Thursday, 20 September 2007

Good enough

I am getting quite fond of you, dear readers. You keep coming up with interesting and challenging ideas, you are usually extremely kind and supportive, and you occasionally tell me that other people have it far worse and I should buck up my ideas and stop whinging. That is the glory and the trouble of blogging, I am going through my dirty linen drawer in public (albeit anonymously) and talking about things that I would normally keep to myself or perhaps discuss only with my wife or a trusted colleague.

It's true that no-one likes a whinger, especially in Australia. But the stated purpose of this blog (apart from providing amusing and heart-warming anecdotes from the Brown Surgery) is examining to what extent I may be considered a fortunate man, and this necessarily involves dwelling on some negative aspects of the job. First, let me say that in one very important respect I am extremely fortunate: I have a wonderful wife and children who are a delight and pleasure, and I am extremely happy whenever I am in their company. It is the job, as you may have gathered, that is a problem.

My anonymous chum The Shrink came up with (another) fascinating idea today, drawing on the work of Donald Winnicott. I had thought that Winnicott was “just” a paediatrician and that his phrase “good enough mother” was a sort of homely aphorism; reminding us that mothers who try to be perfect the whole time will fail dismally, while those who simply do the best they can will be better for their children in the long run. One of the doctors in this practice tries to be that perfect GP and is constantly screwed up (in my humble opinion) by this heroic attempt at the impossible. (Interestingly it was a different partner who went off with stress last week, and so far shows no sign of being well enough to return). I had imagined that, in contrast, I am probably “good enough” at the job (as The Shrink suggests).

However, it turns out that Winnicott was also psychoanalyst, and that what he meant by “good enough mother” was more technical. Such a mother adapts (consciously and unconsciously) as her baby develops, providing all of its needs at the earliest stages but over time becoming less helpful, thus allowing her child to gradually become independent without excessive anxiety. Winnicott also suggested that a doctor should “display all the patience and tolerance and reliability of a mother devoted to her infant”. At first glance that appears impossible once again. How can I do that for each of the thousands of patients for whom I am responsible? The first thing to say is that Winnicott was talking specifically about psychotherapy. But secondly, the “good enough” doctor need not and indeed should not attempt to meet all his patient's needs. He (or she) should delay or refuse the provision of needs that the patient should meet him (or her) self. He should judge how much to provide, according to the stage of recovery that the patient has reached. But the over-riding principle is that he should do so with patience and tolerance and reliability. In other words, if he refuses to meet a patient's need the patient should know that this is because it is in their best interest, and not because the doctor can't be bothered, or is cross with them.

I can say from personal experience that this is hard work, and it is difficult to be consistently patient and tolerant and reliable to the many people that have legitimate calls on you throughout the working day. That includes colleagues and staff as well as patients, of course. Luke 8:40-48 suggests that Jesus also found healing to be a drain on the spirit.

I would say that almost all of my stress arises from lack of time. When I stop and think about a problem, seeing the patient as required, I can sort almost anything out. But it takes time. So my heart sinks a little when a nurse says “could you just come and see so-and-so”, even though I know the request will be fully justified, because the time to consider and act and document will make my surgery run even later. But that is just a matter of timetabling. What I really hate is finishing late. When I started as a GP two decades ago we did our own on-call at night and at the weekend, but I got home at a reasonable time and often had an hour or so free during the day. Now my days are full, working continuously for ten to eleven hours, after which I return home exhausted.

I recall a conversation with a fellow GP who worked in the same practice as his father before him. A patient once told him how his father had spent several hours visiting her one Christmas Day many years before. She seemed to expect him to be proud of having a father who was so dutiful. But his recollection of the event, which happened when he was a young boy, was that he had wanted his father to be at home with him on that special day.

Although I may gain some satisfaction from the things I do for my patients, there are slim pickings for my wife and children. This has been brought home to me again this week, as our youngest prepares to leave home for higher education. Sure, it will be me who actually drives the car on Saturday, but I have had little time to take part in the preparation, the excitement and the mild anxiety that go along with this major life change.

