8 ~ The Subversion of General Medical Practice
The doctor, family doctor, general practitioner, or primary care physician as they are also known, rather than the specialist or medical consultant, is the second most important division of labour in society after housewives. That this is so is demonstrated by the fact that even Stone Age cultures, such as that of the indigenous people of the Arctic that existed until modern times, had medicine men or shamans. This is in spite of the fact that the number of individuals in any one community is generally so small that they have no more need of a chieftain than a trio of musicians needs a formal conductor. To have emerged so early in the evolution of human culture then for ordinary people the ‘doctor’ must be the most important person in the local community. They must be more important than authority figures such as politicians, lawyers, or even the head of state. Moreover, people often refer to them as ‘my doctor’ like a personal possession.
In this context, it is important to realise that there is a difference between a doctor and a ‘pill-popping’ body technician. The difference is unclear in western culture but in the Muslim world the differentiation is clear in the public mind with special Arabic words for each. Whereas a ‘doctor’ views the mind as a physical entity intimately linked to the body, ‘body technicians’ see the mind as a mere figment of the imagination and ignore its influence.
Traditionally, the doctor not only made people feel better if they were ill but attended births and deaths, attended emergencies day or night as well as being available for what is nowadays referred to as ‘counselling’. Usurping the power and influence of family doctors rather than the primary care of patients has been the covert goal of the National Health Service, (NHS,) since its inception in 1948. Such a manoeuvre was of paramount importance when seeking to undermine a culture such as our own. Before outlining how it was done it is helpful to re-examine primary medical care several decades ago before it was overwhelmed by the increasingly totalitarian dictates of the NHS.
To read the papers one would think that medical science was on the brink of knowing it all but that is far from the case. In fact, only a few patients in every hundred have an illness with causes and cures that are sufficiently well understood to be described in medical textbooks. In many respects, medicine has advanced little since the Stone Age. It is true that a better understanding of disease processes has improved the treatment of many physical conditions, often miraculously, minimized suffering and prolonged life. However, the majority of patients can still only be assessed by clinical judgment. Blood tests, X-rays or other scientific investigations performed to clarify a diagnosis are invariably negative. The big unknown in modern medicine is still the underlying causes of the niggling nerves, coughs and ‘collywobbles’ that make people feel ill.
Most patients are not actually ill; rather they are concerned that they might be. Usually they are suffering from the physical symptoms of anxiety such as indigestion, diarrhoea, palpitations, muscle pains or minor infections. Perhaps they have been unnerved by a thought that leapt unexpectedly from subconscious or perhaps because of something they heard or read. They are suffering from what can be called ‘hypochondriacal anxiety’. Patients become concerned that their symptoms might be caused by a serious illness such as cancer or heart disease thereby creating a vicious circle of anxiety. Seeking advice about such worries is the commonest
clinical problem for which patients consult family doctors worldwide regardless of race, religion, or social class. It always has been and always will. It is a facet of human nature.
Physically, hypochondriacal anxiety is not life threatening and therefore does not immediately appear to be a serious problem. However, it saps the spirit psychologically and lowers morale. This makes it a potential weapon in the psychological Cold War. The sooner it is treated the better, not only for the patient, but also for the family, friends and workmates with whom the patient comes into contact. Consequently, in Britain both before the NHS and until the reforms of 1969, reassurance was quickly available from family doctors in morning, afternoon and evening surgeries. To be examined and reassured that there was nothing seriously wrong, patients simply went to the surgery and took their turn.
The diagnostic problem for the doctor is that the symptoms of hypochondriacal anxiety mimic more serious illnesses. It is the differential diagnosis of these common everyday ailments from rare potentially lethal conditions that is the essence of clinical responsibility. Fortunately the task is made easier by the fact that in serious underlying pathology the symptoms, manner and bearing of the patient are usually more focussed and this alerts the doctor. If the patient has responded in the negative to appropriate questions, been physically examined and no abnormality found then reassurance is the only treatment needed. If any abnormality is actually found then, depending on its nature, it is either treated with appropriate drugs or the patient referred to a specialist for further investigation.
