Delivered to the West Highland Faculty of the Royal College of General Practitioners Glasgow, 12 November 1996
by James Willis
"These occasions are very taxing for me -" he explained, "I'm tempted to do far too much talking."
Ladies and gentlemen, colleagues, it seems almost trite to say that it is an honour to be here. But it is. A very great honour. I feel it very deeply and I am extremely grateful to you for inviting me to give this year's Fulton lecture. In particular I would like to thank you all, and Mairie Scott in particular, for trusting me to choose my own subject. Nothing could have been more stimulat- ing than that trust and nobody could have felt the responsibility more than I have over the last weeks and months. If I too have been tempted to do far too much talking I can promise you one thing - this lecture will have many deficien- cies, but lack of trying is not one of them. As my wife Lesley will all-too- ruefully confirm.
It is an honour, as I say, to be allowed to stand up, as an ordinary GP, and talk to a captive audience about a subject dear to my heart. But to be asked to do so as an Englishman in Scotland is, at this particular juncture of history, all but incredible. We thought that going to France this year in the midst of the Mad Cow controversy was courageous, but coming to Scotland when the English seem to do nothing but undermine your altogether wiser and more egalitarian society, not least your ability to make the Health Service work, without a sem- blance of a democratic right to do so, seems to me to border on the foolhardy!
But I comfort myself with the thought that we have much common ground. Our local MP, for example, way down south in our constituency of Winchester, is a Glaswegian. And while you may not be all that keen to claim Gerry Malone, he certainly claims you whenever he gets the opportunity.
Secondly, like practically everybody else in the world, I claim some Scot- tish blood. My Mother's maiden name was Chisholm! I see in fact that there is a Jennifer Chisholm in this faculty. The current issue of Hoolet describes her as a "young blood of the faculty"; I hope it would not be too presumptuous to suggest that some of her young blood might actually be the same as mine.
I was drawn back to Scotland as a student. I spent one of my four weeks GP elective in Richard Scott's department in Edinburgh. Later I very much wanted to join the Inverness GP training scheme but found I could only do so if I repeated the Obstetrics house-job which I had already done in London, so I joined the Wessex scheme instead. Otherwise, who knows, I might have been out there with you tonight wearing a kilt.
More seriously: The common ground I refer to includes the fact that we all do the same job. I am not the kind of distinguished specialist or academic who normally gives this kind of lecture; I am one of you. I am a very ordinary GP, and proud to be so. All my observations are made from the perspective of an ordinary GP. Strange to say, in these days it is that which gives me a chance of saying something extraordinary. In the country of the blind the one eyed man is King. In the world of specialists, the really clever trick is to put everything to- gether into a whole that works. GPs do this all the time when they are trusted to do so.
I have, indeed, no shortage of things to say. The thing that has occupied me for so much time preparing this lecture is putting them together into a whole. A whole which will stand some chance of recreating in your minds the idea that I am trying to convey. You have taken the first step by trusting me to do so. It is a particular pleasure and honour that William Fulton himself is here with us tonight. I have read and re-read his inaugural lecture in this series. It is a classic account of the revolution that overtook general practice in the years after the Second World War, given of course by somebody who played a very significant part in that revolution.
Willie Fulton took his text from the prophet Joel:
"Your young men shall see visions; and your old men shall dream dreams"
I still have my visions, and I still have my dreams, which I suppose means that I am neither young nor old. Or perhaps that I am both. This slightly weary feeling, which some might call "post-modernist", is summed up in the text which I have chosen for tonight. It is from Robert Burns:
"The best laid schemes o' mice an' men, Gang aft a-gley."
In spite of my Scottish ancestry I can't speak the language, so I won't at- tempt to read this. But I will attempt a translation:
"All innovations have unforeseen consequences - even when they are done for the very best reasons."
I belong to a different generation from William Fulton. He vividly de- scribes entering single-handed practice on the Clyde in 1945, - 500 a year - al- most no time off duty, poor premises, little or no ancillary help, few effective remedies to offer patients, no NHS - no College.
Almost everything was different for me. I was the beneficiary of the in- dustry and idealism - the vision if you like - which brought about the enormous achievements which Fulton describes. From the start I worked in purpose- designed premises, with receptionist, nurse, secretary, attached community staff. We had reasonable pay, reasonable status, reasonable home lives. We had the College, and of course we had the National Health Service, the finest system for the delivery of whole-population medical care the world has ever known.
