Sunday, 7 September 2008

Being a doctor

When I had some time off recently I met up with a close friend whom I hadn't seen for a little while. We talked about her (I'm not completely egocentric) but we also talked about me, and she suggested that “a doctor” is something that I am, not just something that I do. She is both kind and extremely perceptive so I am loath to dismiss her opinion out of hand but I'm not sure that she is right, even though it is undoubtedly true of many doctors that I admire. Her phrase implies that the qualities of doctoring have somehow taken root in my character and become part of me. An unfortunate corollary is that when I cease practising I may become, or at least feel, incomplete.

I have now been practising as a doctor for over half my life and all my early adult life was spent in medical training, so I have little experience of not being a doctor. Holidays are always a good time for reflection and taking stock, and my recent time off was particularly good. I was engaged in a project with some friends doing something that I enjoy very much, and there was a sense of purpose and achievement. I can certainly conceive of having a fulfilling life that does not involve medicine. And on returning to work I find that I can see my own and my patients' problems in a different light, for a while at least.

What does it mean to be a doctor? Firstly, we may receive the approbation and admiration of patients and colleagues, and enjoy good social standing, income and job security. These are all pleasant “perks” of the job, but are not its essence. The job itself involves the intellectual challenge of consultation, the emotional challenge of dealing with many different people and trying to meet their needs, and the stress of balancing patient demands against time and system constraints. But that is what we do, not what we are. Is there some mystical sense in which being a doctor is more than the sum of the actions carried out? Is it like being made a king or queen of Narnia: “once a doctor, always a doctor”?

I certainly gained this impression when I went through medical school. We were made to feel that we were preparing to enter an almost sacred profession, where we would wield great power and bear great responsibility. Tokens of that power included writing prescriptions and signing death certificates. One consultant advised that we should “try not to kill the patient by accident” implying that there could be circumstances under which we might hasten a patient's end. And underlying everything was the idea that we should do our best for our patients, even at risk to ourselves.

In my early years of training I moved from the basics of clerking and sticking sharp objects into people to taking a good deal of responsibility for patients as they were admitted to hospital. That was perhaps the moment of transformation; taking responsibility for diagnosis and treatment means that you have grown up as a doctor.

And now I have been a GP for over two decades, I am not young enough to know everything, and I wonder what it all means and what on earth I am doing. Why do these people want to come and see me? What can I do for them? I feel like the prophets of Baal, unable to produce the miraculous fire that is expected.

Certainly the view of medicine inculcated in me at medical school now looks old-fashioned and dangerously paternalistic. Today's zeitgeist is that no-one can be trusted. After Shipman, quietly hastening the end of a suffering patient is inconceivable. And the emphasis is no longer on what we are but what we do. “Competencies” are measured during training and doctors now have to produce a constant stream of facts and figures about their activities. Even our roles of diagnosis and prescribing are being usurped by nurses and pharmacists, although the buck still finally stops at a doctor's desk.

The basic unit of medicine is the consultation, in which a patient who believes himself to be ill seeks the advice of a doctor whom he trusts. Tomorrow morning I will meet many such patients who will seek my advice, and who will have waited several days to do so. Most of them will trust me: either because of previous experience, or from recommendation, or simply because it says “Dr Brown” on my door. I have had years of experience of encouraging people to talk about their problems, and trying to apply the principles of Western medicine to ameliorate their condition. That process is not emotionally neutral and I shall have to give something of myself in every consultation, sometimes very little but sometimes a lot. Perhaps it is that willingness to give of myself which makes me a doctor rather than just somebody who does doctoring.

I don't honestly think I will miss being a doctor when I retire. By that time I think I shall have given as much of myself as I can. But it may be hard to shake it off completely. I have this irrational fear that when I am in the queue at the Pearly Gates waiting to see St Peter a message will come over the PA system asking “is there a doctor here?”

(Remind me to tell you my Pearly Gates joke sometime...)


Anonymous said...

Don't kid yourself, Dr. Brown. Both you and I will miss it if we can't practice medicine until we get called to appear before the Pearly Gates...

Jellyhead said...

I agree that part of what makes doctoring so fulfilling and so draining, all at the same time, is the giving of oneself. I can imagine you do more than the average doctor when it comes to empathising and taking time and being thorough.

