I recently submitted the following spiel to an essay competition. I wasn’t short-listed. I’m not bitter! But rather than shove it in a bottom drawer and forget about it, I thought I would post it anyway. Apologies: it contains some material I’ve used here previously. Stop me if I’ve told you this before.
It’s a word you hear frequently at medical conferences, often during a question and answer session following a clinical talk. The question from the floor might concern the efficacy, or otherwise, of a treatment or procedure. The learned professor replies, “I’m not sure that the evidence base is very strong here, but anecdotally…”
I always prick my ears up. I love anecdotes. They sound like amusing tales that might be told by droll after-dinner speakers, and indeed, even at a medical conference, they might turn out to be so. But more likely, the professor is going to describe an episode, or episodes, in clinical practice that might suggest some putative cause-effect relationship that has not been firmly established. As those who seek grant-funding might put it, more research is required.
Some people in the medical profession are very suspicious of anecdotes. They have no faith in them. They are too reminiscent of medicine as it once was, before the rigorous application of the scientific method. Anecdotes have nothing to do with double-blind controlled trials. They are the basis of outworn practices like the prescribing of squills, the medicinal leech, or like bleeding or cupping that are either useless or downright dangerous. We ought not blindly to follow an established practice, simply because our mentors told us that it works. We need to demonstrate not only that Treatment A is better than Treatment B, but also better than placebo; it might turn out to be considerably worse.
Yet, despite all that, the fact is that the practice of medicine is entirely based upon our exposure to, and reaction to, an untold number of anecdotes. For every medical consultation starts with an anecdote. In general practice we might say, “What is it that has brought you to see me this morning?” or “How may I help you today?”, and in the Emergency Department we might say, “What happened?” or even “What’s up?” However we put it, we are asking the patient to tell us an anecdote.
Chambers: anecdote n a short narrative of an incident of private life; anecdotes collectively. [Gr an– (privative), and ekdotos published, from ek, out, and didonai to give]
The Chambers etymology captures exactly the anecdotal nature of that which is termed the patient’s history. That which is private, is “given out”, or expressed. The anecdote is not “published” in the sense that it is made available to the public, perhaps put on social media. It is “given out” in a closed environment of confidentiality and trust. The interaction is between two individuals, patient and doctor.
The expression of the anecdote, in the confidential setting, lies at the core of all medical practice. Diagnostically, the ability to elicit, to hear and to understand the anecdote is far and away the most powerful tool in the doctor’s armamentarium; far more powerful than the subsequent elements of the medical consultation, vital as they may be – physical examination, and radiological or laboratory investigation.
Sometimes I confess I glance over Hadrian’s Wall at the latest initiative of whichever Health Secretary is incumbent in Westminster, and I breathe a sigh of relief that Health is devolved. Yet we must take note of any activity of our English cousins. It could be a harbinger. At the time of the pandemic, almost all general practice consultations went on line, and there can be no doubt that Microsoft Teams, or Zoom, or whatever platform you chose, was under the circumstances a godsend. Then we got vaccinations, and the Covid threat began to recede. But, at least according to the Health Secretary, Zoom was here to stay. From now on, the online consultation would become the norm. Mr Hancock said to the GPs, shortly before he disappeared into the jungle, “You will not return to your bad old ways.”
This is an essay in defence of the bad old ways. It is deeply unfortunate that a political initiative should in effect be an attack upon the sanctity of the medical consultation, which is a hallowed and precious thing worthy of our protection. That an online consultation is inferior to a face-to-face encounter is self-evident. The opportunity for physical examination is absent. Why would you conduct a consultation wearing a blindfold? When Mr Hancock issued his directive I found myself yelling at the radio. What’s the patient’s temperature? What’s the pulse? The blood pressure?
But it’s not simply the inability to gather data that’s the problem. The medical consultation comprises far more than the mere trafficking of information. It’s not remotely a tick box exercise. In the best consultations, the doctor asks that opening question, “What happened?” – and then stays silent, and goes into a trance. You step into the patient’s shoes. You relive the patient’s unique experience. For a moment, you become the patient. It comes at a cost.
