Austin O’Carroll is a general practitioner and co-founder of Safetynet Ireland, North Dublin City GP Training, and GPCareForAll. He is on twitter: @austinoc_austin
Western scientific medicine seeks the means to avoid fate. Patients accordingly come to doctors to dodge a destiny they do not want. That fortune ranges from minor ailments to the ultimate fate – death. We have helped to remove fates that cause death or discomfort e.g. infectious sickness; burst appendices; perforated ulcers; brain haemorrhages, cancers etc. Where we cannot prevent certain death, (e.g. from cancer or heart-failure) we have developed the ability to stave off that fate using our full array of medical skills and potions. Preventative medicine seeks to thwart the actual development of a disease that otherwise would be fated for many individuals. Fate still maintains some control in that prevention only saves some -and only from particular fates. It is fate who decides who is saved and who is not.
Stoic philosophy was based on the recognition that we cannot escape what is destined for us. An acceptance of inevitability has a number of implications for working as a GP. The following are some examples:
1. Shifting Emphasis from Cure to Management
An acceptance of inevitability has a number of implications for working as a GP.
If our fate is inevitable, we should not squander vitality fighting it or railing against what we perceive as injustice. The cyclist cursing the wind, the runner cursing the hill, the motorist cursing the jam of cars are wasting emotional energy. This is not to say that we are pure victims and should not try to influence our futures. All (wo)men should try and steer a course that is moral and will most likely result in happiness. Nor does it mean that we should not avoid or rectify our fate. We should avoid known health risks and seek cures for our maladies. If we are born into poverty we should seek to escape. However, when a fate is unavoidable, for stoics, it is the struggling against inevitability that causes distress.
What happens when we meet the patient who has a physical or mental illness with no known cure. This is the case for so many chronic diseases, mental illnesses and conditions based on symptomatology rather than known pathology (e.g. irritable bowel syndrome, fibromyalgia, chronic fatigue, chronic pain etc.) We often criticise ‘quackery’ for giving false hope, yet how often do we indulge in the same quackery ourselves?
Stoicism would suggest rather than waste energy on tests that are likely to result in recurrently dashed hopes, or medication that at best will do no harm, at worst will cause damage, we should help the patient accept their fate and seek to live a fruitful live with their condition. This involves admitting our impotence in seeking a cure. Acceptance requires the absence of optimism. A consequence of this is it directs both doctors and patients away from cure, towards management. This requires us to reach into our deep well of GP skills including those of listening, empathy, negotiation, providing pragmatic interventions (including medications that do help) and visualisation of a fulfilling life with ill-health.
2. Helping Patients face their Worst Fear
Seneca, the leading Stoical philosopher believed that though we cannot escape ultimate fates we can prepare ourselves for the providences that most terrify us.1 Every patient brings a secret cache of fears, some minor, some major. We are often good at helping patients face minor fears e.g. the young man with obvious non-cardiac chest pain who is worried he is having a heart attack. We are not so good in helping those patients express fears that mirror our own, the person with multiple sclerosis who is afraid of total body shut down, or the woman with rheumatoid arthritis who is afraid of disfigurement, pain and ‘the wheelchair’. There are also the patients with morbid fears who present with recurrent minor ailments but who fear major disease.
Susan Sontag writes quite powerfully about how society has encouraged the development of a morbid fear of ‘cancer’. We use the word cancer metaphorically for many things we fear or loathe. We conceptualise cancer metaphorically as an invading force, taking over our bodies. People speak of cancer with hushed tones encasing their own fear in the word and passing it on to other. People who contract cancer become its victims. This is despite the fact that among serious diseases, many cancers are now curable and have better prognoses than severe heart-failure, obstructive lung disease or Alzheimers.2
Whenever, when referring patients for investigations that may result in a serious diagnosis, I always inform them that such a diagnosis is a possible reality. Many of my colleagues believe this is creating unnecessary worry. As a stoic, I believe this allows I and the patient to unpack and challenge their fears e.g. addressing any misconceptions about the incurability of cancer. In my experience, this usually unpacks a fear that they had already and secondly, prepares the patient for those rare occasions the test reveals an unwelcome diagnosis.
One technique that is useful in enabling patients to face their worst fears is the ‘what if’ technique which allows patients to examine their worst fear without facing them and doctor to address any misconceptions they may have. For example:
• “What if it turned out to be cancer – how would you deal with it?”
• “What if the cancer is incurable – how will you cope?”
• “What if the investigations show you are unable to conceive children, how will that affect your life plans?”
3. Confronting Doctors’ Worst Fears
We as doctors too have hidden fears that influence our clinical behaviours. One of the worst fears we have is that of being responsible for a patient’s death or injury either directly or indirectly.
We as doctors too have hidden fears that influence our clinical behaviours. One of the worst fears we have is that of being responsible for a patient’s death or injury either directly or indirectly. We fear is the attendant guilt, having to face the family of the deceased patient, the possibility of facing litigation and complaint to the General Medical Council with the possibility of being struck off the Register. We fear one such mistake could ruin our whole career and negate the totality of our record of good patient care and cure. This often affects our clinical behaviour resulting in ‘defensive’ medicine that serves us and our patients poorly.3
In the US it has been reported 400,000 patients die per year due to medical error.4 In the NHS almost 900,000 medical errors are reported annually with 2000 resulting in loss of life.5 The Medical Defence Union advise that complaints are inevitable and most doctors will have at least one.6 Stoics argue we should not live in fear of mistakes but accept their inevitability. To err is human.5 As a stoic, as long as I act in good faith, I already have forgiven myself for my next mistake. If I make many mistakes, I will investigate and take action. I also reject any notion that a mistake will destroy all the other positive impacts I have had on my patients’ lives. And I have prepared myself for the inevitability of patients being angry with me, making complaints and/or initiating litigation against me. As part of this preparation I have a realistic understanding of the risks of complaints/litigation. The vast majority of complaints (over 80% in 2014) to the General Medical Council are dismissed.7 Litigation is actually quite rare with only 4% proceeding to court.8
We are trained as doctors to battle fate to the bitter end. We are trained to expect super-human perfection. We must learn to continue to seek to battle both our own and our patients fate but recognise that in face of impending defeat, treaty and negotiation can help us accept that reality with honour and a self-fulfilling composure.
References
1. Seneca LA. Moral Essays. Translated by John W. Basore. The Loeb Classical Library. London: W. Heinemann,1928-1935. 3 vols.: Volume II.
2. Sontag S. Illness as Metaphor. Penguin Books 1983.
3. Jain A., Ogden J. General practitioners’ experiences of patients’ complaints: Qualitative study. BMJ. 1999;318:1596–1599. doi: 10.1136/bmj.318.7198.1596.
4. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013;9:122-8.
5. Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010 Jul;105(1):69-75. doi: 10.1093/bja/aeq133. PMID: 20551028.
6. Responding to a complaint in the Republic of Ireland – The MDU
7. State of Medical Education and Practice in the UK report: 2015. http://www.gmc-uk.org/publications/somep2015.asp
8. Cave J, Dacre J. Dealing with complaints. BMJ. 2008 Feb 9;336(7639):326-8. doi: 10.1136/bmj.39455.639340.AD. PMID: 18258968; PMCID: PMC2234562.
