The Heart of the Matter
Quality mantra? Or being pushed into a new way of doing things?
Address given by JARW at the Royal College of Physicians of London on 28th November 2000 in a joint meeting between GPs and consultant cardiologists to discuss the GP/Specialist interface in the context of the new National Service Frameworks for Cardiology
Lip service is paid to professional freedom but the underlying drift is towards any divergence from central directives (currently euphemised as 'guidelines') becoming increasingly culpable. Many in management, government, the media and even in academic medicine currently see this change as being so logical that any debate of its merits is superfluous. This at a time when individual clinicians are required to base their own actions exclusively on formalised, scientific evidence.
I will argue that this approach denies the essential nature of the doctor role, which is a natural role, ours to fill but not, ultimately, to change. Doctors, unlike nurses (for example), are not rule-followers. Evidence Based Medicine, and National Service Frameworks, must remain the tool of Understanding Based Medicine. This is not for the benefit of doctors (although it has an important bearing on the motivation of doctors) but because it is the only way. For society to require doctors to abdicate their understanding-based role is foolish and very dangerous. The idea that join-up-the-dots-and-there-will-be-a-right-answer-to-everything medicine has arrived is an illusion based on the simplistic, distorted view of reality which is the current orthodoxy. This view undervalues not merely the complexity, subtlety, changeability and mystery of reality but, more importantly, the extraordinary (and largely hidden) ability of the human mind to cope with that reality, if it is allowed to.
The next stage of 'progress' may well involve our lightening-up and accepting that life is not perfectible, that risk cannot be eliminated and that the role of society is to celebrate diversity and to set the limits of acceptable behaviour as widely as possible, never to direct the details of behaviour.
This was partly because there was no prospect of the necessary technology becoming available (We often forget how little the micro-electronics revolution was predicted. At that time we were more concerned with colonising the stars) But more importantly, robot doctors were a joke because the principal of professional independence and clinical freedom was basic to the our notion of what it meant to be a doctor.
We GPs took advice, of course, from our visiting consultant colleagues, but in the end it was clear that the decision and the clinical responsibility remained our own. They certainly never gave us instructions.
And so it was with the professional organisations. The GMC had been in existence since 1858,and it took a long time before other advisory bodies began to appear. But as they did so the advice began to appear more and more like instructions.
Abstract
The National Service Frameworks are a particular case of a problem endemic in the modern world: the next stage of 'progress' appears to necessitate systematisation and central control.
Many years ago, and for some forgotten reason, I pushed a bed through the streets of Alton dressed as a robot doctor. My costume consisted of my wet suit, a pair of old sailing boots sprayed silver and a large cardboard box (also sprayed silver) over the top. I had decorated the silver box with knobs and dials and rivets and a notice which said 'RoboDoc - I speak your fate'. There was a transparent plastic lid fixed on the front, containing a telephone handset, and labelled, 'Break glass for second opinion'.Full text (with illustrations)
The growth of the giving-doctors-orders industry
In those days the interface between primary and secondary care was not something we talked about very much, because all the consultants from the District General Hospital travelled the fifteen miles once a week to do clinics in our health centre and we met them on a daily basis. And the idea of being a robot doctor was then very much a joke.The giving-Doctors-Orders Industry
On top of this formidable list we now have all the new doctor-regulating bodies which were announced in last July's NHS Plan...
And in case you are wondering who regulates the regulators The UK Council of Health Regulators was announced as well. With the comment, "Its role could evolve".
I bet it could! (Return to the George Swift Lecture if you came from there for this list...)
Seeing the whole picture But I wonder whether anybody has taken the trouble to make this list of the organisations jostling one another to regulate doctors. If National Service Frameworks were the only one it would be fine. But each is the responsibility of a group of single-minded people. And each body, viewed in isolation, seems to be doing a self-evidently important job.
It is only when you stand back and see the list as a whole, and try to combine it into a world which works, that the madness appears. The exponential rise in doctor-regulating bodies that has marked the end of the 20th century then begins to look like a fad, like a playground craze.
But the world we live in does not see it this way. At least not on the official level. It makes a virtue of not standing back and seeing the whole picture. Focus and single-minded driving for specific goals are the watchwords of success in the modern world. Indeed that is the only way in which success itself is measured, is defined. Nobody knows how to measure and evaluate success across a broad field, across the whole of life, across the whole of a career. That is why nobody knows how to appreciate general practice. That is why, year after year, Doctor of the Year awards go to GPs who have developed a special interest, like my friend, colleague and doctor, Hugh Bethell, Doctor of the Year two years ago, largely and entirely-deservedly for his extraordinarily dedicated work in Coronary Rehabilitation.
