Roger Neighbour OBE is Past President of the Royal College of General Practitioners and author of The Inner Consultation and Consulting in a Nutshell.
‘Tell all the truth but tell it slant —
Success in Circuit lies’
Poem 1263, Emily Dickinson1
‘Life’, wrote the philosopher Søren Kierkegaard, ‘must be understood backwards; but … it must be lived forwards.’2 Let me put that aphorism to the test and reflect on my career’s waypoints.
First to mind comes the memory of a summer’s day in 1964 when, as a 17-year-old applicant to St Thomas’s Hospital Medical School, I was interviewed by the Dean, a surgeon called Nevin. His opening question was a silly one: ‘When was your father here?’ Had he glanced at his paperwork he would have known that my father wasn’t a doctor, let alone one from his own institution. The next question was even sillier: ‘Why do you want to be a doctor?’
Whole books have been written on the depth psychology of doctors, none of them by 17-year-olds. I expect I spouted the usual clichés about liking people as well as science, pretended to like rugby. At any rate, I failed the interview. Luckily.
“… their reactions when startled by the wine question could give a foretaste of how likely they were to cope with the as-yet unknown demands of learning medicine.”
But at least I didn’t claim to have a vocation. I don’t believe in vocation, if the word means an inner voice that presumes to know what’s best for me and will brook no argument. What my inner voice actually offers up by way of explanation is more memories. One is of the tricycle on which, aged five, I would pedal up and down the pavement near my home. On one occasion, head down, pretending to be an ambulance and furiously dring-dringing my bell, I crashed into the milkman and broke his leg. A real ambulance came and took him away. Was that my first lesson in empathy? Possibly; I remember being upset, though mainly on behalf of the horse that had been pulling the milk float and was left standing between the shafts, abandoned and hungry.
Another memory is an auditory one, the sound of the voice of my childhood GP. Ben Heap spoke in a soft West Country burr, like sandpaper on balsa wood, that for me will ever be the sound of reassurance.
Luckily my next interview, a year after the first, went better. At stake was a place at King’s College, Cambridge, where the Director of Studies in Medicine was Kendal Dixon. Kendal had a profound familial deafness, which largely shielded him from the banalities of our conversational foreplay. Then, producing two wine glasses and dispensing generous aliquots from two open bottles, he passed them both to me and posed an unanticipated question. ‘Which of these is better, Roger,’ he asked, ‘this Beaujolais or this Burgundy?’
Whole books have been written about French wines, none of them by 18-year-olds. I expect I spouted some guff about them both being very nice, thank you, much of which Kendal mercifully would not have heard. (The correct answer, I later learned, was that the Beaujolais was ready now but the Burgundy needed two more years.) Nevertheless, something about my artless response must have impressed him, because I passed the interview. Luckily.
Puzzling at the time, in hindsight Kendal’s question was much wiser than Nevin’s. He was shrewd enough to know that youngsters’ real reasons for wanting to be doctors were inaccessible and inexpressible. But he also knew that their reactions when startled by the wine question could give a foretaste of how likely they were to cope with the as-yet unknown demands of learning medicine.
I can recall other moments, events, that in retrospect seem to have been pivotal in my career. Another conversation with Kendal, when I persuaded him to let me read experimental psychology instead of biochemistry for Part I of the medical tripos. Professor Zangwill’s bumbling demonstration of hypnosis, which prompted me to attempt it, successfully, on my friend Phil. Later, trips to the US to learn the mutative power of structured language from the disciples of the master-hypnotherapist Milton Erickson. Meeting the novelist EM Forster and first reading the famous passage in Howards End: ‘Only connect the prose and the passion, and both will be exalted’.3 A conversation at his Malibu home with Tim Gallwey, author of The Inner Game of Tennis, followed by a starlit walk on the shore of the Pacific when the ideas fell into place for a book that became The Inner Consultation. Luckily.
“I’m pretty sure that every doctor — every living soul, indeed — has an inner life much like mine, and that one black hole is much like another.”
Be all that as it may, and with all due respect to Kierkegaard, I’m not sure that life can be understood, even backwards. Narrated, perhaps, but not truly understood — not in the sense of knowing for certain why things could not have turned out otherwise. Rather, we draft an autobiography in which we reassure ourselves that we are not, after all, the playthings of the gods. When it comes to self-analysis, imagination trumps reality. We look over our shoulder and fancy we can see a chain of causality stretching back to — to what?
To a black hole.
