The scene shifts to the relationship between specialist medicine and general practice medicine and similar distortions of perception are found to apply. But in this case they are worsened by artificial certainty.


‘You could be right, Doctor, you see more of it than I do.’

A patient, told he has ’flu.



I was going to say too much again, I knew the feeling.

I had been quite determined to stay quiet for once but I was shifting about on my seat like an excited schoolboy with my pulse thumping away in my head.

I put up my hand.

The Emperor turned to me and smiled.

And I began to tell him that I thought he might not be wearing any clothes.

It was a Saturday morning seminar on cancer at the postgraduate centre of our District General Hospital. The speaker was a gynaecological oncologist. ‘Oncologist’ means ‘cancer specialist’ and ‘gynaecological oncologist’ means a doctor who deals only with cancers of the female reproductive organs. This is a field so specialised that it doesn’t even include the breast. So he was a kind of specialist amongst specialists; what we sometimes call a Super Specialist.

He was an Australian, passing through Britain on his way home after a tour of meetings in America. Speaking with confidence and authority he said how he disagreed strongly with the British policy on how often to do cervical smears (the screening test to detect people who may, without treatment, be going to develop cancer of the cervix). His view was that all women who had ever been ‘sexually active’ should have cervical smears carried out every year, not every three years as in Britain, and that they should go on having them every year until they died presumably, one supposed, of something other than cancer of the cervix.

It was when he had finished that I couldn’t stop myself putting up my hand.

‘What you are saying is that every general practitioner in Britain should do a thousand gynaecological examinations a year. Just for cervical smears. That is twenty a week. Even at fifteen minute intervals that would take up one hour of every working day for every GP in the country — before they did anything else at all!’

‘Yes, all my colleagues in my speciality agree that this is what is necessary.’

‘Then you are wrong! It simply isn’t going to happen! You specialists really must accept responsibility for thinking through the consequences of the recommendations that you make. If you say that cervical smears must be done annually then any doctor who does less than that will be automatically culpable!’

The audience was clearly embarrassed by this exchange. If the specialist in gynaecological cancer said yearly smears, then surely, yearly smears it must be. But at the same time I sensed that there was a sneaking, instinctive agreement with me — and that people found this conflict between their heads and their hearts disturbing.

The next question was on safer ground in some inaccessible region of gynaecological oncology research where the speaker was outstandingly knowledgeable. Everybody relaxed. He was back in his empire again and all was right with the world.

One of the local gynaecologists present at the meeting, a less rarefied specialist, who had known me for years, surprised me by returning to my question after the Australian had resumed his seat. In a kindly sort of way he said that he sympathized with my view but that I should appreciate that I was wrong.

I seized this chance to clarify my position. I said how much I genuinely admired and respected specialists and how much I knew that we needed them. But at the same time, I said, they needed us. The generalist’s viewpoint, which took a broad view and weighed up all requirements, needed to be understood better. General practitioners, like people in many other walks of life, were surrounded by enthusiasts with more and more bright ideas for things that they should be doing and they found it completely impossible to do them all.

The speaker, I continued, had made a logical error which illustrated the point. He had stated that in Australia doctors who aimed at one-yearly smears had found that they actually achieved an average interval of only three and a half years. His conclusion from this had been that any doctor who was unwise enough to aim at three-yearly smears would be bound to achieve something like a nine year interval.

‘Not at all.’ I said ‘The poor result from the annual smear programme is exactly what should be expected from a regime which is perceived by the doctors, and by the patients, to be unrealistic. In other words, against common sense. A realistic plan is always more successful than an unrealistic one. In Britain we aim at three yearly smears and we are trying to get down to the job of making sure that we actually achieve that target - for everybody!’

I reminded him that an earlier speaker had actually ascribed the rather low incidence of cancer of the cervix in our part of Britain to the effectiveness of the GPs’ three yearly smear programme.

To his credit the distinguished Australian smiled at this and was big enough to tell a story against himself to show that he understood at least something of what I was saying. He said that he had once stood in for an evening on casualty duty and had ended up admitting far too many patients to the hospital because he thought they were all seriously ill. No doubt that bigness was one reason for his distinction.



Here we have just the same relationship between the focus of attention and the unseen ‘everything else’ in the last chapter. And the same distortions.

At times we all act as specialists, looking at the world from a narrow viewpoint. But when specialists use their microscopes to magnify tiny details it is often forgotten that microscopes also exclude the surroundings, the context, of the field of attention. While it is natural to admire the magnification, we often forget to notice the accompanying exclusion.

