2 OUR DISTORTED VIEW OF THE WORLD
When a doctor compares his memories of patients’ problems with the ‘reality’ of his written records of the same problems, he can glimpse the distortions normally present in his perceptions of the world.
‘If I don’t come back in
a week — you can assume that I’m better.’
MR BROWN’S SAME OLD PROBLEM
The next patient hesitates apologetically as he appears round the door.
‘Its me again with my same old problem, doctor.’
‘Oh yes?… come and sit down, Mr Brown.’
If you think the skill of being a GP is making clever diagnoses and saving countless lives you are wrong. That’s a piece of cake compared with remembering who people are and what is likely to be wrong with them. If I had met this chap in the street I wouldn’t have had a clue what his name was. But here in my surgery I have two secret weapons — my appointment list and my pile of notes.
Mr Brown is due in next, here are his notes, and in comes a face which fits — Bingo! — I greet him like an old friend. (Most of my patients are old friends, there are just rather a lot of them.)
Now what on earth may his ‘same old problem’ be?… I slide his record cards out of their envelope and go automatically to the date of the last entry — eight years ago.
I look up doubtfully.
‘Your same old problem?…’
‘My leg ulcer — its bad again I’m afraid.’
Sure enough, eight years ago: ‘Leg ulcer’ — the same old problem — how could I possibly have forgotten!
Let me try to explain:
When I get to the end of two-and-a-half or three hours of morning surgery I don’t have any clear idea what I have been doing — I just feel fussed and more or less drained. If you were to say to me, ‘Tell me what you have been doing this morning’, I simply wouldn’t know where to start.
I could pick out a few things to tell you but they wouldn’t begin to give the whole picture — just self-contained parts of it. I could say, to take an example more or less at random, ‘Mrs Grey was very depressed’. But it wouldn’t convey what it was like to be with Mrs Grey when her nicely made-up and smiling face changed and she began to cry.
She had come in at about ten. I was running a few minutes late, about ten patients to go, probably about two waiting already. When Thérèse had brought in my tea she had warned me that there were seven visits in already and that four were in the villages — more calls than usual — the whole day would be a rush. Also I had promised to do something this morning about Mrs Violet who had been wandering all night and had left a towel to catch fire on the cooker. Ante natals at one-thirty but fortunately only three this week. Afternoon surgery starting at four. (I’m not making this up by the way, it all happened this morning.)
As Mrs Grey comes in I am still thinking about the last patient. I look up and see her face, match it with the notes and remember who she is. She sits down and tells me that the pain in her chest is no better — the pain killers have made no difference. I read the last note:
Now I am right back into Mrs Grey's case. The way this happens is rather like the beginning of those old ultra-wide-screen films that used to excite us in the 'fifties. I remember that the performance would begin with an introductory sequence in black and white on a normal sized screen. Then, suddenly, a resonant voice would announce from loudspeakers set all around the cinema, ‘THIS IS CIN-ER-A-MA!’. Suddenly you’d have the music and the colour. The curtains would sweep outwards and the screen would appear to stretch and stretch until it completely filled the field of vision from side to side. There would be a thrilling sensation of zooming right into the scene and becoming part of it.
Big screens seem to have gone out of fashion now, perhaps the equipment was too expensive to maintain. Anyway, the same sort of thing seems to happen when you identify the memory file of a patient and then zoom into it and become part of it. Everything else goes, the patients and the problems that were filling your mind a moment before are displaced, or left behind, almost as if they had ceased to exist. It is as though each patient has their individual box in the memory. Each box is firmly closed until you open it and go in.
‘We’ve got the chest Xray back, Mrs Grey, and it’s completely normal.’
She doesn’t seem to think this is good news.
‘Well the pain is still there.’
The telephone rings. ‘I’m very sorry, will you excuse me a moment… ’ It is a pharmacist in the high street to query a prescription; there has been a confusion over the strength of another patient’s Thyroxin tablets. Thérèse brings in the notes. ‘No, it’s definitely 50 micrograms… No, I’m quite sure about that. Thank you for checking… Thank you, Happy New Year!’
As I look back to Mrs Grey my perception of her problems changes instantly and completely. While I have been talking on the telephone her face has crumpled and turned red. She is crying.
I wait, taking in the situation, sharing her distress, feeling guilty for the interruption, consoling myself that it might actually have given her the space and the excuse she needed to drop her façade.
