In the middle of May the NHS computer systems throughout the UK came under cyber-attack and as a result, the NHS was temporarily crippled. I wrote a letter to The Herald, which they were kind enough to publish, suggesting that it is unwise to become too reliant on computer systems. The computers crash and you can’t function because you haven’t been trained to think from first principles. Now British Airways have suffered a “catastrophic” IT systems failure resulting in the cancellation of BA flights into and out of Heathrow and Gatwick. Serendipitously, I had likened a doctor under cyber-attack to a pilot who can’t navigate using compass turns and mental dead-reckoning. It all reminded me of a piece I wrote in 2006 for Hoolet, the Journal of The Royal College of General Practitioners, Scotland, which I dug out and reread. It seemed relevant to me. As I hold the copyright, I reproduce it now. I haven’t changed a word.
Imagine you have been commissioned to design the front cover for the next edition of Hoolet. The theme: zeitgeist – the spirit of the age. The editor asks for an image that will represent for the readership the atmosphere of le nouveau siècle. What would you choose? Perhaps, the twin towers aflame? An iceberg calving off the Greenland coast? A uranium enrichment plant in Iran? George Galloway dressed up as a vampire on Big Brother?
I choose a word picture, something I happened to hear on the radio, vivid enough for me to conjure the scene with extraordinary clarity. It was a description, one year on, by a British tourist who happened to be in a Thai electronics shop on Boxing Day 2004 when the tsunami struck. One moment he was browsing the shelves, the next he was swimming for his life, to escape from the shop before it was completely engulfed. There he was – and this is my image – surrounded by floating desk top computers, mobile phones, PCs, iPods, digital cameras, and play stations, thinking, “This stuff is useless rubbish.”
He escaped with nothing but his life. He needed rest, warmth, shelter, food and drink, and human companionship. The local people, who had next to nothing, shared with him that which they had. I have no idea what happened to him after that. Perhaps he returned to Britain and resumed his job as a sales rep for Hewlett Packard. But I’d hazard a guess that the experience must have changed his world view, and his sense of the relative value of things. I do believe his experience has changed mine.
I am not a Luddite. I remember as a GP trainee in Edinburgh in 1984 going on a distant house call from our practice to Gogarburn. I made the round trip and got back, only to be given another Gogarburn house call. I said to my trainer, “Do you think the practice should get one of these portable phones?” I’d seen one. It looked like a large brick, the sort of thing John Wayne might have used on Juno, Gold, or Omaha. My trainer was dubious. They were expensive, toys for the rich and famous, and Edinburgh was full of black holes where you lost the signal. So we put the idea on the back burner; I paused for a coffee and signed a few repeat prescriptions that had been hand-written by the reception staff.
How times have changed. I don’t think very many people in 1984 anticipated the sheer scale of the information technology revolution, its power, and the rapidity of its onset. And it would be crazy, it would indeed be Luddite, to wish it away. Apart from anything else, it is just so much easier now than it was in 1984 to book a flight, to withdraw money from the bank, to get an urgent message to New Zealand. As one of the doctors in our practice said the other day, “We’re going paper-light; there’s no point in arguing about it; it’s coming; all that matters is that we do it right.”
Splendid. Yet I can’t say I mind when the system crashes. I say to the receptionist, “The computer’s down. Thank God. We’ll do it the old-fashioned way.” And suddenly we all talk to one another a bit more. A computer outage affords us all a glimpse of our humanity. There is a little frisson of excitement – you feel the same thing during an electricity power cut. I’ve always loved power cuts. The darkness creeps in from outside and you huddle together round the tallow lamps, sharing a kind of underground, blitzy camaraderie.
“That’s all very well,” I hear you say, “but that’s just an indulgence and a conceit. If you were a doctor in Baghdad and you only had power for two hours every 24, you would be monumentally cheesed off!” And would I also feel the same way if the computers didn’t get up and running again? I’m not so sure.
