Getting out while I still could.

Getting out while I still could.

I recall that about half-way through my medical career I had a premonition of the problems with patient dissatisfaction  that we are now see. It was therefore with dismay, but no real surprise, that I read the results of the British Social Attitudes Survey on patient satisfaction with the NHS and social care. This has shown that growing dissatisfaction continues; now only 57% of people were satisfied with their healthcare while nearly a third (29%) were dissatisfied. These were significant changes, and deterioration, from previous reports and there was a particular drop in satisfaction with General Practice services. Primary Care had previously been the jewel in the crown of the NHS but now was viewed little better than other areas of the NHS. Some areas barely managed a majority of the population feeling satisfied (A&E for example at 52%) and these are generally worrisome figures.

These rates of satisfaction should alarm us. We often hold up the NHS as the “envy of the world” despite its relatively lacklustre outcome measures. We are now watching it slip to the bottom of league tables, of developed European countries, in public satisfaction as well as in performance. Why is this ? It does not seem that it is due to sudden increases in public satisfaction with other European services (though they have generally modestly improved their scores on this matter). It is because of an increase in dissatisfaction with the NHS’s provision and people cite unhappiness with inadequate staffing, delays in being seen, and poor quality of care. They tend to view this as a consequence of inadequate funding and government interference.

These two factors will, without any doubt, foster and magnify dissatisfaction but I am unsure that these factors are as important as they might initially seem. European healthcare funding has been squeezed in all countries but other countries have not witnessed the deteriorations in satisfaction we have observed, indeed, some have even seen slight ongoing increases. It is difficult to quantify government interference but it is a safe bet that this has not been absent in any of our comparator countries. But could there be another factor underpinning this dissatisfaction ? I thought I felt the start of this change many years ago, and this premonition, lead me to leave the practice of medicine earlier than I might otherwise have done.

When I finished University and started working as a practicing doctor I was full of enthusiasm and keen to learn and use new skills. I saw myself as a medical technician; the better I could be at various techniques then the better my patients would fare and the more satisfied I would feel. This was a useful approach, it spurred my education and learning. When a young doctor I had little time for the “professional” hokum that my seniors espoused. It seemed to me to be a way of holding onto power in the face of technological change and advancement they seemed to be using calls to “professional standards” as ways to obstruct needed change. I was certain that I would never become an old reactionary like them.

But time progressed and I learnt my craft and I started to realise that technological skill was only one aspect of healthcare. There was also a large number of other skills that were necessary, political ability for example, to effect change. I also learnt through my successes and, more importantly, failures that there was an art to the practice of medicine which was as important as my knowledge or technical ability. I know that the times that I failed patients it was rarely through ignorance or ineptitude but rather because of a failure to relate to the patient equally and fairly. I recognised that when I failed; it was the times I rushed, did the job but little extra, and paid inadequate heed to the opinions of the patient or their wishes. I started to recognise that I needed more in order to be a decent doctor and began to discover the importance of professionalism.

I grew to learn that professionalism was an asset for both me and the patients I worked with. The NHS was changing around me, a culture of target setting and central planning was reducing the autonomy of clinicians and reducing the choice for patients. It is often said that patients have difficulty in making healthcare decisions due to the knowledge deficit and that they are almost wholly reliant on their medical attendants in order to make these decisions. This is not the case. I grew to be very aware that one skill that patients have is the ability to distinguish between good and bad doctors. They are much better at it than fellow professionals, they know who is good at the job and who is not. But unfortunately they do not get to make that most basic choice – the choice of whom to see, whose advice to seek and with whom they will work to improve their health. In the NHS these decisions are removed; you see the GP that covers your area and the specialist contracted for your area, the patient has little or no say in the matter. If they are lucky they will be paired with the best, on average they will receive average care, and if they are unlucky they may be stuck with the underperforming. You could be referred to the best doctor for people with Parkinsons  disease but if your problem is diabetes then this might be less than wonderful. Patients would rarely make this kind of mistake, systems often do.

