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:

Right para-sternal chest pain, Neck and shoulder pain. No root signs.

Chest X-Ray. Try Brufen.

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.

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.

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.

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.