The miraculous thing about the medical consultation is that it can be carried out under the glow of a tallow lamp. It is a beautiful thing. All you need are the skills – to take an accurate and detailed history, and to carry out a physical examination with little more than your hands, ears and eyes. Then you need the wit and experience to interpret what you have found and to consider whether you should intervene, and if so, how. You say to yourself, “What does this person who consults me seek? What does he need?”
Nothing should be allowed to interfere with the sanctity of the medical consultation. If the computers go down and as a consequence we find we are unable to do our business, then I think we are in trouble. I had the misfortune to spend ten hours in Heathrow Airport last December when the departures board suddenly and peremptorily cancelled my connection to Glasgow. There was no explanation. I dutifully joined a lengthy queue at the BA information desk and waited my turn. Still no announcements. A young man just ahead of me in the line began, politely, yet insistently, to complain to the BA staff that in the age of the superabundance of information, we weren’t getting any. When I reached the head of the queue I learned that my flight had been cancelled, not because of a mechanical problem, but because of a computer failure; and that the outage did not affect Air Traffic Control, but the ticketing system. “But I’ve got a ticket!” I waved my boarding pass in the air. No matter. I had to rescue my baggage from the carousel, join another queue, and check in to a later flight. When I got to the head of the queue, I was told I was too early to check my baggage in.
I got home after midnight, and was moved to write a “Disgruntled of Tunbridge Wells” – type letter to The Scotsman disabusing the Roman Catholic Church of its new-found belief that Limbo did not exist; after all I had spent an eternity there. I could give its precise location: Gate Lounge 5, Terminal 1, Heathrow Airport.
Not long after this – and perhaps this is a tiny example of the way our humanity can be bolstered by an outage – a young man came to see in in the surgery. After the consultation, he asked me if I had written a letter to The Scotsman. His father had sent him the cutting with the covering note, “Sounds like this doctor was in the same queue as you.” It was a Buchanesque experience; Buchan might have written, “My eyes dislimned .” I suddenly recognised the articulate, vociferous young man who had been ahead of me in the queue.
For most of us I believe it remains the case that when the computers go down our business doesn’t grind to a halt. Quite the contrary, we feel freed up to get on with our work. This should at least give us pause, not to unplug the terminals, but to consider how we use the technology and whether our use of it really does improve patient care. I can’t decide whether the people who negotiated our contract for us were childishly naïve or cynically Machiavellian in throwing a sop to a government bureaucracy obsessed with the achievement of targets through ticking boxes on a computer screen. I think we all know that many of the measurable parameters deemed to indicate that we perform well are risible in the extreme. Bring me the most intractable hypertensive patient in the practice and I will get his blood pressure under 135/85 – no bother at all. He may not be able to stand up, he may be exhausted, nauseous, impotent, and depressed, but he will be normotensive. Tick the box. This is what happens when the IT system becomes the business. It’s a very dangerous ménage-a-trois, a doctor, a patient, and a computer screen. It is so easy for the doctor to misplace his loyalty within the triangle.
For myself, considering the way things have gone, I find it difficult to separate in my mind IT and childishness. There are 700 channels on the TV and nothing to watch. I get 700 emails a month and about 7 of them are worth reading; the rest are either spam, or “fire and forget” blanket directives sent out by the trust to a vast readership. Travelling by public transport has become a torment not so much because of the grime, squalor, and imminent threat of physical violence, but because of the cacophony of zings and tinkles issuing from the ear-pieces of one’s fellow-travellers, and the mindboggling banality of their one-sided telephone conversations. Mobile phones have become a sex aid for adolescents with repetitive strain injury of the thumb. Well, good luck to them. C U L8R! St Paul had a word to say about IT:
When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.
Now I think of the patient before me as the man in the Phuket electronics shop, fighting for his life, not waving but drowning. What does he need? Certainly not all this cyber-flotsam, impeding his efforts to escape, to be free, to live.