The Other Side of Medicine

Dr. Peter Tate, Sally Irvine

• Publisher: CRC Press
• Year: 2020
• ISBN:
  9781315347189
• Edition: 1
• Topic: Medicina
• Subtopic: Salud pública, administración y atención

"The Other Side of Medicine" is an amusing and challenging reflection of changes and fashions in general practice. Covering various themes including humanity in medicine, communication, and quality assessment of doctors, Peter Tate offers an abundance of personal anecdotes and patient perspectives. Doctors, particularly general practitioners, their trainers and examiners, and medical students will find this romp through a half century of medical life invigorating and invaluable. "This book is a collection of articles and short stories covering a medical career. Some are iconoclastic, the theme of good communication in medicine runs throughout, other themes are quality in doctors and the assessment of that quality but I hope the main strand of the book is humanity in medicine and my attempts at understanding what that is." - Peter Tate, in the Preface.

Chapter 1

Does thinking make us stupid?

Cleverer people than I have mused on the evolutionary merits of intelligence. We have found no fossil trilobites with big brains, and they were around for aeons of geological time. Then the wonderfully big dinosaurs ate, fought and farted around (literally) for a huge time span without ever finding the need to develop mobile phones. So why in the last few seconds of geological time have we evolved intelligence?

Looked at dispassionately, intelligence has not been an unmitigated success. We can destroy ourselves on a scale undreamed of in the animal kingdom and, with our capacity to meddle on a large scale, we can now destabilise our planet even quicker than the vagaries of the cosmic forces that surround us. Human scientific progress is now happening on a scale so fast that makes no sense when compared to the relatively slow pace of evolution, even in human history. After all, since ‘intelligence’, progress is certainly not relentless. Those wonderful and esoteric Egyptians came from nowhere to instant technological wizardry, the Great Pyramid is still literally unbelievable, the second impressive but not as good and in no time they couldn’t build them at all. They could still mould King Tut’s awe-inspiring funerary mask 1000 years later, but they carried on going backwards slowly for another 1000 years till Cleopatra finished it off for good.

Ah, I hear you say, but what has all this to do with general practice? Well, my thesis relates to the dominance of intellectualism over instinct. The real problem is that we are not clever enough; our much vaunted intelligence is pretty superficial and to understand things at all we have to reduce complexities to simple building blocks, thus distorting the true nature of the phenomenon. The number of blocks gets nowhere near the mystery of the Great Pyramid; an equation cannot describe the beauty or the mind-numbing infiniteness of a Mandelbrot fractal. A Manchester rating scale cannot do justice to the subtleties of doctor-patient interactions, and a deep understanding of the Krebs cycle doesn’t help most doctors to cure anyone. On top of this, we become ridiculously possessive and overbearing with the bits of knowledge we have gleaned. Take the health professions. Cholesterol is bad for you as is too much fat, smoking is anathema and obesity is a dangerous state. All such statements have some truth in them but take no account of values, human instinct or experience, and the real truth is much more complex, multivariate and capable of being viewed from many perspectives. Health messages become reduced to little more than slogans and the complex instinctive nature of human decision making is unacknowledged.

We have evolved to make decisions about situations and our fellows almost instantly, we are often attracted to another across a crowded room, sometimes we dislike on sight. We know from personal experience that our original impressions are mostly, but not always, confirmed. Human conversation is based on previous experience, unconscious observations, pheromones, feelings and hunches, but most of our teaching isn’t. We are a funny bunch, opinionated, aggressive and irrational but forever vaunting our intelligence.

You may not have guessed it but the underlying theme of this piece is communication and how we learn it and teach it. We all learn how to communicate from a very early age, and most of us are not taught in the conventional sense. When our teachers do attack us with subjunctives, gerunds, past participles, split infinitives and tell us we can’t boldly go, some of us are instinctively irritated, some of us make it a lifetime study and most just put such grammatical pontifications to the back of our mind to be remembered in exams and interviews but not important in our daily existence.

Now the thing is we are creatures with only a modicum of intelligence, but we do carry with us a barrel load of attitudes. What is an attitude? The OED says it is a considered and permanent disposition or reaction to a person or thing. Ī might quibble with considered as many attitudes I have are not considered, they just are, visceral, instinctive and sometimes clearly tribal. Some Ī am not proud of so I won’t tell you what they are and Ī spend a lot of my life hiding some of these attitudes lest Ī end up with few friends … are you any different? Alan Bennett’s wonderful Talking Heads series allows single human beings to display their naked attitudes for all to hear and makes for riveting, if depressing, entertainment; most human prejudices are attitudes too. Attitudes are only very loosely related to intelligence, they tend to come from the mid-brain, not the cortex; they are based on survival instincts and emotional feedback loops that are hard to dissect and often not amenable to logical understanding.

