David Zigmond is a retired GP and psychiatrist in London. He has written and campaigned on problems within the NHS for several years. His website is at http://www.davidzigmond.org.uk/david-zigmond-archive-homepage
What can one man’s personal reminiscences and reflections tell us about our community’s assets and losses? There are times when personal testaments can achieve this with greater clarity and evocation than any academic analysis or report.
Michael Dixon’s book Time to Heal: Tales of a Country Doctor is part-memoir, part-polemic — a kind of sweet but dark valediction to his long working life as a small-town GP.
Earlier in this offering the sweetness runs freely through his many reminiscences of his early life, and then to a crucial switch: seduced from being a torpid philosophy student to a fired-up medical career. Of his youthful epiphany and enthusiastic resolve he writes:
“… the early-memoir parts of Time to Heal will easily please any reader wishing to be entertained on a rainy afternoon.”
‘I concluded that there was probably no point in trying to think too much … following my time in the African hospital I was only more convinced that a life of action and practicality was what I wanted.’
Yes, but … Dixon’s jejune self-assessment did not then anticipate what was to come later: beneath his love of the manifest and practical lay his growing respect for the less evident, yet more meaning-infused aspects of his work: its ethos and philosophy.
Nevertheless, the early-memoir parts of Time to Heal will easily please any reader wishing to be entertained on a rainy afternoon. The writing is direct; his descriptions and explanations are clear, colourful, and often humorous. His working life is brought to the reader by many personal tales and vignettes that are redolent of Doctor in the House, All Creatures Great and Small, or even some Ealing comedies and saucy seaside postcards — so many of these folk seem quaint, queer, risqué, or bizarre. In this picaresque landscape Dixon himself seems indefatigably good-natured: should this arouse the reader’s scepticism or envy?
Yet amid this early sweet benignity he is already hinting of darker caveats to come:
‘Delivering babies, attending the sick and dying and being responsible for emergencies creates an intimacy with individuals and the community which is long-lasting and good for both clinician and patient. Today’s doctors have more time with their own families – necessarily so, as the era of the full-time working GP and GP’s wife at home is just about over – but the connections and mutual respect and affection between doctor, patient and community is weaker than it was. This may have everything to do with doctors finding their work less satisfying and some patients finding their doctors less caring or available, while litigation bills soar.’
“The writing is direct; his descriptions and explanations are clear, colourful, and often humorous.”
As this book progresses, its early playful, even comedic, lightness gives way to the author’s very substantial criticisms and laments about the last three decades of ‘modernising’ serial reforms — the span of his own career. He describes how the attempts to metricise, micromanage, and proceduralise all medical consultations and services has led to the displacement and destruction of trusting relationships that are necessary to understand, comfort, and heal.
Whatever frustration this de-vocationalised doctor may feel, he does not attempt to discharge this by any riff or rant: his evidence and notions are wide-ranging yet sharply focused and expressed straightforwardly, without rancour and refreshingly free from jargon. Rather than summarising these, here is a seminal sample of Dixon’s own words:
‘There is now firm research showing that if a doctor knows his patient well then he is less likely to prescribe a medicine, the patient is more likely to be happy with the outcome of the consultation and his recovery is likely to be quicker … [here] relationships are everything … ’
‘Thus, it became clear to me that the essential element of any healing relationship was to take time to get to know each patient and to learn to like them. Pretending to like them just doesn’t work — patients can see through that a mile off … [I needed to] better understand why people were as they were.’
‘Evidence-based population research gives us information on the “normal” or “average” patient, but I have yet to meet a normal or average patient. Different treatments suit different patients and guidelines rule out these individual subtleties.’
“As the book progresses … lightness gives way to the author’s very substantial criticisms and laments about the last three decades of ‘modernising’ serial reforms … “
‘The strength of primary care and general practice is that it reaches beyond each system and disease. Much of what happens between a doctor and the patient is unspoken. Our most important work cannot be entered on a spreadsheet.’
‘The success of any given treatment is thus only partially a factor of the doctor getting the right diagnosis and treatment and has much to do with the patient, the doctor, their relationship, and their perceptions of each other. If some successful treatment is “all in the mind”, then far from regarding it as illegitimate, perhaps we should see it as far safer and more sustainable than some of the procedures and strong medicines that we currently give.’
‘We must also review the whole issue of indemnity or litigation in the free health service, which not only threatens to bankrupt it but also keeps our young doctors in constant fear of making a mistake that might bring their careers to a premature close. Fears … which are also stopping clinicians doing the right thing.’
‘ [The current system] is designed to reward the lumbering box-ticker, those who keep their noses clean and those who do not think for themselves.’
‘It is the splintering of the relationship between family doctor and patient that is leading to the unhappiness of both. Once that relationship is fractured there is less give and take between doctor and patient and healing becomes all the more difficult.’
“He describes how the attempts to metricise, micromanage, and proceduralise all medical consultations and services has led to the displacement and destructing of trusting relationships that are necessary to … heal.”
Such observations and explanations of lost worlds and values will find much welcome recognition by most practitioners who knew the NHS in pre-marketised and pre-commodified times. Yet Dixon brings some respite to his threnody. Amid the shattering and impoverishment of personal care he sees great, if alternative, possibilities in his late-child project of social prescribing. Of this he writes:
‘Social prescription does two other very important things. It moves medicine and general practice from a very biomedical model that previously only provided tablets or procedures to a more psychosocial model of care that makes better use of the patient’s physical and social environment. It is about de-medicalising care and avoiding patients becoming dependent on doctors and drugs and seeing themselves as their own agents of healing and health … ’
This is bold optimism, yet such initiatives are rendered far less fertile when husbanded by a here-today-gone-tomorrow harried practitioner.
Indeed, this veteran doctor may battle to retain his optimistic pragmatism:
‘Working in a system that has lost its kindness and which underrates and undermines the importance of kindness provided by its staff adds yet another pressure to those of being a modern family doctor … I feel ashamed to practise in a system that may do technical things so much better than ever before but which has also had to become expert at protecting itself against the greedy, the vindictive and the embittered. Too often it means we fail those who are none of these. Many of them — particularly the elderly and the vulnerable — want … a service that is easy to get to, compassionate and which is provided by people that they know and trust.’
In recent years he is ruminating about many of his work’s predicaments:
‘… I find myself as an elderly family GP acting in the role of an apologist for an unkind world — trying to understand and restore the self-confidence and self-esteem of children, who have lost hope. It is a very privileged role but what on earth can a few minutes with me achieve?’
“Amid the shattering and impoverishment of personal care he sees great, if alternative, possibilities in his late-child project of social prescribing.”
Yet he is able to offer such therapeutic consolations because of this:
‘Forty years in my profession has taught me a great many things: I have learnt that first and foremost medicine is not about anatomy, physiology, care pathways or always finding an evidence base. It is about people. How they are, how they feel, what they believe, and their hopes. It is about our common humanity. It is also about a doctor’s place in a community; having the time to get to know and to understand an individual as well as understand the community in which they live.’
This personal summation-credo certainly grew from Dixon’s own experiences but was also fertilised by earlier luminaries whom he quotes. Two in particular.
First, attributed to William Osler, a pioneering scientific physician who lived from 1849 to 1919:
‘It is as important [for a physician] to know what sort of a person has a disease as what sort of disease a person has.’
Second, Albert Einstein:
‘The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honours the servant and has forgotten the gift!’
The young Michael Dixon’s intuitive decision to change course was only partly right: he certainly found action, but he was mistaken in thinking he could abandon philosophy. Time to Heal is evidence of his continuing possession.