My doorbell rang early yesterday morning – Friday 13th, take note. It was my neighbour. He said, “Do you want the good news or the bad news?”
“I’ll take the good news.”
“I have an air compressor.”
“What’s the bad news?”
“You have a puncture.”
I wasn’t entirely surprised. I said, “Front, passenger’s side?” I’d actually checked the pressures the day before, and found the latter to be a little soft. What was it Matt Damon said to the magnificent Franka Potente in one of the Bourne films? “I thought your tyres were a little squelchy.”
“No. Back, driver’s side.”
True enough, flat as a pancake. Anyway my neighbour kindly pumped it up. Not only that, he then followed me in his car, with compressor, ten miles into Stirling and made sure I got there. Such kindness.
At the tyre shop, they told me both front tyres needed replacing. I wasn’t surprised by that either. I have a talent for ignoring impending problems until they turn into a crisis. I said, “Whatever it takes. All-weather tyres, if you have them.” They cracked on. While I was waiting I ran into a friend from a German class I used to attend in Stirling, and we had a blether. Einen Schwatz. The puncture was repaired and the tyres replaced in double-quick time, and I headed into town for breakfast of coffee and a croissant. Back at the car, rear driver’s side was flat again. I hobbled back round to the tyre shop. They took the tyre off and invited me to join the examination and subsequent morbidity and mortality meeting, glooming me up for the bad news that, basically, the tyre was, to use the technical term, f*****. I acquired a third all-weather tyre. Should I bite the bullet and replace the lot? No, the fourth tyre still had some mileage. It’s a good place, that tyre shop. They are straight. They don’t rip you off.
Well, if that’s the worst thing to happen to me on Friday 13th, I won’t complain. I couldn’t help but contrast my experience with the appalling reports we hear of people whose problem is not a leaky tyre but, let’s say, a leaky aorta. I suppose an equivalent experience in the motoring world might, in the absence of a kind neighbour, look something like this:
I call a breakdown service to find they are on strike, for all but the direst emergency. A flat tyre is no such thing. Call again the day after tomorrow. I do so. I’m still a low-echelon caller. Expect a delay of two weeks. Three weeks later the breakdown vehicle picks me up and drives to the tyre place but can’t get near it because of the tailback of waiting, ailing cars. My car is incapacitated so the breakdown vehicle has to stay in line with me, inching agonisingly forward.
Eventually I reach my destination but I can’t get any further than the reception because the bays are all occupied. The throughput is agonisingly slow because, as it turns out, the mechanics are on strike and are only attending to the worst cases. And so on.
You will jalouse, gentle reader, I am making reference to the NHS. But you know, such an analogy, the leaky tyre leaky aorta analogy, is of little use. Human beings with hearts are not remotely like cars with internal combustion engines. Car mechanics might talk about “running diagnostics”, but pathophysiological diagnosis is something quite different. I remember Joe Epstein, one of the great founding fathers of emergency medicine in Australia, used to say, “People do not come into emergency departments with diagnostic labels attached to their foreheads. Some people think they do, but I can assure you, they do not.”
Of course much of the current crisis (sic) in the NHS is due to chronic understaffing and underfunding, but I believe another problem exists at a deeper societal level. I call it the erosion of the medical consultation. The sanctity of the medical consultation has been under attack throughout the twenty-first century. Lay people, and, I have to say, some health care professionals, don’t really understand what a medical consultation is. The medical profession cannot be exempt from blame in allowing the structures of health care systems to be designed by politicians, management, and the IT industry. There is no more instructive example of what I mean than Matt Hancock’s dictum (a few Health Secretaries ago) that GPs conduct the main part of their business online, and not return to their “bad old ways”. You can certainly run a health service on line if all the patients have a diagnostic label attached to their foreheads. Heart attacks and strokes down this corridor, cancers here in this fast track, hip and knee replacements here, mental health in an entirely different wing, worried well go private, malingerers get short shrift, etc.
What medicine fundamentally needs, is an ambience in which a patient can meet a doctor in a quiet, safe, confidential environment, and an atmosphere of calm. The doctor greets the patient, bids him sit down, and says, “What’s up?” Then the doctor goes into a trance and listens. For a moment, he steps into the patient’s shoes. He becomes the patient. And he doesn’t interrupt. Only later will he ask a few pointed questions, for sake of clarification.
Next comes the physical examination. If you don’t look, you don’t see. After that, nine times out of ten, the doctor will have not only a diagnosis, but a notion of how the diagnosis affects this particular patient, in a unique way. Further tests may be needed, but they must be used sparingly.
If ever you want an example of a bad consultation, listen to the response to the first question on Friday/Saturday’s Any Questions (BBC Radio 4) from Newport. An A-level student asked the panel whether they would advise her to pursue a career in medicine. The members of the panel translated this question into politik-speak and started haranguing one another along traditional party lines over the management, or mismanagement of the NHS as it currently is. They didn’t listen to the question. They didn’t listen. As usual, the chairperson became a fifth voice in an increasingly incoherent ramble. Nobody answered the question. And critically, the chair did not return to the student questioner to ask her opinion of what she had heard. It was beyond pitiful.
And on Tim Harford’s statistics show More or Less, a study suggesting there are excess deaths in England and Wales due to “A & E” (sic) “waits” (sic) was discussed by an economist and an actuary. Statisticians I know and love always tell me that when they enter somebody else’s world, it is not enough merely to crunch the numbers; in order to understand the numbers, you need to have some understanding of the field into which you have been invited. From the discourse and the language, I don’t think the economist or the actuary knew much about emergency medicine.
Then Sir Keir Starmer wrote in The Sunday Telegraph. I think he’s glooming up the left for the need for a radical reform of the NHS. There are no sacred cows. But he was pretty thin on detail. And why would he not be? He’s not a doctor, he’s a lawyer.
However things turn out to be organised, we need to protect the medical consultation. Doctors must not allow bureaucrats to tell them how to do their job. And diagnosing a subarachnoid haemorrhage, or a ruptured spleen, or an aortic aneurysm, is not like diagnosing a flat tyre. Some people think it is, but I can assure you, it is not.