A celebration of the reality of life
‘You’re a remarkable chap.’
‘Everybody’s remarkable if you look closely enough.’
Conversation with a (remarkable) patient
I have said how stressful a GP’s work can be. A problem shared is a problem halved indeed. I end up a day with ever so many half problems. A weekend on duty can be utterly exhausting.
But that is nothing compared with the problems of a weekend off!
One of the features of the modern age is greater freedom and self determination for individuals. In some ways modern life is like a weekend - and believe me, they are not all beer and skittles. Weekends for a generalist can be a nightmare and I mean it. With all these lovely things that I could be doing, and all those dull things that I should be doing and all those other things that people tell me I ought to be doing, HOW ON EARTH DO I DECIDE WHAT TO DO!
I mean, I have the greatest difficulty choosing what I want on a menu — choosing one thing means you can’t have any of the others so I go round and round in circles. Some restaurants only offer one thing and I recommend them — they are very relaxing. Obviously they are run by sensible people who understand and they are bound to cook well. Patronise them. Unless of course you are allergic to everything except Quails — in which case you have solved the problem in your own way. Unfortunately I like almost everything.
So, if life is like a meal in a restaurant with a very large menu, what are we going to do about it?
‘Wisdom consists in doing the next thing you have to do. Doing it with your whole heart and finding delight in doing it.’
A saying of Master Echart, thirteenth century German mystic, which I heard quoted on BBC Radio Thought for the Day
When an animal is faced with a dilemma it can perform something which biologists call displacement activity — an apparently pointless ritual action such as preening.
Humans do exactly the same thing; faced with a dilemma, many people will walk to the mirror and comb their hair. Or they will start doing some other quite arbitrary activity whose real priority would be way down in any rational list. The fact is that there is no rational way of arranging all the possible courses of action in a busy life into order of priority. Everything is relative, what seems important in one context of thinking can come to seem trivial quite a short time later. The problem has no rational solution.
The day on which I settled down to start this chapter was an example. It was a Saturday. Here is a copy of the list of ‘things-to-do’ which I jotted down on a piece of paper. As you see I attempted a simple classification to help me decide priorities:
Easy but time consuming:
Necessary but not productive:
Relaxing and fun:
Chores: Write letter to Z
Then I wrote ‘Allocate time’ and underlined it heavily…
That morning, as always, when setting off on my run I had unlocked the back door and as always, I had been irritated by the door lock.
For years it had been getting stiffer and stiffer and I was finding it more and more difficult to hold the key in the way that, with luck, succeeded in unlocking it. The catch itself was also faulty. When you turned the handle it withdrew all right, but it wouldn’t spring back unless you rattled the handle and the door in a certain way — the door stayed shut because of the pressure of the draught excluder strip, but not very firmly. All this I did more or less automatically, but with subconscious awareness of an irritant — an incongruity, I suppose, in my world.
Replacing the lock was one of my lower order priorities, things which needed doing but the time never seemed quite right because they had been that way for so long. Anyway, I couldn’t think how it could be done neatly because the lock was fifty or sixty years old and it would be impossible to obtain a matching one. What I did do from time to time was to attempt to lubricate it by squirting graphite powder into it through chinks in its casing. This was only slightly beneficial and I was unable to do the job properly because the lock was held together with rivets — or at least it appeared to be.
Anyway, this morning the lock became my displacement activity as I dithered about what to do with my precious day. It suddenly occurred to me that if I was going to throw the lock away I might as well have a go at drilling out the rivets and see if there was a way of replacing them after I had found out what was wrong and possibly put it right. After all, there was nothing to lose.
So I went and got a little screwdriver to take off the handle, and then I went and got a big screwdriver to remove the three big screws holding the lock onto the door. Then I looked at the back-plate of the lock and saw, to my surprise and satisfaction, three screw heads. Obviously the lock wasn’t riveted together after all — in fact it was designed to be taken apart. Furthermore, one of the three screws was loose and was actually lying free in its hole.
Things were looking distinctly promising, provided that the reason the screw had come loose wasn’t that its thread was stripped…
I carried the lock down the cellar steps to my work bench. Making space on the work bench is an art which I perform by placing my forearm along the front of the bench and pushing. Sometimes this results in things falling off the back of the bench and this I take as a signal for the unpopular business of tidying up.
Happily this complication did not arise on this occasion and I sat down, removed the three screws and cautiously prised the back off the lock. It came off, to my further gratification, without the air being filled with flying parts.
The entire lock mechanism lay exposed to my view, lying in a bed of dirt, rust and cobwebs. The pathetic inadequacy of my attempts to lubricate it from outside embarrassingly obvious; all the bearing surfaces were dry and rusty. But more than that, as I looked I could see what was wrong with it. The whole mechanism was meant to be held in place by the three screws which secured the back. But because one of them had been undone and the back plate had lifted away, everything inside had been slopping about, in and out of alignment.