In the final analysis treatment depended on age-old practices. Reassurance has always been the first principle of treatment and is the most powerful ‘drug’ in the doctor’s therapeutic armamentarium. The quality of that reassurance is paramount. By the time patients have decided to consult a doctor they are in a hypersensitive and highly suggestible state. They scrutinise the manner and bearing of the doctor for clues observing every intonation of voice and furrow of brow. Realising this, doctors took care to refrain from voicing words like ‘cancer’, ‘ulcer’ or ‘heart disease’ unless the diagnosis was certain and the patient had a need to know. Since
patients already suspect something serious, simply mentioning such illnesses suggests that the doctor has the same suspicions as they do. Likewise, it is important never to advise that the patient comes back if they do not feel better. To do so also suggests to patients that there might be something more serious the matter with them. Moreover, there is no clinical need to follow up cases of hypochondriacal anxiety; if patients do not feel better they come back anyway. Therapeutic efficacy is further enhanced if the doctor knows the patient and understands their circumstances. The patient is then reassured that the doctor truly understands their problem lending weight to any advice that is given.
Patients feel relieved when told that there is nothing seriously wrong and this has a sedative effect. Reassurance is dependent for therapeutic effectiveness on manipulation of the psychoactive hormones, neurotransmitters and receptors in the body. These are the opioids, cannabinoids and adrenaline described above. While these have only been physically identified in recent decades, humanity has always been aware of their presence from their subjective effects on mood. Manipulating bedside manner to stimulate natural opioids and cannabinoids in the body has been used by good doctors throughout the ages to make patients feel better.
The underlying psychology was studied in depth after the last war. For example, Dr. Michael Balint talked of the drug called ‘doctor’.  Others talk of the placebo effect. Reassurance as the first principle of treatment was taught at medical school in the fifties. It is at this point that the art and science of medicine become one and differentiate the doctor from the mere body technician.
To voice words like ‘cancer’ or ‘ulcer’, or advising the patient to come back if they do not feel better, or misunderstanding the patient’s symptoms, has the opposite effect to reassurance. The patient’s opioids and cannabinoids are not stimulated and instead adrenaline is produced increasing anxiety and fear. When the patients’ worst fears are confirmed by the use of such emotive words they can only be reassured by a battery of expensive investigations together with a second opinion from a consultant. In the old days, some doctors deliberately alarmed wealthier patients, accidentally on purpose so to speak, to create well-to-do hypochondriacs constantly seeking reassurance. This boosted personal incomes and was considered unethical or, less dubiously, paid for the care of the less well off. Exploiting clinical psychology in this way is the oldest confidence trick in the clinical book.
Nowadays this trick has become played routinely as a tactic in the psychological Cold War. Hypochondriacal anxiety often occurs in patients who have been alarmed by something they heard or read. Almost daily, the papers report some trifling discovery and present it as if it was of great significance: ‘Could your saucepans bring on the menopause?’ ‘Spinach really does make you stronger,’ are such headlines taken at random. More seriously, people are still being told that smoking causes lung cancer even though, after fifty years, scientists have been unable to produce tumours in laboratory animals with tobacco smoke. The abuse of medicine by promoting hypochondriacal anxiety is an ideal medium for undermining the morale of society. Rare conditions are publicised as if they were commonplace. More common conditions are attributed to diet with people exhorted to eat less fat or more vegetables. Early diagnosis is presented as the key to preventing more serious damage. People are encouraged to be checked regularly to make sure that they are not suffering the early signs of diabetes, cancer or heart disease. For several decades, there has been a campaign by the Department of Health, vigorously supported by the Royal Colleges and the media, to promote hypochondriacal anxiety. People have become gripped by the notion that there may be something wrong with them and their morale undermined. In consequence, the taxpayer is being unwittingly fleeced of billions annually using the oldest confidence trick in the clinical book.
Once upon a time family doctors played an additional role. They are consulted by patients from all walks of life and see behind the scenes of their lives. With experience, they acquired a broad understanding of human nature and its foibles. While treating illnesses or putting patient’s minds at rest about hypochondriacal concerns was always a priority, family doctors were also willing to discuss personal problems of one kind or another. They were therefore reassuring presences and sources of wise counsel in the community just as they must have been since the dawn of civilization.
