use her common sense?’
‘I know, Doctor, I know. It’s completely crackers.’
‘But what are we going to do about it? The world is going completely mad.’
‘But there’s nothing you can do.’ He laughs, ‘It’s progress, isn’t it.’
My wife has been a teacher as long as I have been a doctor. So, what with the friends and patients who are teachers, my own experience at various levels of medical education, and my experience as a college governor, I do know something about education. For example, I know that teachers are just as frustrated and demoralised as doctors are by progress.
Apparently, one of the chores in the life of a teacher is constructing tables of so-called rank-orders. What you do is to apply a formula to all the marks you have available for each pupil and you end up with an overall figure which enables you to put them into an order. Now, the interesting thing my wife has noticed is that although you know as the teacher that the individual marks you use to arrive at the result are all approximations, once you have given each pupil their rank it is almost impossible not to think of them in that order from then on. The figure, however arbitrary, always takes precedence over the feeling, even in the mind that originated both. If Jennifer came one place ahead of Jean, you cannot stop yourself thinking she is ‘better’ than Jean.
Now whole schools are to be given rank orders and the means by which they are derived are even more arbitrary. But here again, the figure is the thing that counts, and comes to take precedence over the subtle and balanced view of traditional common sense. And here again, it is next to impossible to articulate the passionate conviction of experienced teachers that the new measurements are naive and damaging. Their pleas that rigid job-descriptions and contracts and assessments and audits and mission statements are all two edged weapons which can be profoundly detrimental to the professional values and motivation that have served mankind throughout history go largely unheard. It is not just in the modern BBC that respected seniors are dismissed contemptuously as being ‘tainted by experience’, I know that teachers of exactly the kind that you and I would wish to have educating our children feel that their experience is held in contempt by the new system. I know because they tell me so in surgery when they ask me to support their requests for early retirement.
I couldn’t help laughing as I walked into our beautiful new GP ward recently and found the sister and two staff nurses buried in paperwork which completely covered the surfaces of their smart new nursing station. ‘A picture of modern nursing’, I said.
They looked up genuinely surprised. ‘Is that the impression it gives?’
‘Yes, it is!’
It takes 15 A4 sheets (prettily colour-coded) to admit a patient to our ward these days and so far from being seen as a problem by the managers, this system has actually won a prize. People really do believe that this sort of thing is progress.
Within a week of a widely publicised baby snatch from a maternity unit in the Midlands (and before the baby had been restored to an anxious nation) all these nurses, some of whom we have worked with for twenty years, sprouted ID badges complete with photographs, reminding one of operatives in a nuclear arsenal. This of course was a knee-jerk reaction by the administrators — any would-be baby-snatcher would have a hard time of it on our ward, or indeed in any hospital within fifteen miles, because there aren’t any babies. Any grannies that they snatched would probably enjoy the outing. Meanwhile the message those dreadful badges give about the kind of organisation the ward has become, and the state of the society it exists in, is being received, loud and clear, by every visitor every day of the week.
I remember my astonishment when the midwife who works with our practice was sent away on a two-week course in stitching, leaving all her devoted patients in the hands of a series of stand-ins. Stitching is strictly part of the doctor’s job but in the old, living world she had been doing it as well if not better than any of us for, we worked out, well over ten years. In the new rigid world she was suddenly told that she couldn’t stitch because she hadn’t been on the necessary course and she hadn’t got the right certificate. So, unbelievably, she was taken off duties for two weeks so that she could be trained ‘properly’. Although it was obvious to everybody that the rules were crazy, nobody had the authority to use their common sense and overrule them.
We seem to be approaching the point at which nobody can do anything unless they have been trained and assessed in it. But although having been trained in something appears to be a proof that you can do it well, common sense tells us that there is much more to it than that. Ordinary people can very easily conceive of the possibility that a training course might actually make somebody less good at something. Being a sympathetic listener is perhaps a clearer example than stitching. But people running courses on sympathetic listening, or on stitching, are not acting as ordinary people, they are acting as experts. What’s more they have a vested interest in promoting the cult of training. Training totally ignores the most vital component of performance, motivation. Training is all about ‘How’? Never about ‘Why’?
