These are difficult times for the NHS: junior doctors in dispute with government, recruitment (particularly general practice) difficult, many doctors leaving the profession early or working abroad. Why? The February 2016 issue of the British Journal of General Practice (BJGP) includes several articles on practitioner morale and mental health. One of these is based on interviews with GPs in England who had left practice early. In terms of reasons given, the overarching theme was the ‘changing role of general practice and its impact’. The sub-themes were: ‘organisational changes, clash of values, increased workload, negative media portrayal, workplace issues and lack of support’.
Like all other NHS roles GP work has become ordered by procedure. This reflects the dominance of science with industrial process. Yet science and industry are blind to much human suffering. Here are two examples:
The knitted glove
You come into my office wearing a blue Knitted glove with a ribbon at the wrist. You remove the glove slowly, painfully And dump out the contents, a worthless hand. What a specimen! It looks much like a regular hand, Warm, pliable, soft.You can move the fingers…
… This thing, the name for your solitary days, For the hips, the hand, for the walk of your eyes Away from mind, this thing is coyote, the trickster. I want to take it by its neck between my hands. But in this world I don’t know how to find The bastard, so we sit.We talk about the pain.
Mohamed has been in the UK with his wife and two young children for 12 years and is currently unemployed. He is obese with a BMI of 32, has type 2 diabetes and hypertension. His blood sugars are poorly controlled despite medication change. The GP revisited Mohamed’s diet. He said proudly that he ate ‘very nice food’.This turned out to be two large meals a day of deep fried chicken and chips at one of the many fried chicken shops in the area….He lives in an apartment with 17 other mostly family members, with four beds shared on a rota. His social life revolves around the chicken shop. Mohamed is a content man, happy with his lot.
Adapted from Martin Marshal, BJGP Feb 2016
GPs will recognise these stories – they are part of the job. With Jack Coulehan’s patient, science and industry have nothing to offer. In the case of Mohamed, if we fail to improve his diabetes medically, our income will fall and our competence will be questioned. These cases will demoralise doctors, but in different ways, each represents a failure of the biomedical paradigm and the industrialisation of healthcare. So what can be done about the misfit of expectations and reality?
Martin Marshall’s article, (Mohamed’s story) focuses on coping with the uncertainty deriving from the incompatibility of the unique individual and the standardised protocol. His first ‘way forward’ is to restate, in his own words, HL.Mencken’s famous aphorism: ‘For every complex problem there is a solution that is neat, plausible and wrong’. He goes on to suggest ways of clarifying and ordering the complexity, calling upon ancient wisdom, new business practices and research. BHMA founder member and GP, Dr David Zigmond, would suggest that this is attempting to turn Wilder-Ness into Orderly-Ness. Of course, this Wilder-Ness is real life. How could we imagine that science, theory, abstraction and industrial procedure could entirely capture the crooked timber of humanity?
So what is to be done?
The BHMA is on an ambitious journey to rediscover the human qualities: the skills and especially language needed to counterbalance the hegemony of science and industry. There is an extraordinarily rich domain of ‘treasures in the mist’ that show us how to approach these difficult problems. By the time you read this, a major new feature will be available on the BHMA website (www.bhma.org) the Dimensions of Being Holistic – a treasure trove. For the Coulehan story try the ‘intuitive’ dimension. For Mohamed try ‘community-minded’. Then browse the other ten dimensions. There are also many more recent sources in the back issues of this journal and also, for example, the February 2016 issue of the BJGP. If we do not find a set of solutions to these problems we risk losing the best of our practitioners from the profession.