‘I just seem so tired and ill…’
I spend a lot of the next fifteen minutes listening. I absorb what she is saying and try to fit it into a pattern which provides me with a way of helping her. I try to avoid jumping to facile conclusions. There is no perfect solution — that’s what makes it difficult.
Shall I say, ‘You’re depressed — take these tablets. They’ll make you feel awful at first but you’ll begin to feel better after a week or so. See me next week’? But she has had anti depressants before and she is sure this time it’s different.
Should I certify her unfit to start work at the beginning of term? She really loves her teaching, the new school is such an improvement on the old one where she really was unhappy. It would be a blow to her credibility to miss work and might make it even more difficult to restart subsequently.
But on the other hand she and her husband sat down last night and considered completely re-thinking their lives.
‘Yes, actually giving up for good. It seems such a shame to have the children at home for Christmas and just not have the energy to do anything with them.’
‘Well, OK, what about that? What about giving up altogether?’
But then she would miss her work.
And so on… I have got the picture, as far as I can. I have done all the listening I think will be useful for the moment. My picture is based on the archetype of the over-stressed, demoralized, conscientious, idealistic teacher who has, as so often happens, flopped badly during the holidays. Add to this elements of failure to live up to what she expects of herself as a wife, housekeeper and mother. Add to this a moderately severe clinical depression, possibly post-viral (although she denies any recent illness). Don’t forget the chest pain. I think she probably came to me hoping for a certificate for a few days off work to ease the beginning of term.
I put the options to her: two weeks off work and review, plus or minus antidepressants, or soldier on and see if the stimulus of work pulls her out of it once she is started. Nothing to lose if she is thinking of giving up anyway. Come and see me again anyway especially if the pain gets worse.
She decides to soldier on. I know she is still unhappy as she leaves. I feel for her but I don’t know what more I can do.
I make my record:
Deep in thought, I put her notes in the OUT compartment and press the call button. I confirm that the end of my mug of tea is cold while I wait for the footsteps and the knock.
In comes little Flossie Puce. ‘I’ve got a bad froat ’n all spots…’
Zoooom… I plunge into my mental file for Flossie Puce, everything else is flooded out.
MR BROWN’S DISTORTED PERCEPTION
So it goes on. Patient after patient. Twenty-four consultations that morning; something like six thousand a year. That’s excluding telephone calls, trips up the corridor to patients being seen by the nurses in the treatment room, not to mention home visits. A great many people, particularly when each is as absorbing in his or her turn as Mrs Grey.
I often think that if I could remember them all at once I would go mad. But they must be all there in my mind somewhere, along with the many others who were patients in the past, complete with the complex and emotional sagas of their lives and, often, deaths. And then of course my mind contains all the other aspects of my life. Not least the nebulous ideas I am trying to crystallize into this book. An almost infinite richness.
This is the glory of life. But when nature ensures that we only see a tiny fragment of it all at one time, nature does indeed know best! Every memory stays tightly shut up in its box until wanted. But the result is that we fail utterly, and it is just as well that we do, to perceive the total extent of what is in our minds.
The fact that the focus of our attention — the Mrs Grey or the Flossie Puce — is really such a very tiny part of our total experience, whilst at the same time being so important, is a mystery which our minds can simply never grasp, however hard we try to make them do so.
So when Mr Brown assumes that I will instantly remember all about his ‘same old problem’ — his leg ulcer — he is only showing that his mind separates things into compartments just as mine does. Being a sensible chap he normally gives very little thought to doctors. So he keeps that box closed most of the time. But when he opens it, the few memories of me inside it are almost all related to his ulcer, and since he doesn’t know much more about me than that, he assumes that his ulcer will be a dominant part of my life And before we laugh at this too much, just remember that we are all doing this sort of thing all the time, and that there are special reasons why this is having profound consequences in the modern world.
Mr Brown is right that when he is with me his leg ulcer is the most important thing to both of us. But we are both wrong in forgetting the vast number of other things which are important as well. The fact is that there are simply too many ‘other things’ to fit into the mind at once. But not just more of them than we think, or even far more of them than we think, there are more of them than we believe possible. That is the vital point.