This lack of patient choice was worsened by another aspect. The patient didn’t chose the doctor and the doctor increasingly didn’t feel that they worked for them as an individual. The central planning and target setting meant clinicians felt that their employer was the NHS, in its various bodies, not the patient per se. Targets were set at Health Board meetings not by patient-doctor discussion. Many times targets could be thought of as useful but a target which pays doctors to increase the number of people on statins might mean that the elderly man who went to see his GP because of loneliness and poor mobility might find himself on the bus back home with a prescription for a statin he had never thought he wanted. It may be beneficial for him, and it might reduce the cardiovascular morbidity of the group, but that had not been his issue and it is possible that the time taken to discuss the statin left less time to talk about the poor mobility and their fears about this. Taking a professional approach meant that, while we would try and meet the targets put forward by my employer, my first loyalty was to my patient and we had to address their concerns first, agree a plan of action with them, and only secondly try and mesh this with the central dictats which were aimed at improving the group.

Without this professional approach there was a great danger of starting to practice a little like a veterinarian. When you take your hamster to the vet, the vet assesses the hamster and discusses with you how you would like to proceed. If the vet informs you that you will have to sell your car to pay for the hamster’s surgery, or forgo a holiday, it is quite likely that the hamster’s days are numbered. We will all grieve for the hamster and agree that it was for the best. Increasingly I found that patients came to me for advice, for example with Alzheimer’s Disease, and I would consider whether we should start a cognitive enhancer. But I would not discuss this with the patient, who is now in the role of the hamster, but with the NHS prescribing group who was in the role of the hamster’s owner. They (Hamster owner/ Prescribing Group) often decided that economically it was for the best that we didn’t prescribe and while this was true at a group level (in health economic terms) it may not have been at the individual level.

These are always difficult decisions but they are difficult decisions that should be taken openly, after discussion, with the patient. The patient should be able to trust that the advice they are being given is the best advice for them as an individual not simply the best decision for the community. When patients choose their doctors they are seeking the best source of advice, advice they can trust because it is not skewed to meet a third parties interest.

In the NHS patients lack the ability to choose who they see. Doctors and nurses are  becoming increasingly micromanaged and their professionalism, and thus their independence, undermined. Together this leads to patients unable to work well with their medical attendants and unable to be certain that the advice given is the best available. It sets up distrust and discontent, they see that other European countries, with similar healthcare budgets to ours, do better by patients with common serious medical conditions. Patients read that survival rates for breast cancer in Britain are poorer than elsewhere and that we have more infant deaths than the European average. No matter how many politicians tell them that there are more doctors or nurses, or the NHS is doing more than ever before (which is quite possibly true), will counteract their experience of impersonal healthcare and poor quality outcomes. They will become dissatisfied and this dissatisfaction will continue to grow until the primary problems are addressed.

Until individual patients are again at the centre of how healthcare is delivered it is likely that even if we throw much more money at the system (which will probably be the electoral strategy) this discontent will grow. When we look back, we see the Tredegar Workmen’s Medical Aid Society made a great influence on Aneurin Bevan and influenced the development of the NHS. Unfortunately we seem to forget that the workmen in the Medical Aid Society chose and employed their doctors – they voted on who would be employed and sacked those that were felt inadequate to the job. I am sure this choice greatly enhanced the likelihood of patient satisfaction and is something that we need to rediscover.

Before my career had arrived at its natural end, I had premonitions that dissatisfaction by patients would be inescapable and lead to dissatisfaction in  clinical staff also. I could see the first changes in morale and attitude and felt I had to leave. I hope that I will be proved to be wrong in this prediction, as I have been on many others, but recent news has not given me cause for optimism.