The point I wish to make about attitudes is that they govern our behaviour. Your heart may sink at this juncture and you may stop reading because this point is so obvious … all that for this! But, if you bear with me, I would just like to point out that most conventional educational theory implies, in some cases even states, that knowledge governs behaviour. The health educators are driven unceasingly (and fruitlessly) by this belief. I am not saying that knowledge does not change behaviour, but it only works when what is learned changes an attitude about, say, a procedure, a screening opportunity, or a loosely held attitude, say, for or against the legalisation of cannabis. This, of course, makes the point that not all attitudes are equal; some are much more entrenched than others and much less amenable to the voice of sweet reason. Here again I must disagree with the OED’s use of the word permanent; attitudes do change, but usually slowly. Now, if we doctors concentrated on finding out the attitudes of our patients to the slings and arrows of outrageous medicine, we might be more effective in steering our patients to doing what is currently thought to be good for them. Of course, the same applies to us, we have attitudes too. When ours clash with those of our patients we can only rely on ‘professionalism’ to help us through it, followed by a strong cup of coffee and a gripe to our partners. Trying to find out what our patients’ attitudes are implies that we are minded to do so, in other words we have an attitude to an attitude.

People’s attitudes are not necessarily what they say they are. This again is not a revelation but an uneasy truth about a common lie. In the MRCGP oral examination, for many years, examiners were taught not just to expose the attitudes of the candidate, for or against termination, for example, but to seek for the justification of that attitude. The argument being that you can’t really mark attitudes out of ten, but you can have a stab at rank ordering the justifications. This is not easy and one person’s justification is another’s bigotry. Justifications tend of course to be post hoc cortical intellectualisations of inherently mid-brain feelings. In the oral examination all candidates, without exception, claimed they believed in and practised the patient-centred method, and most could describe several consulting models and the concepts behind them to the satisfaction of the examiners. Then along came the video examination and only 10% could demonstrate actually doing it in the consultations they had selected to demonstrate just that. Here there is a breakdown in the theory; the stated attitudes do not lead to the stated behaviour, so the attitude must not be the real one, and candidates are fibbing. Why? This is one of the big questions for GP trainers and educators.

Practising patient-centred medicine is in fact pretty easy if you want to do it; you just have to listen, be curious and participate in a dialogue, not a monologue, but you do have to want to do it. Communication courses have, for years, used models of educational behaviour: tasks, strategies and skills abound. There have been many programmes full of skilful simulated patients, hours of dissecting videotapes, clever skill training workshops, and having witnessed 25 years of this sort of educational input personally as a trainer since 1976 and as an ‘educator’ contributing more than my fair share of tasks, performance criteria, etc., agonisingly slow changes in actual doctor behaviour. Again, why? The simple answer is that the majority of the profession still don’t rate patient-centred, evidence-based, shared decision making as worth the time and emotional effort to them and, if they feel like that, all the knowledgeable clever teaching in the world is going to make no or, at most, very little difference.

Actually, the majority of humans, as I have previously intimated, don’t need much teaching in communication. Many young registrars of my personal experience have become really ‘good’ communicators in the sense of involving their patients almost overnight, following a real attitude change brought on by an overbearing trainer or a realisation of the annoying consequences of failing the MRCGP video module. Of course, they can then improve, practise the skills till they become automatic and instinctive again, but the first and fundamental step is the change in attitude. If we think about our attitudes, then our intelligence might be useful. Get the attitude right by thinking, then let instinct, experience and evolution take over and the results are almost magical. John Lennon was wrong, all you need is attitude, but it has to be the right one, and there is the rub.

Chapter 2

What really matters?

We live in troubled times and this question is too broad for an easy answer. Dear old Maslow, the famous American humanistic psychologist, devised a six-level hierarchy of motives that, according to his theory, determine human behaviour. He ranked human needs as follows:

1. physiological
2. security and safety
3. love and feelings of belonging
4. competence, prestige, and esteem
5. self-fulfilment
6. curiosity and the need to understand.

His argument was that you start with need 1 and, if you are lucky, you progress to needs 5 and 6, which he unhelpfully labelled ‘self-actualisation’. Currently, most western GPs, and those who aspire to be one, are lucky. If, however, you see this list as an allegory of forever climbing onwards and upwards, like climbing a skyscraper for example, then the shakiness of the structure is only too obvious since the events of 11 September 2001. We have to live for the good tomorrow and continue to self-actualise as much as we can, so how can we help our registrars on this crucial journey? Ed Peile, a GP near Aylesbury, and two colleagues have published a paper in a rival journal that set me thinking, surely the main purpose of journals.¹ The paper’s title asks the important question: The year in a training practice: what has lasting value?