It is perfectly understandable that this should be how things happen, but it does result in a devaluation of what the job is actually about - wholes, rather than parts. Hugh is indeed exceptional on that count as well, as it happens, but you will have to take my word for it, because there is no way of measuring or proving the fact. In fact, it probably can't even be called a fact, although it is certainly true.
General practice, buried deeply in the richness of humanity and life, presents Reductionism with its very Antithesis. But Reductionism hasn't condescended to notice. It continues to require general practice to describe itself in terms which deny its (general practice's) very nature.
It is absolutely clear from a close reading of the NHS plan is that this government is entirely in support of the principles of the NHS (which makes a wonderful change) and is genuinely doing what it believes to be best for medicine, (it is doing what it believes to be best for itself as well, of course, but that's fair enough - a great deal of human motivation comes from enlightened self-interest)
And it is a government that has been listening. They know about the concerns I am expressing today about over-regulation, and they know about our feelings about the importance of trust. Here is Paragraph 6.6, in which they try to deal with this:
"Because we trust people on the front line, the centre will do only what it needs to do, there will be maximum devolution of power to doctors and other health professionals"
But it comes too late - the true voice of New Labour has already blurted out its real thoughts in paragraph 1.22
"Doctors, therapists and nurses will increasingly work to standard protocols."
Professional Freedom, RIP
Pushed into a new way of doing things
To the government, to the media, even to senior members of our own profession, in fact to anyone who stands back and views modern medicine from a detached (yet, as we will see, arbitrarily-focussed) view-point, professional freedom, clinical independence, are already dead. And what's more, from their 'higher' viewpoint this looks like nothing but progress.There is indeed 'a new way of doing things' abroad. And we are 'being pushed into it'. But it is more complicated than that, because we are pushing ourselves into it as well. We can see the point as well as anybody can. We all feel that technology has given us a better way of understanding and running the world. That we have got a higher wisdom. But we are also ambivalent about the change. We sense something is wrong, and we can't say clearly what it is.
A distorted view
What is wrong goes something like this: the new way is based on a misunderstanding of the way the world works. It is based on illusions created when we view the world through artificial media. We base more and more of our actions on an artificially-constructed virtual reality which distorts actual reality in ways which are profoundly important but which are hidden.I have spent much of the last two years, including a six month sabbatical, studying this subject and writing a book about it due out in February, "Friends in Low Places". The book argues for the validity of the front line view of life and seeks to explain why so many things which seem good sense from on high seem like madness from on low. Given the undoubted fact that the observers in both positions include good, intelligent people who are acting in good faith.
This is a mystery which would excite far more attention if it were not for the cast-iron self-confidence of the current orthodoxy. The front-line view I am trying to express is not so much treated from on high with contempt, as totally ignored. It is simply not accepted as admissible evidence in the arena of serious debate. That is another phenomenon which I have sought to explain in my book. But from the mere fact that it is a phenomenon we perhaps glimpse an explanation for the extraordinary dominance of the executive in the contemporary world.
A higher wisdom..
The current orthodoxy, in spite of the governments bland statements about the centre only doing what it needs to do, is that, in a modern world, everything is best controlled from the centre. Management is King, everything must be planned, audited, modelled, accounted-for, assessed.
I only have time this afternoon for a brief account of three of the objections to this orthodoxy:
- It is untested
- It is based on illusion.
- It doesn't work.
1 It is untested
The reason it has not been tested is simple: nobody thinks it needs testing. The thought that it might do harm has simply not crossed the minds of those who are seeking to impose the change.
This, if I may say so, is foolish, and from an executive which increasingly expects individual clinicians to base all their actions on scientific evidence, it is both logically and morally indefensible.
The possibility that drugs taken in early pregnancy might harm the developing foetus never crossed people's minds until the Thalidomide disaster. We find this difficult to remember because of the central importance that teratogenicity plays in our current thinking about drug safety, but by all the parameters against which drugs were then measured, Thalidomide stood out as outstandingly safe.
And we still forget the real lesson of the Thalidomide disaster, which is not that all drugs can have unforeseen side-effects, it is much more fundamental than that - all innovations, of any kind - not 'can', but WILL - have unforeseen consequences. Danger comes from the unforeseen, almost by definition.
Is it really necessary for a country-hick GP, with virtually no academic record, to point this out to a meeting held at the Royal College of Physicians?
I'm afraid that it is.