It was a bitter and certainly unintentional irony that the new system which has so massively increased the paperwork in modern nursing, imported from America even as it was wisely being abandoned there, was called The Nursing Process. As a result of this innovation, nurses have joined the ranks of all those other people in the modern world who spend huge chunks of their time filling in standard procedure sheets. In theory it sounds a good idea to structure and define the job and record how it is done. It seems that it must result in a better service. It will enable managers to count the items of service and prove how much has been done. But you only have to talk to patients to find out the result, they say those poor nurses are too busy to talk to them. It’s common sense again. Process is pure how. Nature cries out that nursing is predominantly why.
General practitioners are a bunch of individualists, perhaps the last professional generalists, impossible to deal with as a group but useful to have around when you need them. It cannot be overemphasised how profoundly the growth of central control and management technology threatens their traditional role. For a traditional role it is — there is an ecological niche for something of the kind in virtually all societies and at every point in history. But now the clash of cultures appears to be irreconcilable.
The technological society has problems with any form of individualism, but in a field as serious as medicine it is obviously completely intolerable. Individualists working within the bright new machine would prove that it wasn’t perfect, because they clearly couldn’t all be right at once. Dangerously free agents, GPs have operated out of control for too long. They need a good dose of ‘progress’ to bring them into line. They won’t like it, of course, but it will do them good… As Jacques Ellul predicted half a century ago in The Technological Society, ‘Mankind is to be smoothed out, like a pair of trousers under a steam iron’.
There is now a crisis of morale in the medical profession which mirrors that in other professions, and although I could see it coming, it has largely materialized since 1984 when I began to work on the project which has become this book. At that time, when medicine itself was the most popular career for bright school-leavers, general practice was the number one career choice for British doctors. We really were getting the cream of the nation’s youth.
Something terrible has happened since then. Nobody wants to go into general practice any more and all the established doctors can’t wait to get out. Everybody says the same thing — there is too much paperwork, we have lost our independence, and the pressures get more and more unbearable. We seem to have been taken over by the same alien culture that we have seen spreading throughout the rest of modern society.
Part of the problem is that we are entering a new phase of medicine which is inherently less satisfying for doctors, in which illnesses really are much less common and are caught at a stage when they are in fact much less troublesome.
Its a bit like the worry I used to have as a young idealist that if we solved all the problems of the world there would be nothing left to live for. I soon realized that solving all the problems of the world was not an immediate prospect, but doctors do get most of their satisfaction and motivation in life from finding illnesses and making people better and it is true that the more successful they are at the preventative side of their work and the more they find illnesses before the patients feel they have got anything wrong with them, the less they get this vital buzz.
So, contrary to what might have been expected, medical progress has not resulted in masses of grateful patients thanking doctors for the blessing of good health. On the contrary, not only do patients tend to feel that they have a right to be well, and that if something is wrong with them it is somebody’s fault, but they also tend to take treatments somewhat resentfully because they haven’t got any symptoms yet. As Osler said, ‘It is hard to make someone who feels well, feel better.’
Instead they become irrationally obsessed with fashionable media scares and are intolerant of any side effects or dangers of their treatment. Persuading patients to take their medicine is now a very significant problem indeed. Hardly a week goes by without someone bringing in a newspaper scare-story or a warning sheet issued by a litigation-wary pharmacist and sheepishly saying that they’ve stopped taking their treatment because of the warnings. The days when patients would say, ‘Give me something really strong, Doctor, it’s kill or cure, isn’t it!’ are now quite gone, although I can certainly remember them. Today such blind trust is only bestowed on the herbalist. Never mind, moves are afoot to get them to issue warning sheets as well.
