Standardisation of medical services – increasingly by electronic monitoring, mediation and management – has become equated with ‘best practice’. This seems to offer undeniable practical benefits: clarity, uniformity, reliability and ease of transmission. But does anything get lost? If so, what? how? why? This short exploration draws from authentic situations in primary care: a ‘heartsink patient’, and a problematic professional meeting. Usual conventions of disguise assure discretion.
We all want to be healthy. No one wants an unhealthy existence. And the job of government is to help people live healthier lives.
Andrew Lansley MP, Secretary of State for Health, 23 January 2012
When you have duly arranged your ‘facts’ in logical order, lo, it is like an oil lamp that you have made, filled and trimmed, but which sheds no light unless you first light it.
Saint-Exupéry, The Wisdom of the Sands (1948)
Dr Q inhales Harry’s fatalism involuntarily. It is not just the lingering and residual odours of his staple props – his nicotine and alcohol – but his anguish-laden physiology. This continues to signal Harry’s troubles, both despite, and because of, his almost unceasing attempts to chemically banish, or at least quell, his morbidly echoing memories, his shame-leeched self-prophecies. Dr Q has come to surmise that such trapped and stultified internal worlds emanate particular kinds of energies and odours: that the physical experience becomes encoded, then signalled – in our sweat, our breath and in myriad thermal and electromagnetic transmissions we are usually unconscious of. He remembers an old designation connoting something similar: the ‘heartsink patient’.
Dr Q has learned to be stoic and philosophical: he can look forward to enlivening counterpoint – very different people who energise the room with an aura of faith, trust and optimism. Reflecting on this, he now recalls conversations a couple of decades ago, when there was much talk of personal ‘vibes’: he never explored what scientific research has been done in this area, but his daily experience reminds him with recurring and fresh evidence of its power and centrality.
Harry’s fatalism can be perceived more consciously, too: his trudging gait, the downcast gaze avoidant of the new or the personal, the sagging voice that has not the resolve to complete its message, his clothes and hair – clean enough – but habitually tousled, drab and dank.
Dr Q has known Harry 15 years, and has witnessed and gleaned the story of Harry’s cumulative desolation. In recent times Harry’s already impoverished self-confidence was dealt a series of grievous blows: a marriage floundering from his difficulties of expression and extension, then foundering on their (his) infertility and poor employment prospects, then finally torpedoed by his wife’s break-out: an affair with an ‘old friend’ – a confident, successful and expansive man whose attractiveness and fertility was soon evidenced by the pregnancy of Harry’s future ex-wife.
In earlier times Harry conveyed to Dr Q descriptions and tales from his childhood. Of a father distant, fractious, discontent, hostile and critical. Of a mother softer, but lost in an ocean of melancholy. Her only child, she confided in him when he was old enough to ‘understand’. Of the unhappy basis of her marital bond: the accidental conception of Harry in an untried relationship, ten years earlier. Of her attempts to conjure love through their Christian faith; through another conception soon after Harry – an obstetric disaster which cost mother her newborn, her womb and her future fertility.
Harry’s childhood was spent trying to appease, comfort, compensate or placate those who gave him life. He could neither understand nor succeed.
Dr Q intuited something of this massive disseminated damage on their first encounter; later meetings confirmed and detailed. Dr Q’s fuller portrait and biography of Harry grew slowly: piecemeal and opportunistically, for Dr Q was always careful not to encourage disclosure more than Harry could bear. Harry developed a reticent and shy trust: Dr Q sensed a flickering, bruised warmth.
Dr Q enlisted support. Psychiatrists at the times of Harry’s greatest incapacity, counsellors when he could motivate himself a little more. Harry complied and they provided, at least, periodic containment for Harry and supportive respite for Dr Q. But Harry is a man of few words and little appetite for schematic enquiry: he did not respond to formal attempts at psychotherapy. His desolate view of himself and his world remains undiminished.
Harry does, however, entrust very limited aspects of himself to others. Now in his early middle-years, he has complied with his GP’s practice screening programme. His blood lipids, checked for the first time, are found to be high. Dr Q remembers, too, Harry’s response to the doctor’s gentle enquiry regarding his feelings six months ago: Harry’s father had just died suddenly of a heart attack. Harry had shrugged with a kind of glum defeat: ‘he was never much of a father to me … now he’s not here at all…’.
Dr Q was then mindful, not just of Harry’s stunted grief, but of the portents, for Harry, for such a death. His emotional tangle of recent-upon-ancient frustrations and hurts, increasingly swallowed down with self-anaesthetising doses of booze, fags and factory foods augured badly. Now with father’s sudden death these portents seemed clearer still: a sharpening prophecy.
The practice receptionist’s request for Harry to see Dr Q about his lipids was a standard procedure: ‘to identify, discuss and take action regarding remediable risk factors’.
At the end of the last meeting, in the fresh shadow of his father’s death, Dr Q had raised those specific concerns, again. The themes were old: the clarity was new. Harry responded with a rare vein of articulation, caustic and taut: ‘I know your job is about saving lives, doctor, and I’m grateful for your kindness with me, but I’m not sure I have the kind of life that’s worth saving … We can’t all choose our lives and we’ve all got to die some time’. This quiet, courteous coda was undramatic in delivery, but arrestingly bleak in meaning. Dr Q had time only to express benign intent and tell Harry the bridge is always open.