I could see how a cam on the handle spindle was supposed to press against a steel arm to withdraw the catch. On the other side of the same arm a spring was supposed to press to extend the catch again when the handle was released. But the arm had moved up on its pivot so that both the cam and the spring had slipped underneath it. The spring was deeply scored by the improper action of the cam over the years. It was amazing it had worked at all.
The lock’s problem had the same cause. The mechanism was a pleasure to look at. A beautiful assembly of shiny, flat, brass levers, each with its own spring. Each separated by a thin brass anti-picking shield. But because they too had been free to slop about on their common pivot they had not always been lining up properly with the profile of the key and you had had to fiddle it about until they did.
I gently released the springs and removed the assembly, carefully keeping the order of the levers unchanged. The rest of the lock mechanism lifted out in turn and I cleaned it all before beginning to replace it. I lubricated the bearing surfaces with a little grease and the lever mechanism with graphite powder, which is the best thing for locks because it isn’t sticky and doesn’t trap dirt. I pushed the catch arm right down on its pivot with the cam pressing on one side and the spring safely on the other.
When everything was in place and I had shown interested members of the family, I put the back on again and began to tighten the screws. To my delight the whole thing pulled up into perfect alignment as the screws went home. I made sure they were tight enough not to come undone again and then tried the key. Sure enough, it turned with the mellow smoothness of a good old wine- the solid clunk of a mechanism happy with itself. Not just good as new but better than new. Any roughness worn off by years of use.
Mounted back on the door, with one of the three big screws which had been loose replaced by a bigger one, with its brass handles polished by my wife, the job was done. Done to perfection. Complete. That box was closed. And, as it happened, locked.
I felt a completely different person and I went up to the computer for the next three hours with a sense of inner peace out of all proportion to the real significance of what I had done.
It didn’t matter in the least that the job hadn’t even been on my list. Although I wrote the original of this section straight away after the event, that is now months ago and the smoothness of the lock mechanism is still giving me pleasure every day. Who can possibly say that it wasn’t a good use of my time?
What I am trying to show here is how different the practice of real life is from the theory — how much more subtle, indefinable and irrational. And yet how much more valid.
It seems to me that as we move into a more and more rational and tightly organised world this validity, this humanity is being destroyed. If things go on as they are, it seems as though our lives will soon come stamped with a label which says ‘DO NOT OPEN — NO USER-SERVICEABLE PARTS INSIDE’ and that we will have to live those lives in a sterile, defined, absolutely safe and utterly dull and unrewarding way. A modern lock isn’t made so that you can open it and mend it, nobody has the time, you just throw it away and buy a new one. Then you can spend the time you have saved ‘enjoying yourself’. We call it progress.
This is why it is so important for us to think about the nature of ideas. Life is an idea in each of our minds. The reality on which the idea is based may be fixed and inanimate but the idea itself is incredibly complex and subtle. Life is vital and ever changing. It is too big to comprehend all at once. It cannot be pinned down and defined. To attempt to do so is to destroy it. But that is exactly what the modern collective mind of society is attempting to do.
Some such control is of course necessary, that is not seriously disputed by anybody. The problems that we are addressing here are the widely sensed, but too little analysed dangers of too much control. Let us continue to examine them within the particular field that I know about, the life of a GP.
WASTING MY TIME?
What would you make of a patient who comes to me for reassurance a week before his regular six-monthly specialist review for malignant melanoma (the most serious form of skin cancer). He wants me to check to make sure the specialist won’t find anything!
Is this a waste of my time, or an integral part of properly balanced care?
It only takes me a couple of minutes but gives enormous reassurance. The head says it’s nonsense. The heart cries out that it is exactly what you would want if you were in that position yourself. Which is right? The patient’s wife says, ‘It’s worth it for him to avoid a week of diarrhoea’. If it has that effect on her husband then surely it must be worthwhile?
I don’t understand how or why my reassurance has this effect but I feel a sense of privilege to be able to give comfort in this way. I share his anxiety when he comes in; I share his relief when I find nothing. That may be part of the answer, I just don’t know. I do know it happens — sometimes.
The principle which I try to go by is that each patient has come about a problem which is important to them.
Consultation involves getting into their box and sharing their anxiety.
At the time the stress and tension of the situation depend very much on that shared anxiety but an objective observer will inevitably judge the importance of the interview in retrospect on the diagnostic label which was attached. In many cases the label may appear trivial because the things the patient was worried about were indefinable or easily ruled out. But that may actually have made the consultation more valuable in terms of promoting health and well-being than if I had discovered something dreadful.