That is why the professional specialist, while he acknowledges that it is the generalist’s role to fit everything together and manage the whole, fails to understand the size and the complexity of that whole. He never has to confront the whole as the generalist must. And the result is that when the conscientious generalist attempts to do everything ‘properly’ he finds that the sum adds up to more than a hundred percent and the pot of life overflows.

In medicine, individual specialists may think that GPs don’t adhere to their particular enthusiasms because of laziness, or incompetence, or bad organization, or shortage of money, or ignorance, or something. What they never realise is that they can only be implemented in isolation. It is quite impossible to put them together with all the recommendations from all the other specialists to make a world which works.

Generalists often react to the advice or the instructions or the criticisms of specialists with exasperation, ‘He must think that we don’t do anything else!’.

The point is that the specialist really does think that we don’t do anything else. Or at least, nothing else which is important.



Technical experts — of the kind so necessary in the modern world, let there be no mistake about that — share the same distortions of perception that I have been discussing. But when they view the ‘everything else’ that exists outside their own speciality these distortions are far worse. For several reasons.



In describing how my mind works while I am seeing patients in surgery I have tried to show the discrepancy between the apparent importance of the particular ‘memory box’ I happen to be in at the moment and the hidden size of the ‘everything else’ which is in the background of my mind. While I am concentrating on the current patient it is quite impossible to retain a grasp of all the other boxes containing memories of all the other patients. But nonetheless there can be no doubt that those boxes are ‘in there somewhere’.

But when a technical expert concentrates his attention on a single aspect of life, there is a fundamental difference. He doesn’t have the unseen background containing everything else. Other things are ‘not his field’ and he simply doesn’t know about them at all. Exclusion is inherent in his specialism. So, far more even than individuals underestimate the size and importance of the ‘everything else’ in their minds, experts underestimate the size and importance of the ‘everything else’ in life. They tend to think it doesn’t matter that they don’t know about the other fields. Those things can look after themselves. They are other people’s problems.



I have a fantasy that sooner or later there will be a night on duty when all ten thousand patients ring me at once. But they won’t. Although the number of calls on a particular night can vary between none and six, it virtually never goes higher than that. The rules of nature seem to prevent it. The number never goes up to ten, for example. Even once, just for the hell of it. Let alone a thousand. If you average the calls over a month or so the variation is even less, a factor of three at the most. And if you average the calls over a year the variation drops to a few percent. And it really is very difficult to understand quite why.

In the same way, when people analyse the combined experience of many hundreds of doctors on duty, the number of patients who will ring on a particular night can be predicted with something approaching certainty.

But it is a remarkable fact that although the overall proportion (or likelihood) remains the same, whether or not a particular individual will ring on a particular night appears to be entirely random.

It is a feature of the modern world that decisions tend to be taken by remote experts and to be based on the near-certainties of the statistical analysis of large numbers. But front-line workers such as GPs operate amongst the random events of the individual scale. For example, although I can say almost exactly what proportion of smokers will suffer heart attacks in a given period, that doesn’t help me at all in telling the smoker sitting in front of me whether he will be one of the ones affected.

It is a commonplace in medicine that the non-smoker who suffers a massive heart attack doesn’t feel the least bit better for the knowledge that his misfortune was very unlikely. He is rather like Jonathan Clay, the driver who, in the rhyme, ‘died maintaining his right of way’, and who, although he’d been ‘right all along’ was ‘just as dead as if he’d been wrong’.



The most time-honoured method of lending events an illusion of certainty is to view them in retrospect. Since retrospect is nothing less than the difference between history and real life it is important to recognise the illusion. We base almost all our decisions about the future on our perceptions of the past and this matter is so important that I want to illustrate it in some detail.

Consider how very easy it is to define terminal illness in retrospect. When we look back on the last weeks of life of somebody who has died, we can say with total confidence that he or she was suffering, during that time, from a terminal illness.

You may think this is obvious, but believe me, it isn’t.

It is easy to pronounce upon the special care and counselling, for example, that a dead patient should have had during that terminal illness, in total confidence that he or she isn’t going to sit up, wink at you and settle down to a few more years of life.

I once had a dear patient who had revealed her breast cancer to me when it was already at a very advanced stage. Almost straight away it was clear that the cancer had spread to bones all over her body and to her lungs. Within a few weeks her left arm broke below the shoulder through the weakened bone and when she was home again after having the arm repaired her right thigh bone did the same thing. When that had been repaired she became short of breath and I had to remove a litre of fluid from one of her lungs and more than half a litre from the other. She was such a tiny person that there had been very little more room for air.