Six months later, as the door opens, Dr Q knows it is Harry, booked in to discuss his lipids. These excess lipids may be the designated problem, but they represent the mere biochemical tip of a vast psycho-spiritual iceberg.
Dr Q holds his breath momentarily; he braces himself as he thinks: ‘How to help Harry?’.
Stella has many similar meetings to address: her working days and diary are full. She has a friendly but business-like, diplomatic manner. This is reflected in her attire: trim knee-length navy skirt, cream blouse, discrete pearl earrings – a kind of uniform, smart but not alluring. Dr Q notices she is wearing her NHS Trust ID card around her neck, an emblem not just of how busy she is, but who controls her. This is a managed excursion.
Stella, though not herself medically trained, is the emissary of an expert group concerned with reducing cardiovascular disease. This committee has devised strategies and procedures which will be enacted by all relevant health practitioners. Stella’s job is to brief and instruct the practitioners: to assure professional compliance for The Plan. Such compliance relieves practitioners of individual judgement and discrimination: The Plan prescribes and directs. Invisible experts decide.
Dr Q is sitting amidst his peers, local GPs. Stella is explaining the latest addition to The Plan. A new computer programme is being introduced. The practitioners will feed in the relevant clinical data, and the computer will calculate the statistical chance of morbidity and mortality. This ‘scientific’ prediction is then shared with the patient for discussion and action. The GPs will receive an extra payment for compliance: Dr Q notices the galvanising ripple of interest and attention.
Dr Q recently attended his own GP and received the kind of consultation that The Plan spawns. Dr Y was young, brisk, authoritative. Her attention was rapt to the computer screen, where she quickly garnered and collated abstracted data. The computer prophesised favourably for Dr Q’s fate. Dr Y spoke for The Oracle, as she turned from the computer screen towards him: ‘That’s not too bad, not too bad at all…’. She illustrated her prognostic cheeriness with some itemised statistics. Her smile seemed winsome, but Dr Q wondered who the smile was for: he was doubtful how much she had really perceived him. There had been little real discussion. Beyond medical questions, she enquired little. Dr Q did not introduce himself as a fellow GP: his curiosity was then roused, to see what a ‘standard’ consultation was like. Was the smile another impersonal, though decorative, generic procedure? What is a smile to someone unseen?
Dr Q is thinking about Stella’s financially-enhanced instructions, his own experience with Dr Y and how these would be templated with Harry. As he understands this, he is being paid to prime the computer, which then primes him to then say to Harry something like: ‘Harry, we have fed all your available personal and family health and lifestyle data into the computer programme. Your computed five-year risk for combined cardio/cerebrovascular events is 38.73%. This comprises a 14.71% mortality group, leaving another 24.02% with significant morbidity events. For your age group, this is very high risk … We can provide you with category subgroup differential analyses, if you wish …’
Dr Q is wondering how such formulaic and statisticised thinking or communication can possibly further help Harry, or many others that Dr Q sees. Dr Q’s monitoring and conversations, for many years, have approached the complex issues of self-protection and self-care, but in a form and language that are personal and vernacular – not those predicated by the technical: tethered to the computer, or decided by distant expert committees.
Dr Q puts such notions to Stella. He adds that he has long-regarded what, when and how to share with each person, in each situation, as a delicate, complex but fundamental skill in medical practice. A good example of what anchors holistic medicine as an interpersonal art, a humanity.
Stella listens politely, nodding periodically, looking tired. Dr Q imagines her nodding represents fatigued diplomacy, rather than engaged understanding.
She reiterates how the computer programme has been designed by a team of experts, and it behoves us to follow their lead. In addition, conveying quantitative information to patients, in a way that can itself be quantified, confers clear advantages to the management of practitioners, in their management of patients. ‘I think you’ll agree, doctor, it will make your treatment of these patients more scientific, and that has to be good for all of us…’
Dr Q thinks Stella is proposing this – especially her emphasised word ‘scientific’ – as an ineluctable summary. But Dr Q has many doubts and caveats. How to engage and interest another person in changing deeply established psychological patterns regarding their relationship to themselves, their body and their fate is often not a simple matter of data, formulation and instruction. Such complexity requires thoughtful investment in interpersonal interest, contact and understanding: activities far less accessible to quantification and science. Will not The Plan eclipse these subtle but important endeavours?
Yet Stella’s declamation on the uncontentious blessings of anything that appears scientific represents a wider, currently thriving, kind of hypnotic rhetoric – a cultural ideology. The presentation of an apparent vocabulary and syntax of science becomes more important than its meaning for the participants. Appearing scientific becomes an end in itself, a new kind of Shibboleth. Science as a posture, a garment, a cultural or status commodity becomes scientism.
Dr Q attempts to courteously and concisely condense this for Stella, but she is now more restive than receptive.
Look’, she says, ‘you don’t have to think about all that, because you’ll be paid for it’: a tired teacher attempting to control the end of a difficult class.
Another doctor, Dr S, turns to Dr Q, looks at his watch impatiently and offers Stella tetchy support: ‘Yes, I can’t see what all this is about. What won’t you understand?! You’re getting paid for it!’
Dr Q thinks he does understand, very well. But he remembers different kinds of meetings, 20 years ago, where they had very different kinds of discourse. He found these much more valuable. He would like to talk with them now about how to help Harry.
Information is pretty thin stuff, unless mixed with experience.
Clarence Day, The Crow’s Nest (1921)
Interested? Many articles exploring similar themes are available via http://davidzigmond.org.uk.