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...)