Doctors practice medicine to earn a living like everyone else. Wage earners have had their fees paid by the government in Britain since the National Insurance Act of 1911. Before the advent of the NHS in 1948, the fees for everyone else were determined by ability to pay. There is a story in the family about how grandmother organized the collection of fees so that mother’s father, a general practitioner in a mixed rural community, could put his mind to the job. She would ask him whether he thought so-and-so could afford two shillings or only one for treatment some weeks previously. A hundred years ago, that would have been the equivalent of a little under ten pounds or a little under five pounds. Such a fee also subsidized the treatment of someone who could not afford anything and never received a bill. Naturally, a few ‘quacks’ refused to treat poor people devoting such talent as they possessed to the wealthy. A tactic in the psychological Cold War was to present rapacious doctors as the majority when they were in fact a very small minority. This was then used as an excuse for totally rejecting the guidance and advice of family doctors when establishing the NHS in 1948.
That is not to deny that the concept of the NHS was a good idea. Grandfather’s brother-in-law was a family doctor in a poorly paid industrial community. Overworked and underpaid, he died prematurely leaving a wife and three children. However, in those days doctors still respected the Hippocratic oath and looked after each other. Two sons went on to qualify in medicine themselves. One eventually became a Professor of Bacteriology at St. Thomas’s having played key roles not only in the development of penicillin but also identifying the cause of puerperal fever that used to kill many mothers following childbirth. The other specialized in industrial medicine.
Then in 1948 the NHS was established and with it a long saga of bureaucratic interference in clinical matters. To begin with, doctors were forbidden from charging patients even if they could afford to pay. Dispensaries were shut down and patients forced to traipse to a chemist with their prescriptions. Doctors were forbidden from performing minor operations such as suturing lacerations or draining hydroceles. They were not remunerated for those services that could be loosely described as psychotherapeutic or ‘counseling’. Some had to junk expensive equipment such as X-ray machines! If family doctors wanted to investigate any area of
medicine that particularly interested them, they had to do so at their own expense. The inception of the NHS in 1948 ushered in a clandestine erosion of clinical freedom to study intractable problems that continues to this day. With nothing to do except treat hypochondria in its various forms clinical practice became dull, depressing and tedious. By the 1960s ‘he never even looked at me’, became a common complaint by patients talking to their friends after they had consulted their doctor. Family doctors were demoted from archetypal figures to mere cogs in an ideological wheel.
In 1969, the Labour government ‘reformed’ the NHS. It was advised, aided and abetted by the Royal College of General Practitioners. This institution had been founded only a few years previously and was anxious to make its mark and achieve the status of the other more ancient Royal Colleges. With a passion for more power than it knew how to handle, it was ridiculed by those raised in the age-old traditions of medicine for an inability to differentiate between timeless principles and old-fashioned practices.
One of the reforms was to induce doctors to adopt appointments systems by paying seventy-five percent of the wages of receptionists. The plausible political objective was to promote the ‘dignity and status of the workers’. Patients could no longer pop into the doctor on the way home from work. They could no longer be quickly seen, reassured and their minds put at rest if they suspected they might be ill. They had to make an appointment, tell the boss, get time off, and generally tell the world of their private personal concerns.
The College advised that five minutes were set aside for each appointment with the result that they quickly became fully booked. Patients whose problems had previously been adequately resolved in a couple of minutes were fobbed off to tomorrow or the day after. In effect quick, cheap, simple and effective reassurance for hypochondriacal anxiety, the commonest clinical problem in the world, became unavailable thus sapping the spirit of ever more people, the goal of subversive ideology. Apprehensions became bottled up and brooded about with patients resorting to self-medication so that the modern market in alternative medicine with its
countless quack remedies, mushroomed like a nuclear cloud. Family doctors became ever more remote from the problems of their patients and increasingly tangled in red tape. With only twenty-four hours in a day, the time they had left for reflecting on the problems of particular patients was diminished. The authority of family doctors slowly evaporated and with it the standing they once had in the community – a victory for the psychological Cold War warriors!