It seems extraordinary that, at time of writing, it is less than a year since Wes Streeting – remember him? – then Secretary of State for Health and Social Care in England, made his statement to the House, Fit for the Future: 10 Year Health Plan for England. Of course, since then, things have moved on. Mr Streeting has certainly moved on. He resigned, not over any matters concerning Health, not, you may say, on health grounds, but as a demonstration of lack of confidence in the Prime Minister, whom rumour has it he would like to replace. I’m struck by the fact that, the higher the office you hold, the easier it is to relinquish. When I retired as a general practitioner, I recall I gave six months’ notice. Secretaries of State on the contrary vanish overnight. It begs the question why we should listen to anything they have to say. There is a famous piece of television footage in which the late great Sir Robin Day interviewed John Nott, then Secretary of State for Defence, and asked him, “Why should we pay heed to the opinions of a politician, if I may say so, here today, gone tomorrow?” Mr Nott, clearly very irritated, unclipped his microphone and left the studio. From time to time in general practice I might have been tempted abruptly to terminate an interview with a “tricky” patient, but I wouldn’t have dreamt of doing so.
Mr Streeting may be “fly by night”, but he was, presumably still is, an advocate for change. He advocated change right across the National Health Service, in three broad areas: the transfer of health care from hospital to community; the transfer of management of data from analogue to digital; and the transfer of the focus on health from treatment to prevention.
Let us approach these in reverse order. Prevention is better than cure. Who would doubt it? It’s true. But it is also a truism. The fact is that you could summarise, nay, you can iterate, the whole of preventative medicine on the back of a postcard, or, dare I say, on the back of a fag packet:
1. Don’t smoke.
2. Don’t drink too much.
3. Don’t be overweight.
4. Get some exercise.
5. Sleep well.
6. Be sociable.
7. Log off all social media.
8. Read a book.
9. Don’t allow yourself to be bullied.
10. Oh – and whatever else you do – don’t be poor.
Now the government may wish to get after the supermarket chains for stacking their shelves with too many products overloaded with sugar or salt, but that’s their problem. Just don’t buy the product. The fact is that with the best will in the world, sooner or later we all run into a health problem, and need to seek help. The Health Service is there to provide us with that help. Like it or not, the Health Service deals with Disease.
With respect to the ambition to switch from analogue to digital, this has been a tremendous enthusiasm for politicians, across the political spectrum, for a quarter of a century. Data, the quantification of human souls, is paramount. Around the turn of the millennium we saw the rise of Information Technology (IT), and at the present time we are seeing IT’s spawned godchild in Artificial Intelligence (AI). Opinion is divided over AI. Is it the bee’s knees? Or is it a bubble? Sir Tony Blair thinks it is the future, and that the United Kingdom will lose whatever power and influence it still has if we don’t embrace it wholeheartedly. On the other hand, another distinguished Roman Catholic, Pope Leo XIV, thinks we should “disarm” IT. I don’t think he means we should get on side with it through personal charm; rather we should render it impotent. Who is right? We have an advantage here, because we have the experience of 25 years’ exposure to IT. The fundamental question is: has computerisation helped medicine?
We may list some potential benefits. Some of them are irrefutable. You cannot run a CT scanner, or an MRI scanner, without computing power. Robotic surgery (suitably supervised) can be extremely effective. In the general practice surgery, computers are fast, fast as the speed of light. Communication can be virtually instantaneous. Computers have capacious memories. Myriad files on a microchip. They are not cumbersome like ancient Lloyd George envelopes or A4 folders. Data can easily be shared.
Perhaps too easily. There already exists, and has existed for a very long time, a highly effective means by which relevant parties, for example a GP and a hospital consultant, can communicate. It is called a letter of referral. People usually don’t need access to a patient’s entire life story. And some of the most confidential and most revealing nuggets of information patients ever told me I made sure I never recorded.
It cannot be denied that, in the context of general practice, 25 years of experience have shown a downside. Quite rapidly, the computer ceased to be a servant, started to assert itself, and soon became a master. The sanctity of the medical consultation became compromised. The consultation was no longer a confidential interaction between doctor and patient; a third party had entered the room. At the same time, GPs relinquished the responsibility for 24/7, round-the-clock patient care, and handed it over to Health Boards. Who could blame us? Who would begrudge us a good night’s sleep? The trouble is, if you relinquish responsibility, you also relinquish power. The champions of IT, either within or allied to the medical profession, devised a computer-driven system of governance called the Quality and Outcomes Framework (QOF) which related clinical performance to earnings, and thus dictated the modus operandi of doctors working under a new contract.