For all these things we have Fulton's generation to thank, but it was not just in medicine but in all walks of life that the post-war years had seen an ex- plosion of innovation and change. They were heady times. The dazzling and apparently on-going achievements of technology had led us all into a deeply rooted belief that we were moving, slowly perhaps, but moving, towards a per- fect world, a Utopia, in which all problems would, as Douglas Adams parodied it, be "Finally sorted out!". Futurologists in the fifties saw an early prospect of cancer being cured, of limitless energy being tapped, of the colonisation of the stars, even of man's life being extended indefinitely.
There was an almost mystical belief that mankind was embarked on an epic journey. Although it wasn't actually acknowledged in as many words, an age which was gaining so much from science and rationalism was pervaded by as real a sense of mystical destiny as any ancient Athenian believing he was the play-thing of the Gods. We came dangerously close, and remain dangerously close, to the extraordinary belief that all change is progress. But for me, right from the start, a few things niggled.
Hey, this doesn't fit!
Karl Popper, once described by Sir Peter Medawer (Nobel prize-winner for Medicine) as "incomparably the greatest philosopher of science that has ever been", pointed out the importance of niggles, although he didn't call them that. He pointed out something which people without a scientific background, which includes nearly all politicians, seem to find it impossible to understand: that you can never prove, for certain, that eating meat from BSE infected cattle (for ex- ample) is safe, however long you go on doing so without apparent ill-effect. But it only takes ONE case of proven transmission to show, for certain, that the statement, "There is no danger in eating meat from BSE infected cattle" is FALSE.
It's a bit like passing your hand over a smooth table and immediately feeling a single grain of sand. Evolution has equipped the human mind to ex- ploit the crucial significance of incongruities by making it incredibly sensitive to things that conflict with the background. It simply won't let such matters rest. It has this irritating need to make sense of the world and when it finds a little bit of nonsense it keeps tugging your arm and saying "Hey, this doesn't fit, what are you going to do about it!"
So this is where I part company from Willie Fulton for a while. Not where he says, "I believe that, speaking generally, Scots and perhaps also Welsh doc- tors have a higher professional ethic than their English colleagues." I think there was some justice in that remark, particularly when so many English doc- tors went on to embrace budget-holding.
No, where I part company is from his assertion that mandatory training for general practice was obviously "progress". I have a niggle here which tells me it can't be true. Many, perhaps even most, of the really outstanding GPs I have known, including my own trainer, did NOT have vocational training. And that tells me, for CERTAIN, that the statement, "all GPs must have vocational training" is FALSE.
"It's a mistake to be right too soon!" said Fulton, however, after describing how he had been almost booed off the platform of the 1950 Annual Representa- tive Meeting of the BMA for being the only delegate to speak entirely in favour of training. But in 1977 when the law of the land had decreed that all GPs must have passed through accredited training programs, I had long ago done so vol- untarily, as I had sat my MRCGP voluntarily, and I had found myself in by far the most vigorous and dynamic branch of British medicine, (far more vigorous, dynamic and optimistic than it is today, it has to be said) enriched as it was by doctors from many backgrounds, not just one.
The cause of the sense of instinctive unease felt by that BMA meeting and shared a generation later by myself was very far from clear at the time. But fur- ther movement in almost every field of modern life, not just in medicine, has made much clearer to us the dangers towards which we were going. will be eliminated!
We now know we were moving into a world of reaccreditation, of practice protocols, of evidence-based medicine, of assessments and audits, not just as- sessments and audits of washing machines and soap powders and drugs, but of teachers and nurses and clergymen and Citizens Advice Bureau volunteers. Into a culture in which a teacher would feel it wrong to put a comforting arm around the shoulders of a distraught child. In which 'care' would come in 'pack- ages'. In which 'management' would be placed above practice and in which the law would try to compel grown-up doctors to spend their time measuring and re- measuring the obstinately unchanging heights of adults, whilst parents had lost the ability to compel their children to do anything.