We don’t appreciate this fact because we have no means of counting or measuring the contents of our minds. We are not even sure that such a concept has any meaning. We are used to dealing with things we can prove and count. And when we make records on paper or store them in a computer we can measure their number and the space they take up. In that way we can be sure about the total size of the store. But we can’t do that with the contents of our minds. It is beyond the scope of this book to go into a detailed discussion of the reasons why memories cannot be counted up or even defined as discrete entities. Nonetheless, I do want to point out a fascinating piece of circumstantial evidence which we can all verify from our personal experience. It is the way we continue to be surprised by coincidences.
However often coincidences occur we go on being surprised by them. And as Edward De Bono has pointed out, the fact that we are surprised by something is highly significant. It signifies that we are unable to explain it in terms of our existing understanding. And that means that provided we have made the surprising observation correctly, our existing understanding must be wrong.
So, even though we usually exclaim that a particular coincidence is ‘incredible’ we always try very hard to find the mistake in our observation . That is why we say; ‘My eyes must be deceiving me’, ‘Something supernatural must be going on!’, or again and again, ‘Isn’t it a small world!’ Any explanation, in fact, to avoid the real one, which seems to be out of the question because it is a paradox. But if we accept that coincidences do happen, that the world isn’t smaller than we think it is at all but quite the reverse, bigger than we can imagine all at once, and if we discount the supernatural, then we have to accept that coincidences are merely one aspect of the way things are. We are left not having to explain the coincidence, but having to explain our surprise — which is much more interesting.
The real explanation of our persistent surprise at coincidences is that the experience of the world contained in our minds is larger than we believe possible. This fundamental distortion in the way our minds model the world, born of their incredibly powerful but essential ability to protect us from what would otherwise be an overwhelming weight of experience, is perhaps the central insight that has lead me to write this book. At every level, from the simplest personal experiences to mighty issues concerning the minds of international statesmen, this same distortion applies. And at every level we remain inherently incapable of comprehending its extent.
THE MIND COMPARED WITH A RECORD SYSTEM
This is the reason, to take another apparently trivial example, why I never tell a patient to ‘stay in bed until I call again’. However sure I am that I couldn’t possibly forget because the patient and his or her problems are so dominant in my mind at that moment, I tell myself that I could. And that if I did forget the patient would remember it until his dying day.
‘If I’d done what Dr Willis told me to, young man, I’d still be in bed, and that was twenty five years ago.’ Cackle, cackle.
Anyway, that was what a old chap said to me once about another doctor, who had forgotten to call again, and he told the story with the ease of frequent repetition down the years. I have always dreaded making the same mistake myself.
Often there’s a great deal more at stake than embarrassment. Even a single error must be prevented. One referral letter not written after surgery, one abnormal cervical smear report filed without action being taken could be disastrous. And it’s all too easy for it to happen.
So the first principle you have to adopt is to finish off as much as possible before closing the notes and moving on to the next patient. This is merely a specific case of the general rule, ‘Do it now’, which applies in so many areas of life. But many things can’t be done ‘now’ — any more than a repeat visit to a sick patient can be done ‘now’. I often need to wait for results, obtain further information or simply move on because of other pressures. Many things are better and more efficiently done in batches anyway, dictating letters is an example.
For all such things that can’t be done ‘now’ the technique is to arrange for something to stick out of the subconscious to remind you. You flag the notes in some way. Perhaps you insert an action-marker card long enough to stick out of the top. Or you stick, staple, paper-clip or rubber-band a label on to the outside. Any signal you can arrange that will make the notes stand out so that they don’t disappear into the ‘subconscious’ of the filing shelves. Anything, in fact, that will act as an incongruity.
Notice here the relationship between the things that have been flagged as ‘outstanding’ and the great majority of things that were finished off at the time. The latter are now neatly filed away, tucked right inside their respective envelopes, and the envelopes themselves will soon be back in the obscurity of the filing shelves. The result is that at the end of morning surgery the only things sticking out in the notes, and because of that, sticking out in the doctor’s mind, are the flagged incongruities. They are really a tiny minority of the things dealt with in the morning but they are the only ones which are still there at conscious level.
The great mass of finished work now appears to be as invisible in the mind as it is in the Practice record system, but in fact there is a fundamental difference. The mind is still subconsciously aware of the whole of that background experience. This is why the mind feels an inner exhaustion after the experience of morning surgery while the Practice record system does not. The extraordinary thing our minds can do is to concentrate on the few things flagged for attention whilst simultaneously remaining subconsciously aware of the ‘everything else’ that is in there somewhere.