No payment for ancillary staff was paid to doctor’s wives who continued to answer the phone, take messages and reassure patients outside surgery hours when their husbands were doing visits. The excuse offered by the government for this continuing exploitation was that payments for this vital service would be open to abuse, a gratuitous insult to dedicated doctor’s wives and typical of the Socialist dialectic.
Another aspect of the reforms saw doctors being remunerated for performing special tasks decreed by the Department of Health. Prior to the reforms, family doctors were paid a capitation fee for each patient on their lists regardless of how often the patient was seen. This was continued after the reforms but supplemented by other payments conditional on them doing other specific tasks. Thus special payments were made for the vaccination and immunisation of children. Previously this had been the responsibility of local Medical Officers of Health but the post was abolished. After the reforms, family doctors had to fill in foolscap-sized forms to
prove they had immunised a child before they could claim paltry remuneration. It did not occur to anybody that sticking needles into babies was not the ideal way to start a new doctor/patient relationship.
Special payments were made for special items of service such as cervical smears to detect cervical cancer. This was a very rare condition causing only about two thousand deaths a year at a time when over five thousand were being killed on the road. Few doctors took this new responsibility seriously and so were not able to collect the paltry remuneration of seven shillings and sixpence (37.5p) that was paid for the procedure or less than five pounds in today’s money.
Special payments were made for postgraduate training. Family doctors had to attend two weeks of postgraduate lectures a year in order to qualify. The plausible objective was to keep family doctors abreast of developments in medicine. The problem was that few, if any, of the developments in medicine actually affected the vast majority of patients seen by family doctors. Special paltry payments were also made for seniority and the length of time working in the NHS.
But far and away the most destructive of the reforms were the special payments made to doctors who practised together in a group. Previously doctors had worked alone, or more usually in pairs, from one of the doctor’s homes in the community. The reforms encouraged doctors to gang up on patients and practice from a central surgery or ‘health centre’. This meant patients then had further to travel to see their doctor. Once there, they never knew whether they would be able to see the doctor they knew and trusted or someone who was strange to them. The homely, informal atmosphere of the doctor’s surgery was eliminated and the stage set forthe brash clinics that have since taken their place.
People can be taken ill at any time day or night and traditionally family doctors were available for consultation twenty-four hours a day, 365 days a year. If they wanted time off or a holiday they had to arrange for a colleague to see their patients and take their calls or employ a locum at their own expense. By 1973, if you totted up all these various bribes or ‘inducements’ as they were called, instituted by the 1969 reforms and divided the average family doctor’s taxable income by the number of patients registered on his list, you arrived at a figure of the order of two pounds per patient per annum or twenty pounds in today’s money. With an average of two thousand patients on a doctor’s list this produced a taxable income of about four thousand pounds a year or about forty thousand pounds in today’s money. This was twice the income of the average worker but for a 168-hour rather than a forty-eight hour week. It was also regardless of the number of times a patient was seen or the trouble that had been taken! For example, a total of twenty-four hours over several weeks were once spent successfully testing an experimental treatment for LSD psychosis but no remuneration was paid because the patient was registered with another member of the group.
(It is only in recent years that the remuneration of NHS family doctors, calculated as an hourly rate, has risen to be on a par with labourers, a fact that newspapers have consistently withheld from the public.)
All these new hoops and hurdles that family doctors were expected to negotiate took time that detracted from the central task of understanding and treating people. The overall effect of the reforms was to place a workload on family doctors that was physiologically beyond human achievement. They were expected to do more than twenty-four hours work a day. Doctors do not sing and dance, whine and complain, demonstrate or go on strike. They simply pack their bags! The upshot was that after the 1969 reforms, large numbers of British family doctors of the old school either quietly sought asylum overseas or retired prematurely on the grounds of ill health. Indeed, so many suffered chronic fatigue or ‘burn out’ that the Medical Sickness Society, with whom many had taken out sickness and accident insurance, was overwhelmed. It had to resort to ruthless interpretation of small print and insist on strict medical examinations in order to limit its commitments. Many were denied the benefit for which they thought they had subscribed. Further reforms over the years have so overworked family doctors that they have been obliged to abandon the twenty-four hour service that they had provided for generations. They now only work a nine to five style routine driving a total bureaucratic wedge between doctor and patient.
