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If Only

Posted by Dr No on 07 December 2012

sassall.jpgA good traveller leaves no track

–Lao Tzu, Tao Te Ching, Ch. XXVII

JT, the well known member of the London Aesculapian Fracture Club, has written another excellent essay, on the feelings engendered in doctors by their patients. This is a taboo but utterly central part of all medical practice, but it is in the over-lapping theatres of general practice and psychiatry that it regularly achieves elephant in the consulting room status. Just as we doctors all love – and that is a word we shall come back to – our good patients, so too do we struggle not to shun, displace and avoid those patients we find distasteful. For many doctors, this one included, it is often the patients we have rejected and failed that we remember most vividly. A chill shudder of shame still strikes Dr No when he recalls some of his more disgraceful moments, like the time he berated a little old lady for insisting on a unnecessary home visit, when he should instead have seen a lonely soul in need of a hug.

Dr No has remarked previously on the goal displacing effects of QOF, the performance management system for GPs that hijacks consultations and distorts priorities. Lately there has been a backlash against this interference, in what Dr No calls the caring and sharing movement. GPs in this movement like to share with us that not only do they care, they care so much it hurts. Many are at it. Most famously we had Dr Clare Gerada, chief pongo at the RCGP, sharing with us in her 2011 Conference speech, in a phrase that somehow leveraged sharing about caring, that GPs must ‘embrace the language of caring’; even if, as Dr No suspects, this is in fact more properly seen as the post-modern way of caring and sharing, where the language sets the tone, and the map precedes the territory. Whether that in turns suggests that sharing about caring is a simulacrum is a post-modernist booby trap Dr No does not intend to fall into today.

Be that as it may, the language of caring and sharing comes easier to women, and so we can confidently say that, when a bloke – a bloke like JT who only a few months back doubted he was kind, let alone caring – shares with us that he has transcended mere caring, then caring has, as they say in PR, got traction. And, boy-oh-boy, has JT got traction too. He has leap-frogged mundane caring, and landed on a distant higher plane, a plane where he loves his patients. If he continues this trajectory, he might just turn into Moses.

Dr No jests. He has every confidence that JT has a thick enough skin to contain even the most tensely inflated caring and sharing love balloon. But that is rare. Others are more delicate: their love balloons can all too easily pop. Every doctor knows colleagues who cared so much it literally hurt them, through burn-out, addiction or mental illness. Paradoxically, and chillingly, it is too often those who care the most who are most at risk. Dr John Sassall, the subject of A Fortunate Man, the revered study of the life and practice of a single-handed country GP in the 1960s, cared so much it didn’t just hurt him, it destroyed him: utterly and irredeemably. He shot himself.

This, then, is the heart of the paradox. The more a doctor cares, the more the doctor and his or her patients reap rewards, but, at the same time, the more the doctor faces the danger of emotional disintegration, burn-out and – in extreme cases – obliteration.

Berger, a humanist and the author of A Fortunate Man, in a note to a recent edition tries to recast the suicide as a tragic inevitability, a inescapable destiny as essential to the man as the life that preceded it. Dr No is not entirely persuaded: the passage itself is precious close to post-modern twaddle dressed in classical drapes, but, more to the point, it ignores - perhaps even insults - the central purpose of Sassall’s life, which was, as well as helping patients accept destiny, also about altering destinies. It seems a little harsh to insist that his destiny was unassailable, and so deny him the offer that he gave to others: that sometimes destinies can be altered.

If there is an answer to this paradox, it may lie, Dr No suggets, in the realms of mysticism. Scott Peck, in his examination of evil, The People of the Lie, says the healing of evil – and what are disease and distress and the deprivations that cause them, if not manifestations of various evils - ‘can only be achieved by the love of individuals. A willing sacrifice is required. The individual healer must allow his or her own soul to become the battleground. He or she must sacrificially absorb the evil.’

The necessity of sacrificial absorption has always troubled Dr No, even if in a round about way it can provide a possible understanding how a good doctor like Sasssall comes to a bad end. Scott Peck does his best to rescue his sacrificed souls by a twist of mystical alchemy. Calling in C. S. Lewis, another Christian, he quotes from The Lion, the Witch and the Wardrobe: ‘When a willing victim who has committed no treachery was killed in a traitor’s stead, the Table would crack and Death itself would start working backwards.’ Even though LWW is one of Dr No’s Desert Island Books, he is not sure it is wise for GPs to rely on Tables Cracking, let alone Death Working Backwards, to save themselves from the dangers of an open soul. Instead, he suggests another form of mysticism, that of Taoism and Zen, may have more to offer.

One of the doctrines, if doctrines they are, of Taoism and Zen is non-attachment. If, paradoxically, a doctor cares, not because he or she cares about – and so is attached to – a patient, but because caring is simply what he or she does, without attachment, then it seems to Dr No at least possible that the doctor can care, even love, freely, without expecting return - and so courting disaster, and, just as if not more importantly, without opening the door of the soul to those dark forces that all too often consume and then destroy the soul that once cared.

A good traveller leaves no track. If only…

1 comment

Whether we are doctor, nurse, plumber or politician – we are who we are regardless of occupation – and there’s the rub for those who work in healthcare.

Is it possible for those who work within the health professions to really love their patients? Depends on who's doing the caring - for one mans vocation is another mans job.

Change patient to resident and I care for, indeed love my residents but I am not in love with them, and much to my shame - one or two of them, well I don’t really love them either. I don’t think I hate them for I do not quite understand what hatred is having never suffered the emotion.

Are these particular residents my heartsinks – maybe so as it is something in their personality (and not their illness) that irritates me because of who I am, the intrinsic me – yet they irritate no one else. Conversely, there are residents who are not very nice people, yet I have been able to find within them a little snatch of goodness, a redeeming feature and I like them or more accurately this part of them - yet they irritate others.

I like to think I treat all residents equally and as equals – but do I or just think I do?

Caring and sharing – sharing being the tricky one and oh how careful we must be in what we share for we can so easily compromise ourselves and become compromised by those we care for in little nuggets shared in a too cosy little relationship. That said, I believe it is possible to become close to a resident, have positive regard for and develop a healthy rapport when both of us accept set boundaries.

Sadly to safeguard ourselves and indeed the residents who may be inadvertently harmed by the lack of it – there is a need for professional distance – but this does not imply that one has to be cold and distant – far from it, and indeed as mentioned above positive relationships develop in spite of it.

So it is very easy to care if you are a caring soul - and so easy to disintegrate if you care too much. Sharing must be done with caution and loving and liking with the safeguard of professional distance.

Anna :o]

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