8 THE OCEAN OF CONGRUITY
An analogy for the way in which we only notice the incongruous in life. And the way everything else remains hidden from view.
Me, to an old lady hobbling into my surgery, ‘What can I do for you?’
Old Lady, ‘Everything…’
And as she leaves, ‘I wish I could have helped you more.’
‘That’s all right, Doctor, you’ve done what you can.’
The sensitivity of our minds to incongruity is so inherent in our lives that we take it for granted and rarely think how clever it is. Consider the ease with which we detect a tiny grain of sand when we run our hand across the surface of a table, or the way we can distinguish a particular kind of vibration made by an underground train.
The power of this filtering process is a matter of common experience. We all share the mechanism which ignores everything that is congruent with the existing image of reality in our minds and selects for attention the odd thing that is incongruent. Some of my patients have houses backing onto a railway line. If you comment on the deafening noise of a train that has just passed you are surprised to find that they haven’t noticed it. They say they are ‘used’ to it. Yet a tiny, barely audible, incongruent ‘click’ in another room will alert them to the fact that an electric iron has been left on.
As I have mentioned, my patients reacted instantly and almost without exception the first time they saw me with a beard. In just the same way it is extremely striking how quickly people notice that you are wearing a new tie or a new suit. The fact that people so often stop what they are doing to comment on such changes itself shows what a high priority the automatic mechanisms of the mind place on maintaining their internal model of reality.
So it is an inescapable fact, demonstrable by mundane, daily experience, that any new observation or idea is compared automatically with a subconscious, background frame of reference, and checked with it for congruity. Only a tiny proportion of new ideas which stand out because of their incongruity are brought to our conscious attention. Thus the overwhelming majority of everything that happens in our lives is invisible because it matches with the existing pattern.
It is the scale and sophistication of this background image, this frame of reference without which nothing has any meaning, that I am trying to describe. And the hidden power and importance of the subconscious mechanisms which maintain it in our minds. And the vital need to incorporate such mechanisms in society’s understanding and planning of the world.
But that is an over-simplification. What I really want to do is transfer my whole mental image in a lump, without being restricted to sending a procession of clumsy words trudging through your mind. I need an analogy to describe the true wonder of the mechanism which makes analogy itself work.
The analogy I want to use is along the same lines as the familiar ‘tip of the iceberg’ but goes further. Forget about the huge bulk of the iceberg which is hidden in the ocean — that’s peanuts — lets think about the ocean itself. Imagine an ocean made up of all the things in life which are unseen and unnoticed because of their congruity. All the things which have been excluded from attention by the selective mechanisms of the mind and of society. An ocean, in fact, of the ‘everything else’ we have been talking about throughout this book. The tiny fraction of life which reaches conscious attention now becomes the beach which is exposed on the edge of the ocean. That is the picture I want to convey.
OCEANS IN PRACTICE
There are countless oceans in life, and they overlap, but I want to stay within the context of medical practice.
In traditional practice, the doctor used to sit in his surgery waiting for patients to come to him with their problems: One patient — one problem — one solution — another life saved, ‘Good-bye — Who’s next?’ Those patients who don’t come don’t register in the doctor’s mind at all.
This is the analogy in its simplest form. The unseen patients are the ocean and those who present themselves are the ones who emerge on the beaches — the only ones the doctor sees.
The old style doctors had one exception to this rule, the chronic visiting list. This was a list of about twenty or thirty patients whom the doctor had got into the habit of visiting regularly, usually once a month. Some of these patients were very ill but this was by no means always the case, many of the visits were manifestly social. Other people who might have benefited from visits never got them unless they requested one for an acute illness.
Whatever modern doctors may think of this arbitrary arrangement there is no doubt how much the patients, and the communities they lived in, valued it. Or how important it was to the doctors themselves.
Twice I have taken over practices from retiring doctors and each time the only aspect of the organisation they expected me to continue was the chronic visiting list. Each time, before they left, they took me round to introduce me to as many as possible of the chosen few. Virtually the only administrative advice either of these retiring doctors gave me was the style of diary to use to organise the visits and apart from selling me the odd instrument (odd was the word) that was it. I emphasise this point to show what a disproportionate effort was required for the active organisation of this tiny part of the workload of a traditional practice. The enormously larger proportion of what the doctor did virtually organised itself.
It is curious that although chronic visiting lists are now unfashionable, other forms of active, doctor-initiated medical care are distinctly in vogue. The old, passive style of practice, in fact, tends to be referred to disparagingly as ‘merely satisfying patients’ demands’. The very term ‘demands’ is loaded with innuendo and ‘satisfying’ demands is seen to be a doubly spineless activity for a modern doctor. Especially when it is compared to the active organisation of childhood immunisations and developmental checks, well-woman checks, well-man checks, old people’s checks, cervical smear checks, blood pressure checks, breast checks, cholesterol checks. Every year somebody makes their name by checking something new. I plan to introduce alopecia* [Footnote: *Baldness] screening (with pre-emptive counselling) to a grateful world when time permits.