The result for the NHS was a staffing crisis in the early 1970s. This was overcome by recruiting doctors from India. There was a hidden agenda behind this tactic. While Socialist propaganda brands the British Empire as oppressive and exploitative there had been sustained subversive efforts to promote nationalism and independence particularly in India and Africa by the likes of Mahatma Ghandi. Little realised is the fact that after the British left in 1947 Indian politics became dominated by Socialist philosophy. The clinical comrades of Calcutta and such places eagerly immigrated to fill the breach and consolidate the new ideological status quo of the NHS. Many thought it outrageous that we should import doctors from a country that was itself short of doctors. Furthermore, although the General Medical Council insisted that these doctors could write English, they did not insist that they spoke intelligible English. By that time the General Medical Council, British Medical Association and Royal Colleges had been taken over by intellectual Socialist ideology and no doubt thought such a requirement would be ‘racist’. But doctors brought up in place like Newcastle, Glasgow or Aberdeen for example, with unintelligibly broad local dialects always learned to speak plain English. The Indians never made that effort so that patients often could not understand what their doctors advised them. Moreover, immigrant doctors were totally ignorant of local custom. But they did as they were told by the Department of Health and that was the political objective. Again the sense of security in the community was undermined and public confidence in the profession diminished.
The coup de grace against British medicine came in the early seventies when all doctors suffered the same fate that had befallen American colleagues several decades earlier. Doctors have long had medico-legal liabilities. For example they could be sued for damages if they accidentally left instruments or swabs inside people after operations. The comrades have been active in America since the days of Lenin. Decades ago they surreptitiously started promoting litigation for errors of judgement as well as for errors of practice on the plausible pretext that it would improve standards of care. But as has already been observed, the medical profession has far from perfect knowledge. Most patients can only be assessed by clinical judgement. That judgement, although paramount in determining the success or failure of treatment, can never be as objective as leaving a swab in a patient.
The doctor/patient relationship is based on mutual trust. With the possibility of being sued for errors of judgement, such as failure to make the difficult diagnose of meningitis in a child, as well as errors of practice, doctors became unable to trust their patients. To safeguard their livelihoods and the wellbeing of their families they had to put medico-legal security above the welfare of patients.
Increasingly patients were referred for expensive confirmatory investigations so that in the event of litigation the doctor could say he had substantiated his judgement. But as observed earlier, when a doctor suggests a need for further investigation, the hearts of patients who are already in a hypersensitive state, leap into their mouths. They fear there is something more seriously wrong. Instead of immediate reassurance, they have an anxious and demoralising wait for results sometimes lasting weeks. Patients feel worse rather than better. The effect of litigation was to exploit elementary clinical psychology and the oldest confidence trick in the clinical book, to undermine morale, defraud taxpayers and undermine public confidence in doctors. This then created a vicious circle of diminishing trust and respect for the power and authority of the medical profession.
The effect was not only demoralising but also sometimes lethal. In ‘More than a Puff of Smoke’, a case in Canada in 1964 is described where a patient asked outright whether heart disease was causing her symptoms and promptly had a heart attack when told the truth.  She was stabilised before moving her to hospital where she made a complete recovery. But when told, the senior partner was livid. To avoid any medico-legal comeback the patient should have been bundled into an ambulance immediately in spite of the fact she would certainly have died.
There was an also an apocryphal yarn in North America in those days. Immigrant doctors were advised by indigenous colleagues never to stop at a road accident. Doctors had been successfully sued if a victim died of injuries in spite of emergency treatment such as arresting a haemorrhage or clearing an airway. By 1964 the entire North American population had totally alienated its doctors. By 1974, the ‘workers’ in Britain and presumably Europe too, had encouraged their lawyers to follow suit!
