Anna Beug is a ‘Deep end’ GP and Medical educator in Dublin, Ireland. She is a senior clinical lecturer at Trinity College Dublin, a GP trainer and assistant scheme director. She is on LinkedIn
I recently travelled to north Wales to teach a course on the narrative based practice method – Conversations Inviting Change.1,2 There, amid the medieval castle walls and fancy-dress pirates, a conversation with fellow medical educators inspired me to share a metaphor which I have long found useful in my own practice and teaching. It has been my experience that metaphor can convey something of the complexity of the work of general practice in unique way.3,4
We were speaking of patients whose suffering is so complete that it becomes almost unbearable for the practitioner.
We were speaking of patients whose suffering is so complete that it becomes almost unbearable for the practitioner. We agreed that it was at times profoundly difficult to be in the presence of so much pain, consultation after consultation. We reflected on the fact that in many of these patients, the alleviation of one crisis or illness seemed to be followed almost inexorably by another. Having spent the weekend talking about the importance and the power of eliciting narratives – we wondered how it might be possible to keep eliciting stories of chaos and despair when we are also charged with providing relief and solutions. We wondered about how to balance the role of listener and witness with the inevitable duties of being agents of the medical system and the real risks of missing serious physical illness.
The metaphor that was evoked for me was the rather utilitarian one of the doctor as train – a train like the one that had taken me from Holyhead, along the beautiful Welsh coastline the day before. For many years I have used this metaphor as a way to steady myself at difficult moments and in conversations with GP trainees about the kind of patients we were speaking about. I have found it helpful to imagine that when working with the most complex patients, we need to aspire to ‘run on two tracks’.
One track could be considered the more conventional medical or ‘normative’ one. This is the track that represents the doctor’s obligation to remain constantly vigilant for identifiable physical illness, to sometimes be assertive or offer explicit advice and to consider whether there might be a diagnosis to make or a treatment to provide.
By definition it can’t go faster on one track than the other. The pace is somehow set. The train’s safe arrival anywhere depends on this.
The other track represents the part of the doctor that has in a sense ‘given up’ on fixing. The part of us that might want to privilege the idea that listening on its own has value and that when all else fails, being a witness or a companion is ‘not nothing’. Running on this track allows me to hold open the possibility that the symptoms causing the patient such anguish are doing some kind of work that I cannot see or understand . This idea helps me to imagine that sometimes pain or fatigue or anxiety are covering over something so unbearable that my overzealous attempts to eradicate them or find a new and better story for the patient is not only futile but possibly harmful.
The further utility of this metaphor lies in the fact that there is for the most part a kind of steadiness to a train. By definition it can’t go faster on one track than the other. The pace is somehow set. The train’s safe arrival anywhere depends on this.
We can’t abandon being experts. We must act ethically within a system that makes huge demands on us and bestows us with great power and responsibility . We have to ‘stay on track’. This necessity does not preclude accepting that we often cannot alleviate pain or anguish, that symptoms are at work for patients in ways that may be beyond our understanding and that the painstaking work of letting people find their own words or stories – something that can take a lifetime or may never happen, is a vital part of what we do.
References
- Launer J. Narrative-based practice in health and social care. London: Routledge; 2018.
- Conversations Inviting Change [Internet]. Available from: https://www.conversationsinvitingchange.com [Accessed 11/9/26]
- Beug A. Making mosaics. BJGP Life [Internet]. 2025 Nov 14. Available from: https://bjgplife.com/making-mosaics/ [Accessed 11/9/26]
- Beug A. The general practitioner, secretary of the alienated subject? Psychoanalytic Psychotherapy. 2026. DOI: 10.1080/02668734.2026.2651136
Featured Photo by Roland Lösslein on Unsplash