Have you considered part-time work?.. just in case you were thinking of working as you do now vs retiring as the only two options. I work the equivalent of around 2 1/2 days, and I (mostly!) love my job. (When working full-time, I was dragging myself to work, completely stressed-out)

As always, it was very interesting to read your thoughts on 'doctoring matters'.

Jobbing Doctor said...

Lovely post, Andrew.

Thank you.


Sara said...

I really liked this post. I hate those comments about it being not a job, being what you are. Something about it just rubs me wrong.

And I loved how you ended it. Nice work. I'm passing this one along.

Dr Grumble said...

......underlying everything was the idea that we should do our best for our patients, even at risk to ourselves.
That's what I remember too. I wonder if we still inculcate that concept into today's students. If we are still respected it may be because patients recognise that vocational element to the job.

That was the element that used to drive GPs (and for that matter consultants) to be available day and night without the government or managers even knowing. And that was why the 'tougher' new contracts resulted in many of us getting paid more for doing less.

The government has done its best to destroy the vocational and goodwill element of medicine. It does not seem to understand that doctors have been trained from the day they first saw a patient that the rules of the game are always to put the patient first. Managers seem to want to teach us that as if it is something new. I rather think it is. To them.

A DoH civil servant told me that the government is baffled as to why doctors are not enamoured with the government. It's because they have done their best to damage the things that are best about our profession. And if we lose those things completely we will no longer continue to be respected as we are. We will become like the politicians and seen as being in our jobs just to get what we can out of them.

Excellent post.

The Country Doc said...

Telling a story to an older physician about another retired physician I noted that he "was" a doctor at which point I was stopped mid-sentence.

"Was?" he said. "Isn't he still a doctor?"

For better and worse this is who we are and I think I could have done a lot worse.

XE said...

Excellent post Dr. Brown. Thanks for your insight.

Anonymous said...

Funnily enough, I had a similar conversation recently when I said that I have always enjoyed working with "patients" as opposed to another job in which they'd be "customers". We decided that our role becomes part of us or something being a part of us is what leads to taking on this role. If I think to what I'd be if I lived in any given period in history, I still would be a healer I think.
The best I can define it is that interaction bewteen people involves giving and receiving "energy" (knowledge, emotion, support, call it what you will.) Healers tend to be givers the majority of the time, I think, which I am sure is part of the reason behind becoming a healer, and then remaining a healer.
(Here endeth the waffle)
Anji - X

No One said...

re "After Shipman, quietly hastening the end of a suffering patient is inconceivable" oh so sedating the patient, withdrawl of fluids, and letting them die from dehydration isnt hatening the end?, as is practised by the nhs thousands of times a day?

what self satisfied bollocks

Jellyhead said...

By 'sedating the patient', I guess 'No-one' means allowing the sedating side-effects of effective pain relief. What is the alternative then? Leaving patients with untreated, unrelieved pain?

I have never encountered a situation involving 'withdrawal of fluids' - just the decision NOT to penetrate the skin with a needle and artifically give fluids - a move which would only prolong the inevitable in a suffering patient with a terminal condition.

I agree that we should not hasten death, but nor should we use intrusive measures to keep a person 'alive' when they are at the end of their life. I understand what you mean Andrew, and rather than finding you self-satisfied, I've always thought you were quite self-critical.

Each to his own.

No One said...

come on we all know folk in the nhs with already adequate pain relief are often sedated and then have their drip removed (or none added as they are no longer able to drink)

who is kidding who?

id like to see some honesty in the death certificates, so that they list dehydration as the true cause of death

with the nhs incentivised to free beds up anyway they can its getting worse

Anonymous said...

Goodness, has doctors net entered your blog Dr Brown? It seems you have attracated a campaigner!

On your main theme I am sure I have heard or read this phrase about different categories of doctors, those who do and those who are, so maybe your friend is not an original thinker (as well as getting you wrong).

Maybe the do-ers are more balanced and the be-ers more sentimental and nostalgic. Does this explain the number of "retired" doctors clinging onto GMC registration despite the absence of any reason to do so, as well as the number of doctors harking back to past golden ages rather than moving with the times.

Anonymous said...

Very nice essay - I think you should submit this somewhere (eg BMJ), so that more people will see it than visit your blog.

BTW what was the project you were working on with the friends?

ageing student said...

Who was it who said (about doctoring) "Thou shalt not kill but need not strive, officiously, to keep alive."I have always felt that fitted the bill - do the best you can, try not to kill any patients, but when the time comes don't keep resucitating hopeless cases (or have I been watching too many hospital dramas?)