A man recently came in white and drawn with anxiety. He had insisted on being seen in the morning because he couldn’t wait until the evening surgery when there was more space. His problem was that he had found his xiphisternum — the prominent lower end of the breast bone which forms a hard lump in the pit of the stomach of most people. They are often very alarmed when they find it for the first time. When I gave this man the familiar explanation that the lump was entirely normal he practically capered around the room. He grabbed my hand and laughed and almost cried with relief. ‘Oh, I’m so grateful — I was sure I’d got what my Father died of…’
I remember another patient whose routine blood potassium estimation came back at 5.5 whereas the laboratory’s normal range ran from 3.6 to 5.4. It had been unthinkingly declared ‘abnormal’ and he had been sent a note to come in for a check. When he came I was horrified to realise the significance that ‘something wrong with the blood’ had had for him. He had assembled his family for the weekend and they had indulged in a roast joint and a bottle of wine before he braced himself to come in to hear the worst.
THIS IS WHAT PEOPLE ARE LIKE
Like all my stories, these are as exactly true as I can make them — this is what people are really like — it is not fiction. The stories happened, it is my interpretation that you may quarrel with if you wish. I think it is only through my human experience and values that I can understand these feelings at all. But I could never quantify and analyse them. I am certain that no central controller could evaluate them. I think the only real judge of their validity is the patient.
Several years ago I wrote myself a computer program to remind me to visit my elderly and disabled patients at various intervals. I have used it ever since because I give a very high priority to keeping in touch with my patients. But it is hard to think of any accounting system which would be able to measure the productivity of this activity which is so important to me. So either the accounting system or my priorities must be wrong. Of course in the quantitative, reductionist environment of ideas it appears self-evident that it is my priorities that are wrong and that is the view that the remote controller would be bound to take. But I don’t think the customers do, and customers are always right.
Another patient — an elderly lady — told me that she was glad to see me when I called on one of these routine visits. She had been trying to pluck up courage to come and show me a breast lump. I had a look at it straight away and it was obviously a cancer. Not a very large one but that was what it was and I told her so. I said I’d put her straight onto some tablets which would shrink it down and refer her to a specialist.
The extraordinary thing was how pleased she seemed to be when I left. ‘Now I shall be able to go out happy, now I’ve seen you, and I won’t have to make up me mind to come and see you.’ The uncertainty must have been worse than the reality, even when the reality was the very thing she had been worried about!
As it turned out she was absolutely right, she responded so well to the Tamoxifen that the lump can hardly be felt several years later. And it certainly isn’t that that is making her consider giving up her allotment to concentrate on her garden.
THE PRACTICE NURSES MEETING
I am at a meeting of the thriving practice nurses group that had its beginnings in the treatment room of our Health Centre. Our six nurses have been the driving force from the start of the group. My role as ‘Doctor in charge of Treatment Room’ has just been to shout encouragement from the sidelines and take a little reflected glory.
Tonight’s speaker is a senior officer of the Royal College of Nursing and she has been talking about training. When she finishes one of the nurses in the audience tells the story of how she had suddenly found herself confronted by a man who had lost his entire family in a road accident. The burden of the speaker’s response to this is that no nurse could cope with such a situation without a training in psychology.
I can’t resist putting in my oar:
‘What worries me is that saying that sort of thing will make people think that they shouldn’t even try to help unless they have specialised training. Some people can do these things and some people can’t, the main qualification they need is experience of life.’
She looks impatient with me and I go on. ‘Don’t you think it is possible that going on a course in psychology might actually make somebody worse at helping in this situation?’
She does not.
‘Don’t you think there must be some examples of training courses which are counterproductive?’
No, she does not. Training is training. By definition, it is a good thing. Like love or happiness.
I know many of the nurses agreed with me, they tell me afterwards. But they are just the workers, the boss knows better.
Notice that if the original reply had been, ‘You might have been helped by the education in psychology that I had’, I would have respected her opinion and agreed with her. What she said was very different — ‘You shouldn’t be attempting such a difficult thing without specialised training’. That is absolute rubbish. Anybody can give comfort and be a sympathetic listener — the more human and natural the better. Some highly trained people do it appallingly badly. Some do it very well, but even then it is impossible to prove that it is because of their training.
At least one of our nurses is, to my certain knowledge, a very effective counsellor indeed with no more and no less than her rich experience of personal and professional life to educate her natural ability. While I normally encourage all forms of postgraduate education I actively persuaded this lady not to seek further training in counselling when she raised the matter with me — though of course she would have had the final say if she had really wanted to. I thought it might well make her less effective and could hardly have made her better. I also thought it unlikely that those running the course would be ready to learn from her to anything like the extent that I would have been in their position.
Here again we have the crucial difference between education and training. Training is the sort of process you use to prepare a performing animal. It is an important instrument of central control. Education is neither of these things.
So that brings me back, more or less, to deciding what to do with my weekend, and to trying to decide what to choose from the huge menu in the restaurant of life. Our minds can sort these things out if we let them. They need education of course. They need to know about locks. They need to know about people. They need advice of all kinds. They even need a plan, so long as they don’t take it too seriously. But however carefully we prepare our minds for life, like precious children, in the end we have to let them go if we are not to lose them.