We were moving into a culture which would lose any ability to keep risks in proportion. Which would frighten old ladies with senseless warnings about unmeasurably-small dangers in the safest and most effective pharmacopoeia in history. And which would frighten young doctors with the knowledge that predatory lawyers might sue them and a cynical and amoral media might pillory them for an infinity of infinitesimal omissions. Into a world in which everybody had to be 'accountable' except the people they were accountable to.
A kind of apotheosis would be reached in the concept of "Total Quality Management", which, having revolutionised the manufacture of motorcars, would be transplanted from industry to become the new idea to revolutionise medicine. It would be taken up enthusiastically by the RCGP, by the Govern- ment, by management and by the training industry.
"Treatment will in future be perfect."
"There will be no mistakes."
"Sub-standard doctors will be elimi- nated."
And the sad truth is that all of this "progress" would be a direct extension of the "best laid schemes" that so illuminated the Fulton years: As Fritjof Capra (best know as author of The Tao of Physics) said in THE TURNING POINT:
"One of the most difficult things for people in our culture to understand is the fact that if you do something which is GOOD then more of the same will not necessarily be better."
Many people simply cannot see that there is a problem. A letter in the September issue of the British Journal of General Practice from Stuart Murray and Malcolm Campbell (based, I believe, not very far from here) expressed sur- prise that there should be any remaining concerns about a final examination hurdle, euphemistically described as "Summative Assessment", being erected at the end of the eight years of GP training. The whole subject had, they said, been fully discussed and 'sorted out'.
Yet, even while their letter was enjoying the prolonged limbo-state re- served for submissions to the British Journal of General Practice, (as indeed was a fuller article by them on the same subject eventually published in the October issue) the assembled GP Registrars at their Annual Conference in London un- dermined their message by voting unanimously against summative assessment. Perhaps they would have taken a different view if Murray and Campbell's letter had been published earlier and they could have read the following comforting words: "The UK Advisers exam has now been taken by over 1,000 candidates with a pass rate of 97% and a pass mark carefully set at the level of minimum acceptable competence."
Or perhaps not.
One of my objects this evening is to try to explain the illusion that makes us all imagine that such things as "minimum acceptable competence" can be precisely quantified. why we all go on thinking such things, in spite of know- ing in our hearts that to do so is as absurd as the attempt in the Middle Ages, (by the best brains of the time, let us not forget) to calculate the number of an- gels that could dance on the head of a pin.
I believe that it is now becoming apparent that the trend of which sum- mative assessment is part, this 'new way of doing things', which has, within the space of little more than ten years, overturned the means by which mankind has made progress since the dawn of civilisation, and which now touches every sin- gle aspect of our society, is based on a fundamental misunderstanding of life. In particular I feel, with Iona Heath in her 1995 John Fry Monograph, The Mys- tery of General Practice, that it represents a misunderstanding of the nature of general practice.
NOT easily said!
A year ago Alec Logan asked me to contribute to a debate on training in his (and your) wonderful journal 'Hoolet' and I tried to argue that by the time they reach postgraduate level, doctors do not need training, they need educa- tion, which is something entirely different.
Professor John Howie wrote in the introductory overview to that series of articles that the points I had made were, "easy to make For that, thanks." This is another of my objects this evening. I want to tell you that I don't agree with him. These points are very difficult to make. And they are almost impossible to get accepted. It is the easiest thing in the world to dismiss them. The panza division of cold logic sweeping through a cloud of butterflies.
Everywhere we go we find examples of the new kind of crazy progress: Our local hospital is divided into two parts, each administered by a differ- ent trust. You can tell whose territory you are in not just because only one trust believes in mowing its bit of lawn, but also by the fact that all the hot taps in one part have recently been provided with smart, embossed, plastic notices saying, "Danger hot water". To match the notices on the walls behind the radia- tors which say, "Danger, hot surface".
Our GP ward happens to be administered by the other trust which does not have these smart plastic notices. At least, not yet. But, when I walked back into the ward recently, having been taken by an incredulous colleague to see the notices in the other part of the hospital, I found that one of "our" taps also had a notice behind it saying, "Danger hot water". That was a simple sign on a scrap of paper. Hand-written with a sort of desperate urgency. And carrying a message of real importance in the real world. That tap - of course - was a cold tap.