The upshot was the development of intensive care. Medico-legal pressures then ensured that such units were abused for the prevention of death as well as the saving of life. The effect was to produce ever more helpless and expensively dependent cripples. The elderly were similarly treated. Fearful of being sued by relations if they died, patients were treated with antibiotics for what would previously have been their last illness. They then survived as ‘geriatric vegetables’ rotting in expensive nursing homes not only making massive nursing and financial demands for care but also depriving families of their inheritance. Healthy people, fearful this might happen to them, began vainly writing ‘Living Wills’ or ‘Advance Decisions’ as they are now called.
Afraid of being sued for untoward consequences of infection, antibiotics were administered increasingly prophylactically to prevent rather than treat infections. This sped up the process of resistance creating MRSA, C.diff, and a host of other untreatable bacteria that have yet to emerge. A recent spell in hospital led to the suspicion that all medication is now prescribed for medico-legal rather than clinical reasons.
The promotion of litigation has been a clinical and social disaster. It has subversively destroyed trust and increased costs. The expense of medical care in America is legendary spending more money per capita than any other country. It is reported that the NHS now costs one hundred billion pounds a year. Lawyers are not qualified in medicine and cannot appreciate its psychological subtleties. Moreover, no matter how mighty the laws of the land, the laws of nature are mightier. It is the laws of nature that determine the course of illness making them paramount. The elimination of subversive medico-legal manoeuvres would reduce the cost of
healthcare by billions. In the meantime, by forcing doctors to put medico-legal considerations before the welfare of their patients, doctors have themselves been reduced to the status of mere body technicians. Nowadays doctors are obliged to spend much of their time undermining the economy with needless expense and splashing about in bath water from which the baby has long since been thrown!
As the time of doctors was increasingly squandered on bureaucratic activities, their freedom to analyse the problems of patients was diminished. Doctors became ever more dependent on drugs for therapeutic efficacy. Faith in drugs had been vastly increased after the last war by the advent of antibiotics with their miraculous effects. The search was on to find drugs with similarly miraculous effects on other problems such as anxiety and depression or the unrecognised consequences of anxiety and depression such as raised blood pressure, raised blood sugar levels and raised cholesterol levels. However, the chemistry of the body is not yet fully understood. It is therefore impossible to adequately test new drugs for their effects, their action on the balance of the mind for example, or on memory. It is possible that drugs whose full effects are not known are also slowly poisoning society. All that we can be sure about is that they do not kill outright! The side effects of drugs have become an ever more common problem so that people are now prescribed drugs to counter the side effects of the original medication, and a vicious cycle has been created ballooning the drug bill of the nation.
In an effort to combat drug abuse by a minority many familiar drugs such as opiates whose side effects were well known and which benefited the majority, have been substituted by inferior synthetic substances such as Fortral (pentazocine). These are in fact just as addictive as opiates but less effective. Amphetamines and similar stimulants have been banned altogether because of abuse by a minority. Small doses of amphetamine used to be particularly effective in treating boredom and depression in the elderly, keeping their minds alert and bodies active thus preventing dementia and loss of memory.
The medical profession has long possessed more knowledge than one individual can master in a lifetime of learning. Professional organisation had evolved to cope by a division of labour into researchers, consultants and family doctors. Researchers and consultants specialise in small areas of medical knowledge, studying in depth. Family doctors, on the other hand, acquire a more general knowledge of medicine, studying in breadth. Had they been better organised, researchers, consultants and family doctors working together as a team could have made medical knowledge available to society both in depth and in perspective. Burying doctors in the bureaucracy of the NHS has made teamwork impossible.
This failure of teamwork within the profession has had other demoralising consequences. We are constantly being told that smoking tobacco is hazardous to health raising blood pressure, causing cancer and so forth. We are constantly being told that obesity is hazardous to health raising blood pressure, causing cancer and so forth. We are told that statistics ‘prove’ this to be so. But anxiety and ‘stress’ raise blood pressure and it is this that the statistics are measuring. As any good family doctor can confirm people, people smoke more heavily or eat too much when they are anxious and stressed they also put on weight if they stop smoking. But people are stressed not only by everyday life but also from being encouraged to live their lives according to ‘politically
correct’ ideological principles rather than common sense. Berating people for smoking and overeating by threatening them with dire consequences increases rather decreases that stress creating a vicious circle. It has made the problem worse rather than better thus serving the covert subversive political agenda.
