Tag Archives: Peter Aird

Saving the NHS – the struggle to manage increasing anxiety

Peter Aird

Peter Aird

Peter is a GP in Bridgwater, Somerset.
Peter Aird

Photo by hotblack at Morguefile.com

On the eve of the 1997 election, the year I became a GP partner, Tony Blair declared that the nation had ’24 hours to save the NHS.’ Twenty years on, like those who advised the emperor who paraded about town in his nonexistent new clothes, some politicians pretend they cannot see that the NHS is in the altogether perilous state of near collapse. One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

Be that as it may, what is certainly true is that the NHS cannot do all that it is being increasingly asked of with each successive year. This is for at least two reasons. Firstly, as science advances, more things become theoretically possible. But as Isaac Asimov once said ‘The saddest aspect of life right now is that science gathers knowledge faster than society gathers wisdom’. This is still true – not all that can be done should be done. The second reason, I think, is more fundamental. We live in an increasingly anxiety ridden society. Henry Thoreau wrote: “The mass of men lead lives of quiet desperation, and go to the grave with the song still in them.”

Undoubtedly some of our patients are, indeed desperate. Lacking the fulfilment that they desire, but don’t quite know how to realise, they are desperately anxious not to miss out on whatever it is that would give them satisfaction. Idolising absolute health, anxiety rises as their desire for the elimination of every problem, big or small, real or imagined, cannot be met. The constant endeavouring to solve every problem is exhausting and counterproductive, for both those with the problem and those trying to do the solving. As Leonard Cohen sang: ‘There is a lullaby for suffering and a paradox to blame’. Facing our weaknesses and accepting our suffering can be, I believe, paradoxically, comforting.

However this is a difficult philosophy to convey and one that is harder still to convince people of. So anxiety persists, together with its lonely companion, its accomplished accomplice, depression. Anxiety in all its forms is now so pervasive that I think it easily represents the most common problem presented to me at work.

Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

Firstly there are those patients who present with frank anxiety- by which I do not mean to suggest they have an irrational fear of Frank’s be that Sinatra, Zappa or D. Roosevelt. Rather I mean those patients that present with up front anxiety symptoms – panic attacks and the like. Then there are those patients who present with symptoms that they are anxious represent serious underlying disease. They are often hard to reassure, so twitched are they by the twitches that they experience. And then there are the patients whose symptoms generate anxiety in us – the doctors. We can be left concerned that we are missing something serious and fear what that might mean both for the patient and also for our own reputations – reputations that we cherish, perhaps, more highly than we ought. Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

I wonder how much of this is tied up with the current postmodern notion of relative truth and its recent spawned offspring ‘alternative facts’. Many have remarked that 2016 was a particularly bad year and perhaps, with all the terrorist outrages, natural disasters and political upheaval the year brought, not to mention all those celebrity deaths, we do all have good reason to be uneasy. But also concerning, perhaps more so, is the fact that the Oxford English Dictionary made ‘post-truth’ its word of the year – a decision that reflects that public policy is being decided based on appeals to personal emotions rather than objective facts. Paul Weller and ‘The Jam’ sang, ‘The public gets what the public wants’ and it seems today the public is at least sometimes promised what it feels it wants, independently of what it needs, because it is politically expedient so to do. I am left wondering if all the anxiety we see, and feel, stems from the fact that, with the throwing out of the still clean, clear bathwater of objective truth, we have thrown out the baby of any sense of assurance.

If nothing is certain, how can our patients be anything but anxious about everything? How can they be reassured that their symptoms are not concerning when the opinion we hold can never be more than what we feel to be true? Our feeling, that their symptoms are not worrying, can never counter their feeling that they are, since their feelings are no less valid than ours. I was surprised once when my assurances, that a lesion on a patient’s scalp was a harmless seborrheic wart, were not accepted by the patient because her hairdresser had felt it was a skin cancer. But then, if truth is relative, an expert’s opinion (and I use the term lightly) has no more authority over that of a non specialist.

Another patient once challenged a consultant cardiologist’s opinion that her ECG was normal as she felt her symptoms were consistent with what she had read of Wolf-Parkinson-White syndrome. The objectively normal ECG, and the expert opinion of the consultant on that ECG, was contrary to the patients feelings. And so a second opinion was requested and, when this was declined, the patient chose to write directly to the consultant expressing her belief that her concerns were being ignored.

This notion extends to the anxieties we experience as doctors. If truth is relative, how can we have any confidence in what we feel to be true, and, if the patient feels differently to us, how can we say that we are right and they are wrong? I am aware, of course, that there are, inevitably, times when a diagnosis is in doubt, when the truth is uncertain, but it sometimes seems we are no longer confident that we know anything for sure. In a society suspicious of intellectualism, the learned are themselves suspicious of their learning. Too concerned that our patients be happy with our opinion, our clinical diagnoses have to be malleable, tempered to acknowledge the validity of the patients’ opinion regardless of how lacking in objectivity that opinion might be.