It may even be, and David Vicary asked me to be controversial, that the problem is only fully visible to the kind of country hick GP who once ran through the town dressed in a cardboard box.
"You're the doctor"
From my perspective it seems that during the last very-few years, if not months, our profession has found itself drifting across a perilous - and absolute - divide.When I used to take advice from, say, the cardiologist it was on the basis of mutual respect. Of course I 'took' the advice. But that was still the basis on which it was given - as advice. I could have practised for a whole career without the difference ever showing, but even if I never diverged from the advice on a single occasion, that difference would still have been absolute.
We were both independent professional people, independently responsible for what we did. If I did what he said and it was wrong, the responsibility was mine. He gave, and I took, advice on that understanding. That is the privilege, the challenge and the solemn responsibility of being a doctor. The government may now think otherwise, indeed it is quite clear that they have absolutely no understanding of these matters at all, but our patients do understand it, and that is still the role they expect us to fill.
When they say "You're the doctor" (and they still do) they are saying something profoundly significant. Which has to do with the profound change that comes over the world's perception of a doctor as soon as he qualifies, moving on that instant from being (for example) one of the worse motor-insurance risks - a medical student - to one of the best.
Nursing is different
Patients do not say to nurses, "You're the nurse." At least not in the sense, "Come on, give me the answer, weight it all up, tell me what to do, I know what the book says, what the rules are, but what do you think?". Nurses are rule-followers and that is what they are happy to be. That is their role. I know a lot of nurses well and they see it as absolutely natural to work under protocols.
If protocol-following in nursing is natural, protocol-following in medicine is a cop-out. It is a seductive trap and there is a real possibility that it could have disastrous consequences, not for doctors themselves (that wouldn't matter much in the last analysis) but for Society. There is a real possibility (likelihood, I would say) that needs to be tested that society needs real doctors, even if for the time being it has forgotten the fact. Otherwise, the next time something really unforeseen happens it may this find out, too late.
2 It is based on illusion
Both sources of information, natural and artificial, are astronomically selective. The infinitesimal proportion of our natural, sensory experience which reaches our consciousness is perhaps not that different from the proportion of world events whose news reaches us through the media. But there is a crucial difference, in the one case our subconscious mind does a phenomenal (and almost entirely forgotten) job of vetting the whole of the incoming experience to see what, if anything, is important, and in the other case the vetting is all done before the picture reaches us, and we simply don't construct the background context which is maintained so automatically in our subconscious minds.
But both pictures look the same, and the distortion of the artificial picture is largely hidden. The mediated news of a boy of three dying of flu in China seems to make an impact very similar to the direct person-to-person experience of a child in the next street being killed in a road accident. There is an inherent fault in the way we process artificially-mediated information. We have simply not been equipped by evolution to make sense of our newly enhanced experience.
No audience of doctors needs to be told about the phenomenal power of the media to highlight the exceptional horror story and ignore dull normality. We know about trying to persuade people to have their children immunised while the media sing and dance about one adverse reaction and utterly ignore a million successes.
The Utopian illusion
Modern medicines are the safest and the most effective the world has ever known and people have never been so worried about them. The same remarks, broadly, apply to modern doctors.Of course a lot of the improvement has been the result of the kind of regulation we are talking about, but the point is the same - there is no end to it. We have made progress but the calls for further progress get more, not less. People are never satisfied. Patients are more dissatisfied, litigious, vengeful in the new world than they were in the old. I can only see this getting worse unless we confront the Utopian illusion head on.
Stand far enough back and nothing is safe. It's illegal, it's immoral or it makes you fat. From the detached view, everything is dangerous and no-one can be trusted.
"If you believed everything you hear you wouldn't know what to think. One minute something is a good thing to take and the next minute it's not."
(Listen to what the patients say, they are telling us something important...)
Our society is suffering from an obsessional neurosis, paralysed by a host of dangers which it has no means of getting into sensible proportion. Choruses of voices crying 'wolf' on every corner. Blind to the subtle balances of real life...
It is no longer good enough to practice to a standard which means you never make a mistake yourself, you have to practice to a standard which will eliminate the risk of a mistake happening at all. The soup is thickening up, we have less and less room for manoeuvre. We have simply not begun to ponder the consequences for doctors' motivation and satisfaction now that doing the best you can is never good enough.
On the personal scale: the presumption is innocent until proved guilty,.
On the media scale: the presumption is guilty until proved innocent.
Inevitably... that is a colossal difference.
We are all Shipmans in the governments eyes until we have been proved not to be.