 

 

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12 Rules for Life

12 Rules for Life

I watched an interview of Jordan Peterson by Cathy Newman recently and was rather surprised by what I saw. I was bewildered by Cathy Newman’s approach to her subject, she obviously found his views distasteful and was trying very hard to trip him up and reveal his dark and unpleasant, presumably misogynistic, side. She failed to do this and he remained placid, un-rattled, and replied fully and reasonably. Now I have seen her interview many people over the years and she is usually an excellent interviewer; able to debate with the best and able to handle herself in an argument She is, without doubt, one of the best news journalists we have on British television.  I was therefore surprised to see her have such difficulty with this subject, to the extent that at one point she was literally struck dumb and at a loss for words.

At this point I had not heard of her subject Jordan B. Peterson, a Professor of Psychology at Toronto University, nor did I know of his views. But, spurred by this interview, I read a little about him. It became clear that he has become very popular on account of his most recent book and also for his lectures on psychology which are available on YouTube. He is a clinical psychologist and academic who has made a bit of speciality of examining the role of religion in culture and personal psychology. But it became clear that this was not the reason for his widespread, and increasing, fame (or notoriety), this was because of his position on the issue of “compelled speech” (in regard to pronoun usage with transgendered people) and because he has recently published a book which has become a surprising best seller “12 Rules for Life : An antidote to chaos”.

The book, a self-help psychology text, has been very successful with young men and his position on free speech has caused him to be seen as a darling by the “alt-right“. The latter problem is a common difficulty experienced by those of us who try and safeguard free-speech. Those on the far-right often like to profess a support for free-speech as they think it protects them when they spew their bile, particularly their misogynistic or racist ideas. They do not realise that those who support free-speech do so specifically to be able to debate with such hateful ideologies and, through debate, destroy them. The best way to get rid of hateful erroneous ideas is to debate with those who hold them and make them, and their fellow-travellers, feel embarrassed and ashamed town such thoughts.

The fact that his book was popular with young men was interesting as this is a demographic not often drawn to reading. This in itself did not cause me concern, despite Cathy Newman’s obvious distaste for the book, but it did suggest to me that I should read his book. A quick trip to the kindle store and three days later  I was finished. It was a gripping read and one of the best books I have read in a long time.

To be fair this is a “pop psychology” book. It is written in easy chapters, each describing a basic rule. For example  “Chapter 6 : Set you house in perfect order before you criticize the world“, and so on. He writes well and is an erudite thinker with a wide knowledge base. He starts each chapter with a story to outline his thinking on the subject or rule. He then considers the cultural history and scientific knowledge about the issue before completing the chapter with practical advice on how to apply this knowledge to your own life.

Much of his thinking is based on current knowledge of scientific psychology but it is mixed with practical experience of working in clinical psychology, especially in working in the field of deep insight orientated psychology. He refers back to Jung, Neitzsche and Adler as well as to recent neuropsychologists. But perhaps more interesting is his use of knowledge of religious history. He looks at how the major religions have addressed psychological issues such as suffering, death, guilt and happiness and points out, whether you believe in a deity or not, that religion was mankind’s way of making sense of our life experience and many of the lessons learnt millennia ago are just as applicable today.

In essence, I discovered a very readable and wise book. I am glad it has been successful as it will prove much more valuable that many of the faddish self-help bibles which have come and gone. The chapter on parenting is a valuable counterpoint to many of the prevailing mistakes we are making today.  I found no evidence of misogyny or racism at all. Certainly there were some areas where he suggests that our evolutionary history has meant that some biological factors continue to influence our gender behaviours and he does not agree that this is entirely a social construct. Indeed, this might be his heresy. Today, we are meant to believe that all aspect of gender are socially constructed and that, barring organs of reproduction, there are no differences between men and women. This is clearly not true and the scientific literature attests to this. Unfortunately this is becoming a rather inconvenient truth and one that is not allowed to be said. I think this was the dynamic underpinning Cathy Newman’s interviewing style.

This is a problem. Womens’ rights have improved over the recent years but there is still a long way to go. If we are to obtain equality and fairness we will have to continue to fight for it. However, if there are uncomfortable facts, if there are biological factors influencing our behaviours, then we need to know about them and discuss them. It will not help our progress to pretend they do not exist and to cry “heresy” when people raise them. Biology is not necessarily our destiny but it has a bigger influence when it is ignored or denied; as a man I may be more prone to aggressive behaviours than a woman (on group averages) but knowing this only means I need to be more mindful. It is not an excuse and has no exculpatory power. For example, if I want to be a good man I need to know how to control and curb my aggressive instincts, to pretend that these  impulses are not there helps no one.