PUSHING AGAINST A SPRING
There is another demoralising effect as doctors are required by society to behave more and more perfectly and to be more and more infallible. Everything is getting more difficult as we get nearer and nearer to perfection. However high our standards, people will come to judge our performance by those standards — regardless of the difficulty of maintaining them. The nearer we get to achieving this impossible ideal the more we feel that we are subject to criticism and feelings of inadequacy. When we push forward to a new balance-point at which our available energy is matched by a new, higher level of complexity, any errors that we then make will be just as prominent as the errors which we made previously at what was actually a lower level of effort and complexity. It is like pushing against a spring.
The importance of errors is another thing which is assessed relatively not absolutely. In absolute terms, the old errors were actually more important because they occurred at a lower level of perfection. (When I started in my present practice I had no less than three patients whose lives had been blighted by botched thyroid operations — all by the same surgeon — two of them had silver tracheostomy tubes in their throats for the rest of their lives and the third was permanently hoarse.) But because the things that are now being attempted are inherently nearer to an impossible level of perfection, it appears that more errors are being made and that the service is getting worse, not better as is actually the case.
Medicine has never been safer than it is today, yet public anxiety about safety has never been higher. Although we have made enormous progress, society’s appetite for further progress and ever greater levels of safety seems impossible to satisfy.
It is in response to this situation that the present vogue for centralised decision making and regulation has arisen. It is an inescapable fact that the first reaction to any tragedy such as the baby-snatch already referred to is to look around for somebody to blame. Strangely enough this person rarely seems to be the person who snatched the baby. The automatic response of the all-powerful media commentators is to look for more regulation. Time and again you hear them talking as if more and better regulations can only be a good thing.
No matter that the hospital concerned had only just had a security review and already had a department of specialist security officers and, who knows, perhaps even ID badges for its nurses; a junior minister was wheeled on to say that he was going to make sure security was tightened even further! And I can tell him something — the rarer such incidents become, the more will be the outrage, the anger and the calls for further controls. Poor chap, even Hercules might have quailed at such a labour!
And, er, the baby was, let me remind you, returned. But oh, so much less boring than the five (or is it seven) people killed each day on the roads!
The futile attempt to live to a standard which will eliminate media-scale risks is destroying the joy of life for individual people living in the real world. Risks which are only perceptible on the media scale can only be prevented by media scale supervision, and that leaves little role for the individual. Often the minuscule good done by the elimination of a remote, theoretical risk is outweighed many times by the harm done to the independence and motivation of people.
But that doesn’t worry the regulators in the least. They have all the certainty that they are right of converts to a new religion. They are absolutely unshakable in their conviction that the representation of everything in rigid rules and formal mathematical models is the very epitome of progress and they present their beliefs with a self-confidence, not to say arrogance, which would be fatuous if it were not so familiar.
Speaking their own strange language, they talk of attempting to ‘capture’ the problems we front line workers are desperately trying to get them to understand. The shortage of community nurses is a recent example: ‘We are trying to map the nursing services in your area’.
‘Yes, but we are all busy people who have come here to tell you that the shortages are our top priority!’
‘Ah yes, but we have got to have the data to make a proper business case.’ (Notice the implications of the word ‘proper’)
‘Look, the nurses have been using their computers to make their returns for years - where is all that data?’
They look at us primitives with pitying eyes.
The trouble is that we have broken the feedback loop. The people who make decisions are no longer the ones who see what happens as a result. They don’t think they need to because they are so sure that their models are a much more accurate, reliable and valid way of finding out what is happening. They completely reject the old way of doing things, which is to let the vast bulk of the world sink into the ocean of congruity and just concentrate on the problems that appear on the surface of the mind. By wildly underestimating the size, complexity and subtlety of the ocean that they are dealing with, they think it is a huge advance to use their new machines to model the whole thing at once.
What we have here is an uncontrolled experiment, which looks as if it is going to be an historic failure. You have to make an effort to remind yourself that these ideas, which have overturned the means by which mankind has made progress since the dawn of civilisation, have been current for little more than ten years.