Dr Andrew Brown said...

Wow! This post really has generated a lot of comments. Thank you everyone. I was particularly pleased to see many of my favourite bloggers making comments.

Just a few specific points.

Jellyhead: I have thought about going part-time. In the first place I am dropping some private commitments which will reduce my workload (and income). I'll see how things go after that.

Blue Spice: Yes, I think that "giving energy" has a lot to do with it. I often quote Luke 8:40-48.

No One: I'm afraid I don't have much experience of what goes on in hospitals nowadays. Your descriptions sound unlikely, or at least I hope they are. I was thinking of a time when GPs would sometimes give a large dose of morphine. I am sure that never happens nowadays.

Anonymous 23.01: I think doctors ought to balance doing and being. I am actually in favour of retired doctors being allowed to remain on the GMC Register.

Gareth: Thanks for suggesting my essay is worth submitting to the BMJ. I don't think they accept anonymous contributions and of course I couldn't submit it under my real name. No - people will just have to come here if they want to read my stuff!
I can't be more specific about what I was doing, except to say that it was immensely satisfying.

Ageing student: You are thinking of "The Latest Decalogue" by Arthur Hugh Clough, which was not intended as a serious contribution to ethics but was an ironic take on the ten commandments. Another line reads:
"Thou shalt not steal; an empty feat,
When it's so lucrative to cheat."
On the other hand it does neatly sum up the approach many doctors take to palliative care.

No One said...

yea maybe GPs should go round hospitals a little more like the used to do in the old days

i remember the family GP randomly turning up on the wards and keeping the hospital on its toes in my youth

i am very sure large numbers of people die from dehydration in nhs wards every day

it cannot be that big a secret in the medical world

or maybe youd all just prefer to look the other way

Anonymous said...

Dear Mr no one
You sound very hurt and angry and may snap at this but has it occurred to you that the reason today's GPs don't visit their patients in hospital is that their time is filled up with other things. If you read this blog you will see how Dr Brown spends his long hours at work. Many doctors - including older ones like me - used to visit their patients in hospital in the day between surgeries. Now there is no time - it is back-to-back clinics, meetings, audit groups, training courses, inspection visits, paperwork etc.

I remember the good old days when I had time to visit the hospital. These days, it's a miracle if I am even aware someone has been admitted to hospital until days after they come home. Regret for the passing of this sort of thing is regarded as sentimental twaddle by the modernisers.

No One said...

theres nothing sentimental about good levels of care

if GPs in Italy, Belgium, New Zealand to name but a few can take the time to occasionally visit their patients in hospital I dont see why its impossible in the UK

too few docs, dealing with too many dross cases, and doing too much stuff that should (and would be elsewhere on the planet) done by consultants

im sort of on your side

but i feel a little sanity from the patient point of view is missing

i have great sympathy with the best GPs, tolerance for the middling GPs, but feel the bottom %'s of GPs should be stopped from practising

i really dont see any good answers here that will improve the service to patients

and I'm really hacked off with a system that allows folk to die for want of treatment that should be routine

so hopefully i wont snap, but hopefully you understand where im coming from

David Adam (zanchey) said...

Fantastic post. I first had the difference between saying "I am a doctor" and "I work as a doctor" pointed out to me by a very learned professor of General Practice here in Western Australia. It is well worth considering how the shift in the way doctors describe themselves correlates with the problems with the medical workforce, though which precipitates the other is beyond me.

Dr Andrew Brown said...

No One: It's true that hospital visiting by GPs is almost unheard of nowadays, and that is a shame. It is quite simply a matter of lack of time, due to ever increasing demands. There are more doctors per head in the countries you mention where GP visits still occur.

Your criticisms are reasonable, and welcome. I'm not promoting complacency or trying to defend bad or incompetent doctors. I'm just describing how it is for me.

David: Thanks for your kind words. I'm always glad to have visitors from WA as my father now lives there.

Anonymous said...

Dr. Brown,

Thanks for choosing to be a General Practitioner! Not a lot of people find the courage or even have the localizzatori gps to make a difference.

Anne said...

I came across this post when I tried to search for House, MD. I am just so addicted to the series. And I find the post quite interesting, Dr. Brown. Just a question though, if you were House, would you be doing the same decisions to your patients?

I believe he (House) is able to save many lives at risk especially those with very unique illnesses, but does this end justify his means?