The new trend has been dignified with its own jargon. ‘Pro-active care’, organised from the centre, is seen to be more important than ‘re-active care’ which is diffuse and unmeasurable. Meanwhile politicians capitalise on the illusion that a health service can remove the need for a sickness service by somehow abolishing illness. Doesn’t it all sound wonderful!
The new style of practice has many bonuses for the doctor. He feels he is in charge, he gets appreciation from the patients who feel that he is looking after them, he feels that his work is more purposeful, he can measure what he is doing. He can define his job and prove that he is doing it well! Not least, he has discovered that all these items can be identified and charged for. Cheques for checks indeed.
Doctors throughout the western world have learned the advantages of spending their time examining the healthy. Curiously, however, even the most sophisticated programmes of checks do not seem to have abolished, or even reduced, the need for treating the wealthy. The idea that preventive medicine will abolish illness and make everybody well remains what it has always been, an illusion. But it is an illusion which exerts extraordinary influence in the corridors of power at the present time.
THE ENORMOUS PROBLEMS OF ACTIVE CARE
Of course there are advantages in properly organised preventive checks designed to serve the needs of patients, not those of doctors or politicians. But the snag that conscientious doctors are discovering about active care is that they have no alternative but to face the size of the task they are undertaking. They can’t allow the practice to ‘run itself’. It is no longer enough to be passive and allow each patient to come and open his own box within the doctor’s mind and then close it as he closes the surgery door. The motivation and the plan have to come from the doctor at the centre. And he finds to his surprise that the whole is far larger than he thought it was.
All sorts of difficult decisions have to be taken. For example, which things to check and how often to check them. Although we can agree, perhaps, that it is a good thing to have a full examination, there is no rational way of deciding how often. Once in a lifetime? Once a year? Once a week? And how full is ‘full’?
Once doctors start taking the initiative in looking after their patients, they come face to face with these enormous problems. They sometimes long for the old days when the initiative came from the patient and there was no need for them to have any clear conception of the whole job.
THE OCEAN OF ORGANISATION WITHIN A PRACTICE
Most modern doctors do take a succession of such difficult decisions and as time goes by the decisions accumulate into a complex system of organisation for their practice. This complex system is another ocean. But here the ocean isn’t an unseen mass of patients but an unseen mass of organisation — last year’s exciting innovations which are now routine and which are no longer noticed. The incongruous parts of that organisation which appear on the beaches of attention are exclusively the parts which have failed. And that, as we shall be examining in the next chapter, is precisely what is needed for making progress.
Thus, when everything in the practice is sorted out and the loose ends of the patients’ problems have all been tidied up, when the repeat visits and follow-up of chronic diseases are organised so that they happen automatically, then the work seems to disappear from view. The doctor may actually feel he is under employed. On the other hand, at times when everything is in chaos and he is overwhelmed with unsolved problems and chaotically bad organisation he feels terribly busy. He is terribly busy — the beaches of his attention are crowded with writhing and incongruous bodies. But he is probably being far less effective than when he feels much less busy and his beaches are peaceful and deserted.
Although doctors ought to aim to be effective, not to aim to be busy, patients never seem to say, ‘I’m so sorry to trouble you, Doctor, I know how effective you are.’
CENTRAL CONTROL COMPOUNDS THE PROBLEM OF ACTIVE CARE.
History has moved on one more stage in recent years. Central controllers have also seen the need for organised, active care. And for the very best of reasons they want to make sure that it is uniformly available to everybody, not just to those patients who have highly motivated doctors. (Central controllers, incidentally, are also unsure about whether they want doctors to be busy or effective.) So the controllers develop their own complicated idea of organisation. And that too is like an ocean.
The controllers gambol on the beaches of change, formulating their plans. But there is another important difference here. When they have handed down their instructions they turn their attention to the formulation of the next set of plans. The fatal catch is that they don’t have to face the reality of implementing their plans and assessing the plans' effectiveness or shortcomings — they are above getting their hands dirty. They never have to hold the entire reality in their minds as a consistent whole. They don’t think it is their job to do so. They are specialists. Their job is to selectively notice failings.
Put like this it seems obviously wrong, but it is happening all the time in the modern world.
Here, in microcosm, we have the whole story. The same problems can be seen in almost any walk of life, I have talked about the area I happen to know about. If we solve these problems we have solved the problem of co-ordinating individuals into a coherent, living society.