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured; “They are a little swollen I suppose”?

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured: “They are a little swollen I suppose”. Of course it is no wonder we sometimes behave like this since we have had it driven into us that we be ‘patient centred’ when all along we really should have been urged to be ‘truth centred’. But it’s arrogant to claim to be right about anything these days – facts prove nothing. In a consumer society, the customer is always right. Is it any wonder then that, as medicine was opened up to market forces, the result would be that the patient is always right too?

And if feelings are what are important, then what others feel about me are every bit as much an indicator of who I am as what I feel about myself. After all, a satisfactory satisfaction survey is sacrosanct – I’m OK, if you’re OK with me. But if everybody’s feelings are different, how can I be OK, since how can I be OK with everyone? How can I make everybody feel positively toward me when they all have different criteria for what it is that would cause them to feel in such a way?

Anxiety is, I think, largely, a fear of unhappiness in the future which leads inevitably to us being unhappy in the here and now. That’s why anxiety and depression are such common bedfellows. With, to a great extent, the loss of religious belief, and with it the hope of a better time and place to come, society no longer is prepared to accept that we must sometimes wait for happiness. In an age when everything is instant, waiting is not an option – we must be happy now. But in a materialistic, consumerist society, which daily advertises to us our discontentment by displaying what it insists we need, but do not have, to be happy, it is no surprise that we are anxious that life is passing us by, that we are missing out on being fulfilled today.

And so the National Health Service has become the National Health Slave.

And of course it’s not just material goods that our society consumes. We consume health – it is the ‘must have’ we assume and insist upon. No suffering, however small, ought to be tolerated. We must have health and we must have it now – not next month, nor next week, not even tomorrow. The doctor will see me now – be it Tuesday morning or Sunday afternoon. And so the National Health Service has become the National Health Slave even as the NHS itself, colluding with society that it can meet its greatest needs if it would just do as it was told, slavishly insists patients behave in ways current medical opinion deems appropriate. Don’t smoke, don’t drink, don’t fail to exercise, don’t eat just four of your five a day, and whatever you do, don’t forget your Vitamin D. Don’t, don’t, don’t, don’t, don’t – and you might just live forever.

And so it seems to me that what this all ultimately boils down to the existential question of death. It is the one thing certain about life but we, increasingly perhaps, try to pretend that this too is uncertain as we pursue, and push, eternal life through medicine, lifestyle adaptations and sentimental and fanciful notions of how those who undeniably have died, somehow live on. In a world where nothing is certain, the certainty of death is above all to be doubted.

But we need to face facts, and so must our patients. Despite how much money is pumped into the  NHS to fund all that medicine increasingly can do, despite how long GP surgeries are open or how short waiting times in A&E departments become, and despite how much we heed medical advice and adjust our lifestyles accordingly, we, and our patients, will all one day die. Regardless of what we may or may not believe about life after death, if we are to find any happiness in this life, we need to stop pretending otherwise. We must stop believing that our interventions could ever prevent the inevitable. Rather than doing more for longer, if we want a population that is healthy in the fullest sense of the word, we need to do less. Yes the NHS must be funded adequately but it must be funded adequately to do what a long hard look determines is objectively thought to be important rather than subjectively felt to be urgent.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship and we must stop suggesting to our patients that life is all about attending to our cholesterol, BP and vitamin D levels so that future suffering is prevented. Why? Because a good life is not solely determined by the absence of suffering – now or in the future. Unrealistic attempts to deny the inevitability of death all too often serves only as an expensive and time consuming distraction that compels us to look down at the temporary and trivial and leaves us neglecting to look up at the significant and satisfying.

We and our patients need to learn to ignore the mundane and consider instead the transcendent. Only then will we, and they, instead of enduring an existence weighed down with anxiety and depression, enjoy a life buoyed by contentment and joy.

Being patient-centred – who are we trying to please?

bjgpApr-2015-65-633-204.jpgPeter Aird is a GP in Bridgwater, Somerset.

This week I’ve received some good news. I’ve been ‘liked’ by the GMC. Well I say liked, I mean of course ‘revalidated’ but it comes to the same thing. I posted a few comments of questionable value on an appraisal website and, lo and behold, I’ve been affirmed by no less an organisation than the GMC.

Yet the experience left me feeling somewhat flat. Curiously, being approved of by a faceless organisation, which demands certain requirements that I must satisfy in order to have their approval bestowed upon me, turns out not to be as fulfilling as I’d hoped. Tragically though, it seems that we are being driven by an ever greater need to be liked. It’s not just Facebook. It is a requirement that we be approved of by various groups – groups that sometimes have diametrically opposed ideas of what it is they want from us.