At the heart of every human psyche is a dark and impenetrable region of immense heft. So strong is its gravitational pull that a whole galaxy of thoughts, memories, and imaginings — everything that makes a personality — is kept in perpetual orbit around it. Almost nothing can penetrate its obscurity, certainly not logic or intellect. And as to its own nature it gives almost nothing away. Only images, stories, fantasies, metaphors, and aptitudes are sufficiently insubstantial to break free into consciousness and give some inkling of the massive psychological forces that shape our destiny. Perhaps that’s just as well. Our true motivations, were we able to see them in stark reality, would be too scary to contemplate. We may only glimpse them out of the corner of an eye. Luckily. The Emily Dickinson poem quoted as my epigram ends with this:
‘The Truth must dazzle gradually
Or every man be blind —’
In his 1977 book The Anxious Patient, Danish psychotherapist Torben Bendix proposed seven ‘rules of thumb’ for time-efficient patient-centred consulting.4 His first rule — ‘Situations, not symptoms’ — was for me an eye opener. You can learn far more from the context of a patient’s symptoms and from the effect they have on the patient’s situation, Bendix explained, than you do from the details of the symptoms themselves. It is, for example, more helpful to discover that a child’s tummy-ache keeps him off school on games days than it is to ask how often his bowels are open, (as Dr Heap astutely discovered when I was 12).
Freud would have agreed; the unconscious mind has its ways of revealing motivations that are too difficult or too embarrassing to express in words. Needs are revealed in the behaviour that satisfies them. Observe the behaviour, note the consequences, and infer a need for those consequences — there we have interpretive psychotherapy in a nutshell.
Medicine, and general practice in particular, is a wonderfully privileged job. We get to deploy our hard-won expertise in arguably the noblest of causes, the relief of human distress. To us, care is a verb, not a commodity; it’s what we do, not something we market. Our patients trust us with their confidences and vulnerabilities; they count on us for comfort and succour during critical episodes in their lives. In exchange we are well rewarded, financially and with social standing.
Many would see this happy state as the just deserts of altruism, whatever that is; and maybe they’re right. But how does it look if we apply the Bendix approach, ‘spot the result and infer the motive’? Are we perhaps driven, at least in part, by a need to be needed; a need to matter, to be of consequence; to be admired and respected — loved, even? Do we search for a kind of one-way intimacy where we are allowed to probe other people’s secrets while remaining private ourselves? Do we hope to be remembered with gratitude and affection? It has to be asked: are there lurking within us traits of narcissism, voyeurism, and megalomania?
“Learning medicine calls more for perseverance than for academic brilliance. Being clever is a bonus, not a prerequisite.”
As the self-confessed proprietor of a black hole, I’ll not deny the possibility.
But so what? Is the value of a person’s achievements necessarily negated by the possible ignobility of their origins? I hope not. If one’s good deeds were somehow to be disqualified by any grubbiness of their unconscious motivations, then the world would be the worse off for it, and Heaven would be a lonely place.
I’m no solipsist. I don’t believe I’m the only sentient being in a world of zombies. I’m pretty sure that every doctor — every living soul, indeed — has an inner life much like mine, and that one black hole is much like another.
And now another memory surfaces, this time of Herbert L, an irascible moustachioed martinet of a teacher, known to us schoolboys as Fanny, with whom we are doing Macbeth for O-level. In Act 1, Scene 5, Lady Macbeth suspects her husband won’t have the balls to kill King Duncan, and tells him that he is ‘too full o’th’ milk of human kindness, / To catch the nearest way.’ ‘Explain human kindness’, says Fanny. Well, it’s people being nice to each other, someone offers. ‘No!’, Fanny barks. ‘Shakespeare means humankind — ,’ (and he pauses), ‘— ness. Humankind-ness. The condition of being part of humankind.’ We nod in feigned comprehension, the clever boys make a note; then luckily the bell goes.
Kindness, mankind, kinship, the several meanings of kind — the words all have a common linguistic and psychological origin. Kindness is the spontaneous expression of kinship, the recognition of being of one kind with one’s fellow humans. It seems to me that kindness — the quality in a doctor most appreciated by patients, possibly even more than clinical competence — manifests in direct proportion to the extent that we doctors realise that, deep down, we are just like everybody else.
It’s a well-kept secret, but you don’t have to be exceptionally brainy to be a doctor. Learning medicine calls more for perseverance than for academic brilliance. Being clever is a bonus, not a prerequisite. Yet we continue to select for medical school on the basis of applicants’ command of the formulaic logic required for A-level maths and physics, rather than the depth of their self-awareness and emotional intelligence. Maybe we would do better to recruit as medical students not the youngsters brandishing certificates of intellectual distinction but instead take those with a track record of kindness and who are comfortable in their ordinariness. Had I been a cleverer schoolboy I might have given a more sophisticated answer to Kendal’s wine question. But I didn’t know at the time that the Gevrey-Chambertin needed more bottle age than the humble Beaujolais Villages.
Luckily.
References
1. Dickinson E. The Complete Poems. London: Faber and Faber, 2016.
2. Ratcliffe S. Oxford Essential Quotations. 4th edn. Oxford: Oxford University Press, 2016.
3. Forster EM. Howards End. London: Penguin Classics, 2000.
4. Bendix T. The Anxious Patient. London: Churchill Livingstone, 1982.
Featured photo by Denis Sousa on Unsplash.
