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‘You could be right, Doctor,
you see more of it than I do.’
A patient, told he has ’flu.
THE SUPER SPECIALIST
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.
THE EXCLUSIVE APPROACH OF THE SPECIALIST
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.
THE SUPER-DISTORTED PERCEPTION OF THE EXPERT
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.
REASON 1 EXCLUSION
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.
REASON 2 LARGE NUMBERS
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’.
REASON 3 RETROSPECT
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.
TOP
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Chapter 1
Understanding
Chapter 2
Our Distorted
View of the World
Chapter 4
The Myth of the Ideal World
Chapter 5
Weekend
Chapter 6
Everything in Life is Relative
Chapter 7
Analogy
Chapter 8
The Ocean of Congruity
Chapter 9
Making Progress
Chapter 10
Nature Favours the Generalist
Chapter 11
Good Intentions
Chapter 12
Prescription
Chapter 13
Epilogue
Booklist
HOME PAGE
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