However crazy the contrast may seem, nobody has any doubt these days about which of the two approaches represents the future. The plastic signs, every time. You can explain why you need the plastic signs in a single sentence: If people scald themselves with hot water they may be able to claim compensa- tion because they were not warned. Nobody can deny the logic of that, particu- larly if it has ever happened, which is entirely possible. But to try to explain why you should NOT put up warning signs behind every hot tap, everywhere, takes much longer, and relies on airy-fairy concepts like likelihood of risk, common sense, judgement, and people taking responsibility for their own be- haviour. There is absolutely no contest.
No contest
It is a problem which has been traced back to the triumph of Classism (or Materialism if you like) over Romanticism in ancient Greek philosophy. It is a case of not comparing like with like. We just don't know how to weigh up the relative merits of things which are so fundamentally different from one another. The hard, the factual, the measurable always seems to win over the instinctive, the soft, the indefinable. The artificial, in fact, over the natu- ral. The head over the heart.
The comparison is between one group of things which can, by definition, be measured and another group which, also by definition, CANNOT. But it is impossible to make comparisons without some form of measurement - that is what measurement is for. It is therefore an inevitable, natural law that quan- tifiable and definable things will always take precedence over intangible and un- definable ones when we make judgements. Apples will tend to be graded by size and freedom from blemishes rather than by taste, because we don't know how to measure taste in order to compare it. Even though that is what is really impor- tant. Still less do we know how to measure beauty, kindness, integrity and common sense.
Somehow it seems necessary to find a way of convincing the modern world that these things are still important.
My attempt this evening to contribute to this argument starts from the premise that understanding exists in two quite different forms.
There is the natural kind of understanding, exemplified by the natural faculties of the human mindand there is the artificial kind of understanding of computers, sys- tems, formulae and words.
Then there is a third kind of understanding - this is the shared un- derstanding of the culture we live in, and this third kind is made up of a mixture of the other two.
A mixture of the knowledge and experience in individual minds, the shared cultural traditions and myths held in common in many minds, and the mass of records and scientific knowledge, rules and formulae (even protocols) held in artificial media of one sort and another.
Throughout history the third, 'shared understanding' of society has been more of the 'natural' kind than the 'artificial'. The technological explosion, and in particular the information technology explosion, has meant that this situation has now changed and that the shared understanding of society is now predomi- nantly of the artificial kind.
This change has been more in the nature of a shift in the balance point than an abrupt switch, but the effect is as fundamental.
The reason we think this shift from animal to artifice represents progress is that we are impressed by the power of machines to do things which we are bad at doing: like doing sums very quickly, doing things very reliably, and remem- bering facts in a most unnaturally fixed and permanent way.
My hypothesis is that the reason we feel a deep sense of unease, and the reason we find it so difficult to express this unease in a way which will make any difference to anything, is that the strengths of the animal kind of understanding are hidden, automatic, taken for granted, unmeasurable and above all, un- provable.
So what I am going to do for a few minutes is to explore differences be- tween these two kinds of understanding using quite simple observations and ex- periences, many of which we all share, and building up a picture, I hope, of some of the hidden powers of our minds which we normally underestimate, and which society underestimates. I am not going to get side-tracked into the fasci- nating question of whether our minds are just very sophisticated computers, or whether, as Roger Penrose says in books like, "The Emperor's New Mind", that he has proved mathematically, they are something entirely different. For what it is worth I think Roger Penrose is right, and so do mathematicians I have talked to. But even if he isn't I think we have ample evidence, when we look for it, that our "brave, new," mechanical world needs free, independent human minds just as much as it ever did. Which is good news for us people!
Some of the functions of the human mind I have selected to discuss are:
Their storage
Their number
Patterns
Analogy
Maintaining the background model
Higher functions
Throughout all this I want to carry the idea that we are comparing those three different models of reality - the human model held in each of our minds, the artificial model held in computers and other mechanical media, and the shared model of society, on which society bases its decisions and plans.
Storage of thoughts
My wife was getting a biology class to chart the growth of stick in- sects recently and one of the girls was surprised to find that hers had got smaller.
"Mine is one point nine centimetres long today and last week it was one point thirteen!".
She may not have learned very much about number position, but she had learned something about the two different ways of understanding size: you can use your eyes, or you can make a measurement. And she had already learned the lesson that when there is a conflict between the two it will always be the measurement that is right.