THE BEST STORAGE SYSTEM IN THE WORLD
Almost exactly the same considerations apply when you are picking articles out of newspapers and journals. Over and over again when you have read an article in the morning paper, or a journal, you put it aside thinking that it is so interesting that you will return to it and read it properly. And you never seem to learn that you almost never do. The article is inevitably usurped by layer upon layer of subsequent interests. ‘The interesting article is dead; long live the interesting article’. Over and over again. You just never seem to learn.
I have tried to overcome this problem. Never to close a memory box containing something I want to remember without arranging an action marker of some kind. When I read an article to which I really want to refer I have tried sticking a semi-adhesive label on the page so that it sticks out at the top. It works beautifully. It warns me not to throw away the magazine, it says on the label what the article is about and it directs me straight to the correct page. Brilliant.
So why don’t I do it?
It’s just not possible. If I did it for any length of time at all I’d have piles of flagged journals everywhere and no time to read them. Like those video taped television programmes we all have gnawing away at our consciences until someone boldly re-records something else, newer and even more un-missable, on top.
In spite of all these discouraging experiences I go on trying this or that system for organizing all the incredibly large number of things I am interested in at the time. But the lesson that has gradually dawned on me over the years is that the size and complexity of our experience is so vast that it will eventually overwhelm any system. And the better we get at organizing ourselves and arranging clever ways of coping, the bigger the eventual problem becomes. All we are doing is putting off the evil day of reckoning when we will throw up our arms, say we can’t cope and decide to do nothing at all.
This is where the specialist comes in — he (or she) is sure he has the answer. He thinks it is obvious that you must restrict the field of interest by specializing.
What a cop-out that is! Just another technical trick. If you don’t include everything in your perception of life then you are not really dealing with life at all, but an artificial model of a tiny aspect of life. A far tinier aspect, what’s more, than you will ever be able to understand, however hard you try. Specialization is certainly not the answer we are looking for.
A generalist has to be a realist, he has to cope with the world as it is. He has to tell himself that it doesn’t matter how interesting the article he is reading seems to be; it is extremely unlikely that he will ever look at it again. And that the tidiest place to store it’s contents is in his head.
As a storage system the head is far from perfect. But the fact is that it is the nearest thing we have to a solution to the problem of gathering and making sense of our experiences of the whole of life.
ANOTHER SURPRISING THING
To re-emphasize the point of this chapter, let me tell you what I noticed when I grew a beard. I had it for about a year before I got fed up with it and shaved it off.
I expected people to comment at first, and they certainly did.
Everybody had an opinion and it was sometimes quite difficult to drag them back to the subject that they had come to see me about. I got quite used to the double-take as people came in and it was a sort of instant pointer to the fact that it was our first contact since the great change in my appearance.
Gradually, as one by one the patients updated their mental pictures of my face (I suppose), this reaction became less common. But when it did occur it was an instantaneous signal that it was a long time since I had last seen them.
The thing that surprised me was the mismatch between my mental perception of the time since I had seen them and this novel indicator of ‘reality’. For example, when a particular individual entered my room I might get that old, familiar, sinking, ‘Oh my God… Not him again…’ feeling.
At that moment such an individual might seem to be dominating my whole practice, my whole life. An overwhelming feeling that his problems would prove as intractable and frustrating as ever. This Jack-in-the-memory-box would come bursting out at me and leer hideously as it wobbled on its spring.
But then, in the same instant, the incongruous signal, ‘You’ve grown a beard!’ Meaning, without any doubt, that I actually hadn’t seen (and therefore hadn’t thought about) this person for nearly nine months — which in other contexts seemed half a lifetime away. Certainly somewhere near five thousand consultations away.
‘I must be doing this sort of thing all the time, without realising it,’ I would think. ‘We all must. It must be terribly important that we realise it…’
It is terribly important that we realize it. That we can only glimpse the whole that is ‘in there somewhere’ through the tiny window of our conscious attention and that, however much insight we think we have gained, the view that we get through that window will always remain distorted. It is only contact with real life that enables us to maintain a sense of proportion and balance by constantly reminding us of the reality which is hidden by the selectivity of our perceptions.