This is a personal column, so I considered my own story to see what had lasting value for me. I am able to look back with a reasonable depth of perspective because I was a registrar, trainee then, 30 years ago. A few personal details to set the scene: my dad was a single-handed GP, who had only my mother as help, as he consulted from a damp basement surgery in South Shields. He liked people, hated the NHS because of, as he perceived it, the Stalinistic second-class patronising nature of the whole organisation. He died, in harness, of myasthenia gravis aged 38. My experience of general practice was thus a cautionary one. When I qualified in 1968 I had no idea what I wished to do in medicine. Father was still working then and, though I loved him dearly, working with him in those conditions was not an attractive option. A bit of Maslow’s needs 1 and 2 was missing. So I did what many young doctors have done. I dotted around, trying a bit of this and that to see if anything appealed to me as a life-long calling. I moved down to London, The Royal Northern Hospital Holloway Road to be precise, and found that Sunderland General was better than I had thought. I went away to sea as a ship’s surgeon and was lucky enough to be promoted to senior surgeon on a big white P&O liner. The medicine was terrific, the responsibility awesome, the social life unbelievable, and the career prospects nil. A ship’s surgeon is an old-fashioned GP; the job description is that you do everything that needs doing, with the help of your team. For the first time I began to think that Ī really wanted to be a GP. I got off the ship in 1972 and moved into a flat in Southampton Row Wl, owned by my future wife. Training was not compulsory then and I toyed with going straight into practice; there were a couple of tempting offers, but a little inner voice told me that I was nowhere near the finished article and that I needed more help. I applied for a traineeship in Kentish Town and, against the odds, got it; to this day I can’t get over how lucky I was. Curiously, I wrote to my trainer at the end of the year, this was to thank him and tell him what I had learned. I was his first registrar so I wished to be helpful. I still have a copy of this letter and my toes curl with embarrassment when re-reading it, but it does remind me of my short-term perspective.

So back to Ed Peile’s question. What had lasting value?

Number one, without a shadow of a doubt, was the enthusiasm for general practice demonstrated by all in my training practice. This enthusiasm osmosed into my being over the year, and has remained there ever since. Looking back, I can dissect out bits of specific enthusiasms that were demonstrated to me. My trainer was currently sitting the MRCP examination, having gone into practice straight from pre-reg as you could in those days. To do this required an enormous amount of extra work, not just book reading, but ward rounds, etc. There was no obvious professional gain attached to this qualification for him at that time; it was a matter of pride and an external proof that Lord Moran was wrong about GPs just being those who were not good enough to climb the hospital ladder. I suppose the modern equivalent is the MSc or similar. The practice had two trainers, so I had the luxury of alternating tutorials, giving different experiences and different perspectives. I quickly discovered that my other trainer was very special too – a thinker, painter, polymath and an enthusiast for the College of General Practitioners. This was different for me; my father disliked the RCGP, certain that it was populated by self-seeking pompous people with inferiority complexes. This was a widely held view then, and is still current in some quarters. I learned then, and know now, that in that belief father was wrong. Before my first tutorial with trainer two, the trainer gave me a brand new book called Future General Practitioner: learning and teaching.² He asked me to read chapters 2 and 3 on the consultation and then we would talk about it. He modestly asked for my opinion as he was the main author and worried that it might be difficult to follow. It was; I tried to do as he asked and, slowly, a creeping terror enveloped me – I hardly understood any of it. I read it again and again hoping for the light to dawn, but it didn’t. At this stage of my life I was a sybarite, practical and un- but not anti-intellectual. This was clever stuff and I was not ready to understand it, but I was annoyed at myself for being so thick. This realisation that thinking was going to be a necessary prerequisite of good general practice was a much-needed jolt which has proved of lasting value. With the example set by both trainers, I started working too, and sat the still fairly new MRCGP examination at the end of the year. Something I had not even thought about on starting.

The same trainer introduced me to Bahnt; he was a member of the original group, and, although I have not become a true disciple myself, the insights about the drug doctor and the role of emotions in consulting were revelatory and permanent. Looking back, these experiences that related to thinking about consulting metaphorically took a lot of the stones from the ground and so, when I met David Pendleton some five years later, the seeds he sowed in my mind germinated because of my training practice experience.

I am lucky that my life is full of heroes. Henry Miller, the wonderful neurologist and dean of my medical school, was my first, and the aforementioned David P has the uneasy role of hero and friend, but my two trainers top my current lengthy list. This is not the same as role modelling; it is recognising special people who have enthused me in one way or another and so changed my li...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Preface
• About the author
• 1 Does thinking make us stupid?
• 2 What really matters?
• 3 Assessment: is it good or bad for training?
• 4 What are we training for?
• 5 Hypertension: a tutorial for our time
• 6 A retrospective look into the future
• 7 Mabel: an anecdote
• 8 The ICE man cometh: a painful tutorial
• 9 Making a difference
• 10 Trust me, I’m a doctor
• 11 Modern general practice and the laboratory
• 12 This is a fine mess you have gotten me into
• 13 The pursuit of happiness
• 14 Managing the conflict in the consultation between data entry and caring
• 15 To understand everything is to forgive everything?
• 16 Depression: another disease of our time
• 17 What is the secret of healing?
• 18 Where from and where to?
• 19 Waving not drowning
• 20 Measureless to man?
• 21 Good points first
• 22 The Pharaoh
• 23 Smallpox on a passenger liner
• 24 A big electrician, a bigger shock and the biggest ship
• 25 A terrible illness
• 26 Mickey