The thing that makes artificially recorded facts so useful is that they are fixed and permanent. They do not change with time. You can write something down and use it as a sort of piton driven into the rock face of under- standing and then you can lift yourself up on it and drive in a new fact a little higher up.
I use a little pocket computer to make records these days. I have it in my pocket all the time and I whip it out and jot things down before I forget them. Ideas always seem to come while I am at my busiest and I am familiar with the problem of trying to keep the exact wording of something a patient has just said, or something which seems to be a penetrating insight which has just occurred to me, clear in my mind whilst finishing off the consultation in a way that won't land me in the courts.
But when I've got it down it is fixed and permanent! Totally different from the way memories are stored in our minds - which seem to make a virtue of forgetfulness. They forget so that we can forgive. They forget so that time can be the great healer. Above all they forget in order to prevent us from becoming overwhelmed by the sheer weight of our experience.
I don't know why, but I have always thought of this as onions going into a pot of stew.
I have always pictured "memory onions" pouring endlessly into an enor- mous pot in my mind and gradually sinking as more are piled on top. But when I began to examine this analogy I realised it wasn't really as simple as that. (You can see why I was hesitant about discussing my project in academic circles when I first started it, in 1984!) Anyway, it seemed to me that as the process goes on and the memory on- ions sink slowly out of sight, I keep on dragging some of them back to the sur- face as I recall them to my conscious attention - just as if I was dipping a long spoon into the pot and scooping up the ones I was interested in. Back on the surface I clean them up a bit, re-examine them, brush them up a bit, and then drop them back in, to start sinking again.
Most of the onions, of course, don't get resurrected in this way and go on sinking and become more and more difficult to retrieve until eventually they are out of reach of even the longest spoon (even, it has to be said in this company, the kind of long spoon you need when you sup with a piper.) Now the really interesting thing is what happens to memory onions which keep on getting dragged back to the surface - because they behave distinctly oddly (for onions) in becoming more and more buoyant and more and more in- clined to stay there.
So what I am saying is quite simple really - it is that human memories, like all the ideas in our minds, are not very like onions.
2. Their number
In his novel Watership Down, Richard Adams created a picture of what the world might seem like to a colony of rabbits.
Apart from the necessary artistic licence of allowing the rabbits to speak, he adhered faithfully to what is known, and what can be guessed, about the way rabbits think. In doing so he created a book which can be read in a number of different ways. It is an exciting adventure. It is an excellent Natural History text and it is a celebration of the beauty of the North Hampshire countryside. But most of all, for me, it was a powerful insight into our own thinking. The point that I want to pick out from Watership Down is the idea, appar- ently supported by some experimental evidence, that rabbits are unable to count beyond the number four.
Rabbits can count up to four. Any number above four is Hrair - 'a lot' or 'a thousand'.There were probably more than five rabbits in the litter when Fiver was born, but his name, Hrairoo, means 'Little thousand', i.e. the little one of a lot or, as they say of pigs, 'the runt'.
-Richard Adams Watership Down
This is the thing which is so fascinating to imagine. When Hazel (the hero of the story) and his friends thought of a number between one and four, they had a clear idea what it represented, but any number larger than that merged into a vague concept called Hrair which meant something like "a lot". Now while we can only make educated guesses at the thought processes of rabbits, we can be certain from our own experience that there are limits to the size of numbers that we ourselves can understand. Thus, for every one of us there is a limit above which numbers mean little more than "a lot"; perhaps the number is "a thousand million"; perhaps it is much less.
Let's think about the way we understand numbers for a moment. Often, we compare a figure with something we can picture; sometimes we count on our fingers; sometimes we imagine patterns of dots. Perhaps we recall the memory of a school which we know contained 1,500 people, or of a football crowd of 30,000.
However good we are at doing this (and some are better than others) na- ture contains numbers large enough to defeat us all. To take a grand example, we are unable to begin to comprehend the numbers of stars in the universe. There is no problem about working out the figure; by a convenient chance (I suppose) there are about the same number of stars in an average sized galaxy as there are of galaxies in the universe. It also happens to be about the number of neurones in the human brain. It's rather an easy number to remember - one hundred thousand million (1011) of each. All you have to do to obtain the answer to the number of stars in the universe is to multiply the two together 1011 X 1011 = 1022 - Easy!