The bottom line is that family doctors are now paid for doing what the Department of Health tells them to do rather than for treating their patients as individuals.
The damage cannot be repaired overnight or by what has passed for ‘reform’ in the past. Restoration of the reputation and skills of family doctors will take time. It will first be necessary for them to resign from the NHS and take control of their own practices working from simple surgeries scattered throughout communities as they did before the reforms of 1969. For remuneration, they should charge the government on a fee for service basis perhaps using the schedule of fees that worked so well in Saskatchewan in the 1960s. Regional Medical Officers of Health should be reinstated to supervise preventative measures such as immunizations and
screen for such conditions as can be screened for as was once done with Mass Miniature Radiography for the detection of tuberculosis.
In the final analysis, most diagnoses in medicine still have to be based on clinical judgement. This places family doctors in a position of great power in all societies. However nature together with the presence or absence of confidence in individual patients rather than governments, places checks and balances on abuse of that power. Moreover, in spite of the contrary impression created by the media, not only is medical knowledge still far from perfect but there is also an enormous variation between individual patients not only in their makeup but also in their ability to describe their symptoms and inform the doctor what is troubling them. Diagnosis is seldom clear-cut. Medical conditions can improve or get worse regardless of clinical intervention. The clinical picture early in an illness is often less clear than it might become later. It is impossible for a doctor to be one hundred per cent certain at any time. All the doctor can be sure of is that most of the time a specific course of action, be it simple such as reassurance, or complex such as an operation, is usually successful otherwise it would not have become routine.
In effect, doctors make life or death decisions on each patient that consults them. In the final analysis, a clinical opinion is just that, not a statement of indisputable fact. No doctor can ever give a cast iron guarantee. No matter how much care is taken while examining the patient, infallibility is impossible and occasional errors of judgement unavoidable. While litigation for objective errors of practice, such as leaving an instrument in a patient after an operation, is fair and just, litigation for errors of judgement, which can only be subjective, is grossly unfair and unjust. Support by Social Security rather than the awarding of ‘damages’ should be the
reparation for those unfortunate enough to be adversely affected. Only in this way will the mutual trust between doctor and patient be restored. However, it will take time and meanwhile people will have to start looking after their family doctors as well as they expect their family doctors to look after them as they did before the inception of the NHS in 1948.
To conclude this passage on a lighter note and illustrate traditional medicine this passage ends with a case history:
Johnny was only 3. He had a previous medical history of minor upper respiratory infections for which the doctor had treated him so that he was no stranger. The by walked into the consulting room, smiling and confident, ahead of his mother. With great respect for her son’s pride, she stated that he had started wetting thebed after being dry for a long time. Johnny’s father was a soldier on active service.
‘Oh!’ the doctor said seriously, trying to imagine himself in Johnny’s world in the middle of the night the better to understand his problem, ‘That must be very uncomfortable!’
It is at about this age that boys first become fully aware of the reality of metaphysical fear. Shadows become infested with ghosts and ghoulies.
‘Many boys of your age are frightened of the dark,’ the doctor said informatively, ‘are you?’
‘Yes! I’ve got a little light.’
‘Do you sometimes want to use the potty if you wake in the night?’
‘Are you sometimes frightened to get out of bed?’
‘Do you think you could be brave like daddy and force yourself to get out of bed and use the potty in
spite of being frightened?’
Quickly the problem was teased out so that it explained itself. Mother suddenly understood what had been happening and her anxieties dispersed as rapidly as if she had been intravenously sedated. Johnny, learning that he was not the only boy to be frightened of the dark, felt less vulnerable and better able to defy his fear. By increasing the level of understanding of both the mother and the son, their perception of the problem was changed in such a way as to reduce rather than increase their anxieties When the boy was next seen some months later, there had been no more wet beds. His enuresis had been cured and recurrence rendered highly unlikely. The time taken to conduct the consultation was about two minutes.
- The Doctor, His Patient and the Illness. London: Churchill Livingstone, 1957.
- Ian Dunbar, More than a Puff of Smoke, (Lulu, 2009), 41.