Take the antibiotic prescribing issue. On one hand we are quite correctly being encouraged to reduce our antibiotic prescribing and being threatened with a reprimand if we do not curtail their inappropriate use. But, on the other hand, we are being judged by how satisfied our patients are by our practice and, despite what patient education programmes try to convey, the idea continues to be held, even by some of the most educated of our patients, that antibiotics are required for minor self-limiting infections. Without them many of our patients won’t be satisfied. One wonders if scientific explanation of the facts will ever be effective in a society that increasingly has dismissed scientific fact in favour of what it feels is right.  Aren’t we all a little like Stewart Lee’s taxi driver who dismisses what he doesn’t want to believe with, ‘Well you can prove anything with facts!’? Leaving aside that particular question though, one thing is certain – it is impossible to satisfy the competing desire of patients who want antibiotics and those who want us to reduce antibiotic prescribing.

Similarly we are being asked to avoid unnecessary admissions to hospital whilst being increasingly criticised for delays in diagnosis and referral. Some have called for a doubling of our referrals to cancer services and starting primary prevention for heart disease at ever lower levels of risk, and yet our referral rates and prescribing practices are under ever more scrutiny.

Who are we going to choose to please?

I wonder if we doctors are particularly vulnerable to the need to being liked. How many of us were the good boys and girls at school who, driven by the desire to please, worked hard for our teachers, didn’t like to disappoint the careers advisor who suggested we tried our hand at medicine, and jumped at the chance of entering a profession which made our parents proud? Not that there’s anything wrong with any of this – it’s just that we may not be the best people to say an appropriate ‘No’ to our patients and risk disappointing them. After all didn’t we go into medicine, first and foremost to help patients – to please them, and not our bureaucratic taskmasters, who we find it equally hard to say no to?

The truth is that one can’t please everybody all the time – and we are fools to try. In a society that constantly and increasingly seeks affirmation it is no wonder that we are overwhelmed by the need to please those with competing desires. Whatever we do is wrong in somebody’s eyes. The incessant double binds threaten, not only our own happiness but also the stability of the whole system. A system already creaking from the overwhelming demand and time limitations that together drive us, perhaps, along the route of least resistance – the route that earns us a ‘like’ most easily – the one that comes from our patients. We may not be proud of it, but haven’t we all issued an antibiotic or renewed a sick note, not entirely appropriately, as we simply did not have the time or energy to do otherwise and out of a desire to please the patient?

Something is going to have to change in regards to the way we behave if things are to improve. We need to be professionals who are in the job, not to be admired, but to do what is necessary. Whisper it quietly, but we are going to have to be less patient-centred in order to be more patient appropriate. We are going to have to be less concerned about doing what our patients want, what they will like us for, and try instead to do, to the best of our ability, what is right. And we are going to have to care less about how we are thought of by our patients – I’m not sure just how valid their opinion always is anyway. On a single day last month I received two pieces of feedback – one accused me of incompetence, the other rated me as unusually astute. So which is it? Well of course it is neither – I am no more awesome than I am useless. I am in fact ordinary – an ordinary GP who, like ordinary GPs up and down the country, knows less cardiology than a cardiologist – but more than my patients. Our patients, our politicians, and we ourselves are going to have to accept this – whether they, or we, ‘like’ it or not.

The NHS – ‘S’ is for Service not Slave

photoPeter Aird is a GP in Bridgwater, Somerset.

It’s a confusing time for the NHS. One minute there’s talk of if being ‘weaponised’ like some all consuming superhero, the next it’s being sent to bed with no supper for causing all those ‘avoidable deaths’.

It seems the NHS is not so much a service that is offered but rather a slave that is used – and abused – by those who would seek to master it for their own, often political ends. But it’s not just the politicians who behave like this. Nor is it only the pharmaceutical industry who use it to push their products beyond where there is a genuine need. We patients also use the NHS, arrogantly proclaim that it is ‘our NHS’ and demand it meets ‘our wants’ – in a manner which we deem appropriate and in a time scale we consider acceptable. It’s time we appreciated that the NHS is just that – a service that we are privileged to have offered to us, not a slave we own and can demand of what we will. Something of a completely different perspective is required.

It’s time to free the NHS.

Free it from political interference, pharmaceutical manipulation and unreasonable consumer demand. Free it to become the genuine service that we require – one that seeks to meet only the genuine health needs of the nation.

So what exactly will this emancipated NHS offer us? That is something that needs to be decided upon by guardians of the service – appointed because they are wise enough to see that there is a difference between what medicine can do and what medicine should do. They need to be clear headed enough to appreciate that advances in medicine have outstripped the capacity that exists to deliver healthcare, both in terms of finances and workforce, and as such decisions on what services will and won’t be offered have to be made.