It is the replacement of individual experience, common sense, and responsibility by an external structure of rules which is the key change in the new situation. Although originally created by us, this structure of rules has now taken on an existence which is quite independent of any single human mind. The tools we originally created to serve our needs have taken over and made us their servants.
The impracticality of strict adherence to rules as way of running the world is a matter of common sense. In industry the term ‘working to rule’ actually means the same as going on strike. But when any of us looks at the world from a restricted view point we can’t avoid the distortions of perception. Doctors are notorious for not following their own rules when they take medicines and I sometimes think that anyone who can take tablets four times a day without fail is an obsessional neurotic and probably needs treatment for that. Nonetheless, we go on expecting people to do it. When I started work at the Middlesex Hospital my senior medical registrar told me that our job in life was to make sure the patients died with their electrolytes balanced (in other words having the right proportions of sodium and potassium salts in their blood). Once I commented to a local undertaker on a body lying rosy-cheeked in his chapel — ‘He looks surprisingly well, considering he’s dead!’.
Joking apart, when doctors work to rule there is a grave danger that the rules will do better than the patients.
BALANCE AND UNBALANCE
I remember visiting an old lady when I first started in my present practice. She wanted something new for her aching knees and I gave her my honest scientific doctor’s advice, according to the rules. I said that she had already tried everything that could conceivably be of any value, from every sort of pain-killing and anti-inflammatory drug to bandages, rubbing creams and physiotherapy and that there was really nothing more that could be done. I was very sorry but the Paracetamol she was already having were as effective as anything else, safer and cheaper and that I thought she should go on taking them.
There was a pause and she surveyed me shrewdly. ‘You know,’ she said, ‘Dr Larcombe (my predecessor) would never have said that. He knew it wouldn’t really make any difference and I knew that it wouldn’t, but he always gave me something.’
Then more kindly, ‘You’re young though — you’ll learn.’
Over the years I have told this story to a number of doctors who remain completely unmoved by it and go on insisting that I was right in the blunt truth which I gave. But I have no doubt at all that the old lady was right. At the same time I continue to believe that modern medicine is founded on the bedrock of science and that to abandon science would be to return to the dark ages. These two approaches may seem to be opposites when we view them literally and scientifically but our minds possess the mysterious artistry necessary to merge the two opposites into a balanced synthesis and a way forward.
Long after that old lady died scientific evidence began to accumulate which has now proved beyond reasonable doubt that virtually any treatment which a patient believes in will indeed help them, physically and measurably. This means that science has proved that doctors can always help patients who trust them. Which is what the old lady knew all along!
We use the word ‘unbalanced’ to describe an insane mind. Thus the accumulated wisdom embodied in the very language we speak acknowledges the fundamental role of balance in the definition of sanity. So when I say that the common mind of our society is unbalanced, I am making a very serious diagnosis. I am saying that the common mind of society is, to some extent, insane. But that is what I do say.
The overwhelming tendency in the modern world is to listen to the hard, precisely defined certainties of the expert and to disregard the softer, more vulnerable, but far more important balanced hypothesis of the generalist. As a result, very many aspects of the contemporary world which seem logical and sensible when viewed in isolation by the remote specialists who are in charge of them, seem obvious madness to everybody else.
The current trend towards external review of everything is fundamentally flawed. The idea that regulation is a good thing per se is an illusion. Regulation destroys humanity. It undervalues the individual human being, his mind, his motivation and his integrity. Unfortunately general practitioners have to some extent colluded in the process of reducing their practice to a lot of sterile formulae. They have done this because they have shared in the illusion that this is what is necessary for progress. This means that general practice, the last great bastion of professional generalism and common sense, is being judged by the wrong criteria. It has lost its self-respect because it is trying to express itself in a language which denies its very nature.
Fortunately he hadn’t been too giddy to get to the front door to let me in, and he certainly wasn’t unbalanced, but I didn’t agree with him. Sitting on the nice, comfortable sofa in the flat that he had hoped to share for much longer with his wife, I told him that I thought there was something we could do about it.