I think therefore, on this occasion, Cathy Newman was wrong. Rather then trying to explore or debate his ideas she tried to shut him down. Others, with a similar agenda, have  tried to minimise his works by smearing it, and him, as alt-right or similar. This means that his genuine insights are not considered but more importantly those young men who find meaning in his writings will be pushed and corralled into the area occupied by those who are indeed of the alt-right. This is a danger, as Peterson is aware, we need to help men to maturity and insight in our society, we need to make them more self aware, strong and confident because if you think tough men are dangerous, wait until you see what weak men are capable of”

 

 

 

 

 

Dr Zhivago

Dr Zhivago

I never thought it would happen. I almost thought it was impossible. But, I have found the situation when the film was better than the book, and not by a small margin : Dr Zhivagio the film is much better than the book. Dr Zhivago is a classic of the film-makers art, the book, on the otherhand, is an overlong and maudlin saga.

I remember well when I saw David Lean’s “Dr Zhivago” as it made an immediate impact on me. The photography was spectacular, there was an epic tale of revolution and chaos, upon which was played a moving love story. The whole thing was bound together by the magical music particularly “Lara’s Theme“, by Maurice Jarre, the leitmotif that glued everything together. Even today I only have to hear a few bars of this, or the opening of “Somewhere my Love“, to be instantly back remembering this film. Although I enjoyed and regarded the film highly it was initially a difficult film for me.

When I first saw the film I was a youth, a teenager, and a firebrand for the left. I found it difficult that a film as powerful as this was not a paean to the great communist revolution, but rather a shocking indictment of the treatment of the individual at the hands of the state. Being obstinate and foolish, as a lad, I omitted to read the book as I had the habit then of only tending to read what confirmed the prejudices I already cultured. I was therefore delighted when our bookclub decided to do Dr Zhivago, it gave me the chance to rectify a wrong and I would read Dr Zhivago, the book.

I knew the history of the book, I knew it had won the Nobel Prize for Boris Pasternak, and I knew that it was an important text in revealing the problems of totalitarianism. I had mentally filled it alongside George Orwell’s “1984” and  Alexsandr Solzhenitsyn’s “One Day in the life of Ivan Denisovitch“, both of which I had re-read recently and found excellent. It was therefore with expectant optimism that I started “Dr Zhivago”.

The first couple of days were fine, but as time passed my spirits sagged and my reading slowed to a barely perceptible crawl. I found the text dense and difficult, there was far too much detail which failed to add to setting scenes or developing characters or relationships. The frequent use of multiple, different names for characters was occasionally confusing. The story was rather jumbled in its chronography and relied heavily on coincidences for plot development, many of which were very contrived. None of this was helped by the poorly drawn characters who failed to engage with me. In particular, our hero, Yuri Zhivago, is rather dislikable; arrogant, self-opinionated, a philanderer and user of women. He is a poor example of the individual in a book promoting the Tolsoyian ideals of the individual.

I have to confess that I could not continue reading after a third of the way through and I cheated. I switched to Audible and had Philip Madoc read the remaining two thirds of the book to me as I walked the dog, fleshed the sheepskins, or cooked the meals (It’s 18 and a half hours long on audible). But this was the only way I could have completed my task. I found it difficult to see why the book won the Nobel Prize for Literature as I agree with Vladimir Nabokov who found it “a sorry thing, clumsy, trite and melodramatic” and presume it won for its political impact rather then its literary merit. All in all a great disappointment but did reveal that my earlier prejudice that the book is always greater than the film was wrong.


P.S. Since then I have started to reconsider whether Christopher Isherwood’s “Goodbye to Berlin” is better than Bob Fosse’s “Cabaret“, this is a tight contest.