And by a terrible, a truly hellish happenstance, or coincidence, the rise of the computer aligned itself with the revelations concerning the activities of one Dr Harold Shipman, the most prolific serial killer in the UK’s history. The QOF, the new system of governance, was linked in with a new form of oversight, “Appraisal”, an annual examination by a fellow professional but not a close colleague, of one’s clinical activities, and continuing professional development. You could not read a report in the newspapers about Appraisal without encountering the name Shipman. Many of my colleagues thought that Shipman “caused” Appraisal. It was a slap on the wrist to the profession for having had the carelessness to harbour a mass-murderer within our midst. It was widely held that Shipman would have been an exemplary Appraisee. Apparently he was a good GP, liked by his patients. If there was any truth behind the purported causative relationship between Shipman and Appraisal, the connection was certainly incoherent. Using Appraisal to prevent another Shipman would be like putting an airline pilot into a simulator and testing his instrument-flying capabilities in bad weather, because one of his colleagues made a habit of going back into the cabin to give a passenger a lethal dose of medicine.
Initially, the fulfilment of the GP contract by adherence to the QOF was a simple matter. Remember doctors have been trained to jump over hurdles since their student days. 100% adherence, and 100% remuneration, was not difficult to attain. So the QOF became more complex. It became aligned with a whole series of administrative initiatives apparently designed to streamline communication, especially between general practice and hospital. In my locale, this was known as “Whole Systems Working”. QOF and WSW. Is there not something Soviet about this type of nomenclature? It seems to allude to its diametric opposite, like the Ministry of Love. “Working” becomes dysfunction, and “quality” becomes tat.
For that is precisely what happened. Quality became tat. General practitioners became demoralised and miserable. They had to spend time, not looking after patients, but obeying the diktats of the computer, chirpily sending pop-up reminders on to the screen. Don’t forget this, have you thought of that, have you met this target, and are you within the stipulated time limit? Doctors became profoundly unhappy, because they had lost control of their own destiny.
The QOF no longer exists. It was dumped, with a little ceremonial humbug. “The QOF was of its time, has served its purpose, and now needs to evolve.”
And now history is repeating itself. Here and now, already, Artificial Intelligence has infiltrated the consulting room. Have you heard of ambient voice scribes? They are sitting there, invisibly with you in the consulting room, these hallucinatory spectres, recording everything. Some GPs have taken to consult with AI before making a diagnosis, or indeed making any clinical decision. By a remarkable piece of cognitive dissonance, perhaps even doublethink, it is simultaneously held that the doctor’s failure to consult AI might constitute medical negligence, while it is recognised that reliance on AI will inevitably erode the doctor’s own clinical acumen.
It seems to me that “Artificial Intelligence” much like “Quality and Outcomes Framework”, or “Whole Systems Working” is a misnomer. For AI is not intelligent. In the late 1700s in Brunswick, a schoolmaster, Herr Büttner, who wanted to sit and read the newspaper for half an hour, once set his pupils the task of summing all the integers between 1 and 100. It so happened he had a mathematical genius in his class. After a few seconds, a seven year old Carl Friedrich Gauss gave him the answer: 5,050. Rather than laboriously adding all the numbers up, he had instantly realised that they could be paired as follows – 1 and 100, 2 and 99, 3 and 98, 4 and 97, and so on. Fifty pairs each adding to 101. Now a computer just scours all the numbers and sums them; that is number-crunching. Gauss found a clever way; that is intelligence.
So I would give AI a different name. In the health care setting, I would call it Blunderbuss Medicine (BM). Actually Blunderbuss Medicine has been around for a long time. You don’t know what’s going on with a patient, so you cast the net wide, and order up every diagnostic test you can think of, in the hope of turning something up. As junior doctors, forty years ago, we were criticised by our consultants for adopting such a procedure. It was seen as the absolute antithesis of best clinical practice. There was no such thing as “routine blood tests”. You only ordered tests, sparingly, to answer specific questions that had been thrown up by the history and examination. Everything was subservient to the history; the anecdote.
Mr Streeting’s first idea, the change of focus from hospital to community, is his best. It needs to be fleshed out. We can describe the problem easily enough. In the community, there is the 8.00 am telephone scramble to secure a GP appointment. But you can’t get one. So the hospital emergency department (ED) is oversubscribed. At the back end of the hospital, patients cannot be discharged because they have an inadequate social care package. They become “bed blockers”. Because there are no available beds, the patients in the ED awaiting admission cannot move, so they are stuck in a broom cupboard or a corridor. “Corridor care” has become normalised. Because the ED is full, the ambulances cannot unload the next tranche of patients, who languish for hours in the ambulance bay, stopping the paramedics from attending to their next patient. It is a picture of total gridlock.