If anybody ever appeared to be terminally ill, she did, and I told her so. She accepted this with the calmness and bravery which is the rule rather than the exception and which it is such a privilege to witness.

Her friends came from far and wide and her family came home from abroad to say goodbye to her. But she just went on. She had the most incredible and humbling faith. She said that with God’s help, and Doctor Wilson, she would be all right. (The first time she said this I didn’t want to spoil the moment by pointing out that she had got my name wrong, and when she continued to repeat it for months afterwards it just had to be God and Dr Wilson who got the credit.) I visited her once a week, usually doing very little for her, always thinking it was near the end. Her family came back the next summer to say goodbye to her again but the illness seemed to go into suspended animation in a way which could never have been predicted from the treatment she was on. Almost a second whole year went by before she went into her final decline and died peacefully in our little GP ward half a mile from her home.


This is what life is really like. It holds infinite richness and variety as we live it but when we look back our minds select the things that actually happened and totally exclude the myriad things that might have happened but didn’t. Again and again we forget that all those other possibilities existed at the time and it all seems so much simpler and so much more fixed than it really was.

I think this largely explains why front-line jobs like general practice are so much more stressful than external observers understand. Moving forwards through life you continuously confront a legion of open possibilities. But as each moment of choice or chance passes, the possibilities continuously collapse down to leave behind the single narrow path that you have actually followed.

And once again we have just the same contrast of scale between the focus of attention and the everything else, the things that happened and the things that might have done. And here again the everything else is invisible, at least in retrospect. Life is a constant movement towards open possibilities which are closed for ever by the cutting edge of time.

Imagine one duty Sunday. It’s lunch time and we are just starting dessert when the telephone rings…

‘My Daddy has just collapsed, please come.’

‘OK, I’ll be with you straight away. What’s the address?’

‘Please come quickly, my Daddy is ill.’

‘Yes, but where are you?’

‘Please hurry, Mummy asked me to get you as quickly as possible.’

‘Now look, I can’t come until you tell me who you are and where I’ve got to come to…’

He tells me in the end. Through a mixture of luck and daring I negotiate the country lanes unscathed and arrive, tingling. The boy is at the gate and I follow him up the stairs at a run.

Daddy is lying on his face in the bathroom, looking distinctly dead. I kneel down over him. No pulse. Pupils dilated. Certainly dead. I try to look as if I’m doing something useful. I glance back over my shoulder and desperately search for words to begin to break the news to the poor wife who is standing anxiously behind me with her son - their son.

But she gets in first — ‘I’ve got a homeopathic remedy here which is very good for collapse.’

There is a pause, and I begin to explain.

Just as I am getting back into the car my bleep goes off with the next call. So I have to go back and knock on the door, apologise, and ask to use the telephone…


Something like that can suddenly happen every moment I am on duty, and I know it. In retrospect I know that most moments they didn’t happen. I know without the slightest doubt that they didn’t. But although the memory is very much simplified in this way, the real experience of what it felt like at the time is in there somewhere, being taken into account subconsciously in my plans for the future. And when I view a coming weekend on duty with a feeling of deep apprehension, as GPs almost invariably do, I know something that an objective observer who looks at a bare account of the sort of problems I have dealt with during previous weekends on duty doesn’t know, and doesn’t realize that he doesn’t know. The almost physical burden of things that might have happened but didn’t.


The approaches to life which appear to hold the answers for the modern world are those which can be stated with precision and can be formally justified. One technique is that of the specialist who narrows down the world until some tiny aspect of it can be expressed in absolute terms. Another is that of the central planner who stands back from the unpredictability of events on the individual scale and views the world with the artificial certainty of large-scale norms and historical record.

It is difficult to say precisely what is wrong with these techniques. It is only through technical means that things can be measured and objectively evaluated. Technical means are in fact the very basis of rational argument. Therefore the technical approach to life carries with it an apparently unanswerable argument for its own validity. In more and more areas of life the superiority of the machine over the man appears to be self-evident; the head over the heart.

I’m not saying that artificial techniques don’t have their uses, they do. We need them. What I am trying to show, against these formidable odds, is that the world also needs people.




Chapter 1

Chapter 2
Our Distorted
View of the World

Chapter 4
The Myth of the Ideal World

Chapter 5

Chapter 6
Everything in Life is Relative

Chapter 7

Chapter 8
The Ocean of Congruity

Chapter 9
Making Progress

Chapter 10
Nature Favours the Generalist

Chapter 11
Good Intentions

Chapter 12

Chapter 13