Decisions do need to be made, but not because they are politically expedient or serve an individual’s self interest, but because wisdom dictates that they are so made. Not all such decisions will be popular but they need to be made, and accepted, none the less. Of course where inefficiency and poor practice exists there needs to be improvements but the fact remains that with the body of medical knowledge increasing exponentially, and more and more expensive treatments appearing on the market on a daily basis, it is simply no longer possible to know all their is to know, or fund all that could be funded. Finances are limited – as are the human resources within the NHS. Constant promises by our politicians and demands by its users of what the NHS will provide, along with often unwarranted criticism and blame when these impossible targets are not met has a human cost on those who try to do their best in an increasingly difficult workplace – a workplace that is threatening to become a battleground.

It’s true that the NHS is ‘not the Messiah’ we would perhaps like it to be, but neither is it ‘a very naughty boy’.* As Goldacre has said, I think you’ll find it a bit more complicated than that.

It seems to me that the fundamental problem lies in the fact that we as a society continue in search of the holy grail of eternal life – death must be avoided at all costs. And we have charged medicine with delivering this dream. So certain have we become that this is possible, that when death does rear its ugly, unwelcome head, the appropriate response so often becomes one of moral censure of those who failed to deliver the impossible.

When things go wrong, it seems, we are more comfortable attributing the problem to the moral failings of those who have tried to help, than the reality that death and suffering are part of the world we live in. And here is the irony of it all. By treating the NHS as our slave, demanding it deliver us from our inevitable death, we have made medicine our master and have become ourselves enslaved by it. By making the meaning of life the avoidance of death, we are in bondage to the health parameters that we have imposed upon our selves, even as we strive to impose them on others. As Augustine wrote:

What does it matter by what kind of death life is bought to an end? When man’s life is ended he does not have to die again. Among the daily chances of this life every man on earth is threatened in the same way by innumerable deaths, and it is uncertain which of them will come to him. And so the question is whether it is better to suffer once in dying or to fear them all in living.

*With apologies to Monty Python.

Introducing GPs Anonymous

photoPeter Aird is a GP in Bridgwater, Somerset.

Is it just me or is being a GP increasingly being portrayed as something for which one ought to be ashamed? If so, then perhaps we should consider if we need some help.

With the latest suggestion that patients will be able to bypass their GP and refer themselves for cancer investigations, perhaps it’s time to face up to an uncomfortable truth. We’ve been told enough times by enough people – perhaps the implication is true: we’re not up to the job. It’s all the fault of we GPs.

We mustn’t  go on denying it any longer – convincing ourselves we’re OK – after all, until we acknowledge our problem how can we expect anything to be done to help us. We will just go on making everyone’s life a misery.

We all know how embarrassing GP behaviour can be – you know the kind of thing, spoiling everything for everybody on Christmas Day by turning up at a family gathering rather than opening our surgeries as normal – and thereby compelling people to waste hours in A&E departments with their sore throats and itchy toes. And then, of course, there is the wilful ignoring of our patients who clearly have cancer whilst, at the same time, putting an unnecessary burden on secondary care services by admitting patients to hospital just for the fun of it.

So let’s all face up to our problem. I’ll go first by introducing myself:

My name is Peter – and I’m a General Practitioner.

There that wasn’t so bad -to be honest it’s a relief to have it out in the open – I hope you can find it in your heart to accept someone as shameful as me – after all the hurt I’ve caused. If you’re similarly afflicted, come and join me – I’m setting up ‘GPs Anonymous’ in the hope that together we can support all of us who are stricken with the affliction that is ‘being a GP’.

But perhaps you’re still unconvinced you have a problem. Can I urge you then to ask yourselves these four screening questions? Answer two in the affirmative and you may have a problem – answer ‘Yes’ to all four and you’re in real trouble.

C – have you ever felt you wanted to cut down how much general practice you do?

A – have you ever been annoyed by criticism of your actions as a GP?

G – have you ever felt guilty for what you have done as a GP?

E – have you ever started early in the morning doing your ‘GP thing’?

Extra phone lines will be installed should demand for this new service prove overwhelming.

[bctt tweet=”BJGP Blog: Peter Aird is joining GPs Anonymous. Try the CAGE questionnaire.”]

So why do people fall into the destructive behaviour patterns of general practitioners? Well there seems to be a genetic component in some cases – seeing your parents behaving as GPs seems to predispose some to follow a similar path – though, thankfully this is becoming less common. Others experience a little bit of general practice early on in their medical career and naively imagine that it’s a good thing – something they can control. After all, just one attempt at a ten minute consultation can’t hurt can it? But before long they’re out of control – only in it for the extortionate pay, long hours of ‘off duty’ and the kicks one gets from the systematic mismanagement of those who thought they were there to help.

It’s a tragic condition but, with the arrival of ‘GPs Anonymous’ at last there is some real hope for change. Perhaps together we can rid the country of the blight that GP’s have become.

And then won’t everyone be happy?