Politicians have tried to tackle this problem with the imposition of rules and deadlines. 95% of ED patients, for example, must be admitted, discharged, or transferred, within 4 hours. The ultimate destination of the patient is termed the patient’s “disposition” (I suppose “disposal” must have sinister overtones). Of course, across the nations, the “four hour rule”, the 95% target, month on month, is seldom met. Remorselessly, the newspapers report this as, for example, “35% of A & E patients wait (sic) for longer than four hours”. The terminology is revealing. The use of the word “wait” is, frankly, sloppy. Patients are not primarily “waiting” in the ED. They are being triaged, nursed, seen, examined, investigated, and treated. But the popular image of “A & E” (sic), or “Casualty”, or, worst of all “Cas”, is of a dressing station on the Somme in which patients hope and pray for a quick evacuation.
Forty years ago, in Australasia, the emergency physicians realised they were running a “Cinderella” service. They dropped the name “A & E” as being hopelessly obsolete, formed a college, and approached the politicians, not to ask them what they should do, but to tell them what was required. The politicians responded positively, funds were allocated, the specialty of Emergency Medicine in Australasia was born, and the face of hospital acute care was totally transformed.
Some of the elder statesmen of the ancient Royal Colleges Down Under hated it. The fight for the Australasian College for Emergency Medicine (ACEM) to gain recognition from the colleges’ governing body was protracted and sometimes bitter. But ACEM won in the end.
There are some wonderful emergency departments across the UK, but by large, this battle for specialty recognition has not been fought. The Emergency Department needs to be the acute hub of the hospital. A good ED can see, sort, and send away (sounds like a jingle for British Rail) a far larger proportion of the patient population than is currently the case, without the rest of the hospital ever knowing about it.
The other major source of hospital gridlock is at the back door. Again, for a quarter of a century, politicians have been wringing their hands about a lack of an effective Social Care Service, and a lack of collaboration between social care and the NHS. Successive governments have vowed to do something about this, and then put it on the back burner so that the next Parliament can do some more hand-wringing. For all the good intentions, what is lacking is a model of care, an idea of what an integrated service would look like.
This is where general practice needs as much of a makeover as hospital medicine. Much as we have normalised the notion of the ED as a zone of chaos, we have also got used to the idea of GPs being overworked, overtired, and overwhelmed. We should start by considering a mode of practice and a workload that is sustainable for the GP. There is some evidence base for this, but in the meantime, anecdotally…
Let a full time equivalent (FTE) GP look after a flock of 1,000 souls. Let GPs collaborate, so a sizeable health centre might comprise ten FTE GPs (with associated health care professionals) looking after a population of 10,000. With that size of list, a GP would be unlikely to conduct more than 100 consultations per week. One might, for example, see on average about 25 patients daily, over 4 days. The fifth day in a 5-day week might be devoted to administration, research, education, pursuit of a special interest, or catching up on sleep following a night on call.
For make no mistake, it is absolutely imperative that GPs take back responsibility for round-the-clock patient care, 24/7. The on-call GP, sustained by the fact that the following day will be a free day, will be on duty on site at the health centre for the period on call.
The health centre must have an in-patient facility, a ward containing a small number of beds. Hence practice nurses must also offer 24/7 care. The in-patient facility would afford a means of avoiding an unnecessary hospital admission, for example of a frail elderly patient primarily requiring short-term nursing care.
But that’s not all. The health centre would also offer two other previously “Cinderella” services. There would be a palliative care unit. For too long, palliative care has relied on charitable donations for its continuance. Its availability can be patchy. It needs to be subsumed within the brief and remit of the GP.
And lastly, the Health Centre should contain, or be attached to, or adjacent to, a small care home.
All of this asks a lot of the individual GP. That is why they must each have a list of no more than 1,000 souls, because the availability of services for each individual must be comprehensive. I have absolutely no doubt that my erstwhile colleagues are up to it, and, with a little gentle persuasion, up for it. It’s the sanctity of the medical consultation that counts. Cum Scientia Caritas, as the Royal College of General Practitioners would have it. The computer, IT, and even AI may have a role, but fundamentally they don’t matter a fig.
I had cause to visit my GP the other day, with a minor ailment. We exchanged courtesies. He listened to my history, asked a few clarifying questions, and undertook a physical examination. He made a diagnosis, ventured a prognosis, and offered me a treatment. And he even, God bless him, asked me an open-ended question: Is there anything else I can do for you today?
And all without a computer in sight.
jamescalumcampbell 