There I go, whinging again. I will finish on a positive note. It seems that no-one in authority likes GPs, who are all overpaid and underworked and mainly on the golf course. A thousand little obstacles are constantly set against us. Sleeping policemen spring up on the roads we need to use to visit our patients, as do parking restrictions which are closely policed by the local authority. When we asked whether GPs might possibly be issued with parking badges to allow us to visit our housebound patients we were told not to be so silly. Exceptions cannot be made. But today I visited a patient in a block of flats that were constructed in gentler times, the 1960s. At the foot of the block, near the entrance, was a car parking space clearly marked “Doctor”. By some miracle it was unoccupied. So I parked in it! As T S Eliot wrote:
Oh, do not ask, "What is it?"
Let us go and make our visit.


Elaine said...

Umm, do you think that any of your angst is due to a fledgeling leaving the nest, or is it just that the government is determined to make life for the poor old GP so appalling that they can sell it off to American big business? The latter would be appalling.

Come back Dr Brown, all is forgiven.

A. said...

And we're quite fond of you :) Actually, very!

The Shrink said...

However, it turns out that Winnicott was also psychoanalyst
There's no reason you should have known that. I spent 3 years of weekly psychotherapy practice and teaching doing so much about European psychodynamic psychotherapy with Winnicott as one of the true giants up there on a pedestal.

I love the notion that perfection required in all areas is, obviously unrealistic and undesirable.

If quoting scripture I'd go for Mathew 5:38-48 with the bit, "You, therefore, must be perfect, as your heavenly Father is perfect."
This is moer than advice, we've been charged with this directive and that's that. Fine (erm, who am I to challenge His words!) and as an aspiration for Christian living it's key. But it is rather too lofty for more mundane or secular activities.

I do like the notion of "good enough" though. A colleague, beleaguered by frankly malign managers, sent a letter to all colleagues and dozens of her patients simply asking for an anonymous reply to the question, "Am I a good enough psychiatrist?"
She's more than good enough, she's excellent and had glowing feedback, but her position of "good enough" rather than "bad/average/good" and the like appealed to me. Rather than fishing for complements or trying to get "ratings" it's cutting to the chase and answering the right question.

Anonymous said...

Dear Dr Brown,

Having been on the receiving end of some excellent shrinkage dispensed by one of the most excellent shrinks in this country (hurrah for the Swiss health system - expensive but damn good!), I can tell you that Donald Winnicott is unreservedly right.

Please continue to be good enough; that's plenty good enough.

orchidea xxx

XE said...

Awww... you're fond of us! Hope that all gets resolved.

Anonymous said...

You may indeed be a fortunate man but I'm fortunate too to be one of your readers and that's "good enough" for now!

Dr Andrew Brown said...

Thank you all for your supportive comments. You are most kind (not to say flattering).

The fledgling appears well settled in new abode.

Anonymous said...

Dear Andrew

Another thoughtful post "good enough" is a concept I keep returning to with patients and trainees (and myself!)
I am a GP trainer and course organiser (programme director) and have recommended your blog to my trainees and educational colleagues. Whilst the shouty and angry have their place yours is a beacon of calm and reflection in the medical blogosphere Keep up the good work Thank you

Dr Andrew Brown said...

Treehugger: Thanks for your comments, and thanks for recommending the blog to others - I think! I am currently grappling with the concept of my audience, which seems to include doctors, medical students, nurses and a fascinating variety of non-medical people. I'm not sure whether I can cope with course organisers as well. :-)

I'm glad that I don't appear too "shouty and angry". I have at times slipped into polemic, and rightly been castigated for self-pity and special pleading. How I feel about things is bound to affect what I say, but in general I think it is best if I stick to describing how things are for me rather than write political diatribe.

I try not to write specifically for "my audience", but I suspect that keeping the great diversity of my readers in mind helps me to write in a more balanced and honest way. That is probably a good thing.