The Uncomfortable Professional

Peter Aird is a GP in Bridgwater, Somerset.

The professionalism of general practitioners continues to be undermined as increasingly we are treated as naughty children who need to be brought into line. Two issues have highlighted this for me recently.

I used to think that it was bank robbers and murderers who got sent to prison but now it seems that, by virtue of my being, for CQC purposes, the registered manager of my practice, I could theoretically go to prison for the heinous crime of pouring a urine sample down the sink in my room. This is despite the fact that this cavalier attitude of mine has never done anyone any harm. Furthermore I am advised that I could be up on fraud charges for wantonly consulting with an 85 year old lady at what is, for her, a more convenient time than the 7:40pm appointment she had booked under Advanced Access arrangements.

This is, and I hope you’ll excuse the strong language, blinking stupid.

We are having to do things for no other reason than someone, somewhere, demanding that we do. And we are being cowed into submission merely to satisfy their agenda and justify their existence.

And not only is it stupid, it’s also depressing and anxiety provoking.

In his book ‘Lost Connections‘, on the causes of depression, Johann Hari makes the point that “human beings need to feel their lives are meaningful – that they are doing something with purpose that makes a difference”. He quotes a study from the 1970s by Michael Marmot who, investigating stress in the workplace, found, perhaps counterintuitively, that “the lower an employee is ranked in the hierarchy, the higher were their stress levels”. It turns out that the less control you have on your work, the more stressed and depressed you become. “When you are controlled, you can’t create meaning out of your work.”

Hari describes a group of people who worked in a bike store who, depressed and anxious as a consequence of being ordered around by their boss, decided to break away and set up their own bike store – one where decisions were made collectively. By giving themselves autonomy and control over their work, they reaped huge psychological benefits for themselves.

So what of general practice? Like those bike store workers we too are being controlled by others and made to work in ways with which we disagree and in which we see no value. And it is depressing. This extends to much of our clinical work.

Des Spence, writing about the GP workforce crisis in the BJGP identifies the need to reverse the escalating patient demand in what he describes as “today’s largely disease-free Britain”. Unsettlingly, he lays the blame for the increased health seeking behaviour of patients on the clinical practice of we GPs who, by encouraging the medicalisation of human existence, fuel health anxiety and make patients increasingly dependent upon us. Rather than too few doctors, Spence suggests “there is too much medicine” and that “iatrogenic harm is the spectre in today’s world of polypharmacy for all”. He asserts that “the debate about workload in general practice should in reality be a debate about clinical practice” and that if “we want to reduce stress and workload the solution is…to prescribe less, intervene less, and refer less”.

It’s a compelling viewpoint and yet too often we find it hard to stop behaving in ways that perpetuate the problem of an over dependence on medicine. As Bob Dylan once growled “I’ll go along with the charade until I can think my way out”. But thinking your way out can sometimes be hard.

Alan Jacobs has written of how, once established, the consensus is hard to challenge because we naturally tend to avoid the psychological discomfort of disagreeing with what’s generally believed. To think effectively we need to shrink this “hypertrophic instinct for consensus.” but, claims Jacobs, “given the power of the instinct, it is extremely unlikely that [we will be] willing to go to that trouble”. Jacobs says the “instinct for consensus is magnified and intensified in our era because we deal daily with a wild torrent of what claims to be information but is often nonsense”. T.S. Eliot wrote, “When there is so much to be known…when everyone knows a little about a great many things, it becomes increasingly difficult for anyone to know whether he knows what he is talking about or not.” And in such circumstances, Eliot continues, “when we do not know enough, we tend always to substitute emotions for thoughts”.

This is what GPs need to do. We need to practice patience and master fear and thereby do things differently. We need to practice medicine in the way those bike shop workers did, resisting the ‘hypertrophic instinct for consensus’ and with it the demand to behave in ways that are imposed on us by government, pharmaceutical companies and society as a whole. We need to make collective decisions on how to practice based on what we know as GPs to be true, that medicine hasn’t all the answers. And by giving ourselves autonomy and control over our work, we will, consequently, bring about genuinely better health for our patients and happier working lives for ourselves. Just think of the benefits – we could even keep pouring urine down the sink!

But to do so will be uncomfortable – speaking the truth often is – but it would mean we were being professional.

And professional is what we must be allowed to be.