Fundamental flaw
But there is a more basic problem still.
The quantified, reductionist approach, at least when it is applied to the humanities, is fundamentally flawed. It might perhaps be nice if life was as simple as that, but it isn't.
Life is not a simultaneous equation and it does not have one right answer, however complicated and refined we think we could make that answer. Sometime soon it may well once again appear incredibly naďve for us to have thought that it was that simple.
But at the moment the idea that you ultimately can't model reality with any machine is not entertained by the orthodoxy at all. But for those who take the trouble to study the evidence (yes, the Evidence, with a capital E) the fact is that Roger Penrose and Kurt Gödel have settled the issue - reality is non-computable.
3 It doesn't work
So if you can't model a physical thing like that and get it right, how on earth is the government going to succeed in its aim of modelling the unimaginably greater complexity of the entire National Health Service and get that right?
As it happened the Minister of Health was making his statement to the House of Commons about the Shipman case at about the same time that the millennium footbridge fiasco was unfolding on the river outside. Without apparently spotting the irony, he said he was going to introduce systems of new checks to make sure that there would never be another Shipman.
A higher wisdom?
- There is a call to a 90 year old clergyman's widow who has recently been in hospital in heart failure and who has come out on Warfarin because somebody found she was fibrillating. Yes, 90 years old, but the protocols say that 'age is no bar to treatment'. I've been called because she is passing black, tarry stools and feeling faint. And here I am trying to persuade her to stop the Warfarin immediately...
"Are you quite sure, Doctor, won't my blood go thick?"
- A man in his late 80s, also just put onto Warfarin for fibrillation, life now dominated by the palaver of getting to the anticoagulant control clinic and terrified by the interactions listed in the warning sheets.
But, "They tell me I'm a prime candidate for a Stroke, Doctor."
Tell me how I can remove that cloud from his precious final years! And all for what? What is the numerical benefit of anticoagulation in a man of 85, compared with his previous low-dose Aspirin?
The point we can never quantify, never prove, is the enormously greater harm that has been done to his image of himself as a healthy person. As so often, the things you can quantify, measure, and turn into a protocol are the least important things.
We GPs have nothing to crow about. All over the country, GPs are even now checking cholesterols just as inappropriately in order to get the Audit figures for their cardiovascular secondary prevention programs above the thresholds that trigger various payments, or which avoid them being 'named and shamed' in the increasingly-ubiquitous league tables. Don't tell me that the empty box in the ALIVE template doesn't reproach you, or your partners, until you fill in the Cholesterol in every case.
UBM - The Heart of the Matter
There are two views of life, and we assume that the new, technically-enhanced view is better. We assume that there is a new, higher wisdom and we have lost our confidence in our own experience and our own judgement. We have become wearily used to being second-guessed by system.
Everywhere we see the evidence that people have simply given up the expectation that they will be able to understand. That timeless desire to take things to pieces and see how they work is atrophying. We no longer expect to be able to understand how things work. We look up the book, the website, the warning sheet and just do what it says. What's worse, we make a virtue of doing so.
But all too often what it says is nonsense. 100 carat, scientifically unimpeachable, evidenced-based, nonsense.
Doctors cannot abdicate their underlying responsibility and remain doctors. We hear a great deal about Evidence Based Medicine but what we do NOT hear is indeed the "Heart of the Matter" - Understanding Based Medicine. We do not hear about it because, again, it is taken for granted.
But doctors practice on the basis of Understanding.
That is what makes them doctors.
That is why we go to medical school to learn.
That is what we go to conferences throughout our careers to maintain.
The fact that medicine is vastly more codified than it was in the past makes this to some extent easier and to some extent more difficult, but the basic fact goes on. We are not automata. We are not RoboDoc - join-up-the-dots-and-see-the-answer-in-every-situation. We all know that rules can be nuclear weapons in the hands of the second-rate, who apply them without understanding. Rules can be a catastrophe in our hands if we apply them without understanding, or worse, without discretion. We must remain real doctors, even though the difference may not be apparent on the outside, to the world, to the Government.
But get close to ordinary people, one-to-one, and they can tell the difference for sure.
Conclusion
The current orthodoxy that medicine can be defined in systems of rules and controlled from the centre:1. has not been tested for its likely adverse side-effects
2. is based on illusions about the way reality operates
3. doesn't work.
The next stage of 'progress' may well involve our lightening-up and accepting that life is not perfectible, that risk cannot be eliminated and that the role of society is to celebrate diversity and to set the limits of acceptable behaviour as widely as possible, never to direct the details of behaviour.