One with twenty two noughts - not exact of course - but roughly right. Now what kind of words shall we use to describe such a number - to enable us to understand it and to communicate that understanding? Is it a BIG number? Is it an ENORMOUSLY big number? ("Enormous" sounds as if it means "a bigger number than normal" and it is certainly that!).
Perhaps it would help if we used a calculator to work out an illustration. For example - as blood contains five million red cells per cubic millimetre I calcu- late that it would take a cube of blood 1.5 kilometres on a side - 2.25 cubic kilo- metres of blood - to contain as many red cells as there are stars in the universe. NOW do we understand?.
Well... actually... no we don't!
Another Adams, Douglas Adams, appreciated the fundamental problem here in his classic radio play , The Hitch Hikers Guide to the Galaxy:
"Space," it says, "is big. Really big. You just won't believe how vastly, hugely, mindbogglingly big it is. I mean, you may think it's a long way down the road to the chemist, but that's just peanuts to space. Listen..." and so on.
The point that I am making is that, above a certain size of number, we are as vague in our understanding as are the rabbits in Watership Down. The difference is not in the nature of the mental processes involved but in the order of magnitude of numbers at which the transition occurs.
With my pocket computer, of course, there is no such problem. It can store 500,000 characters in its internal memory (about ten lectures like this) and one million characters in each of its two memory cards (fifty of these lec- tures). I know that because I paid for that much and it says its capacity on the outside. I could have paid more, incidentally, and had two million characters internal memory and four million in each memory card - making nearly five hundred of these lectures.
These are big numbers and you could be forgiven for not guessing them from external appearances, or indeed by entering facts into the machine and then recalling them one at a time.
With human minds, of course, it is even more difficult. They don't have their capacity written on the outside, and there is no equivalent of pressing a few keys and getting the answer that this lecture contains 55,575 characters. So, even it they actually contained amounts of information which we could only call astronomical if we could count it up, we simply wouldn't have any way of knowing it. All we would get would be occasional glimpses. We might find our- selves, for example, saying in astonishment from time to time, "Good gracious, what a small world it is" even when we knew, in a very definite, physical sense that the opposite was true and it is actually an inconceivably big world.
One month ago, when I was in the thick of preparing this lecture, I re- ceived, out of the blue, a copy of James McCormick's classic book, The Doctor, Father Figure or Plumber. It had been sent to me by my friend Iain Chalmers, Director of the UK Cochrane Centre, "I thought you would like to have Archie Cochrane's copy of James' book", said Iain.
Sure enough, there was the inscription from James McCormick, stalwart defender of personal medicine (who wrote the Foreword to my own book), to Ar- chie Cochrane himself, the very personification of Evidence Based Medicine. What a coincidence! How surprising! How amazing to get sent such an ex- ample of the way two apparent extremes can meeting in mutual respect, and of all the books to be sent, could ANY have been more apposite to my theme? As Edward DeBono points out in his books on Lateral Thinking, the fact that we find the frequent occurrence of such coincidences surprising does not mean that science has got it wrong about the size of the world and it is actually rather a small place after all. It is that little niggle of incongruity at work again, which actually means that we are wrong by many orders of magnitude about the size of our experience.
The reason we are so unaware of the extent of the contents of our minds is that our minds are unbelievably efficient at focussing on the subject of attention and excluding everything else. It is as if we view the world through a micro- scope, but without realising it. A microscope, moreover, whose power can vary almost through infinity. This is the matter I spent most time discussing in my book The Paradox of Progress and I am not going to go over it all again. Suffice it to say that I used the analogy of opening a patient's records and going into them to illustrate the way we seem to open a memory box in our minds and its contents seem to flood our consciousness and drive everything else out. Then, a few minutes later, we will be equally absorbed in another patient's problems, then another and then another. With each in succession becoming, mysteriously, but in a very real sense, the most important thing in the world. Then how we are able to go into the practice record area and put the record enve- lope into its literal context amongst the thousands of others, each one of which we know could be equally important in its turn.
The next stage in the argument was to consider the selection applied by the medical specialist, safe in his restricted field of medicine, and making the abdication of responsibility for a vastly larger whole than he can appreciate into a virtue rather than the necessary cop-out it actually is.
Finally I considered the selection applied by the remote theorist, the me- dia pundit, the manager, removed as he is from personal daily experience of front-line reality, yet basking in the artificial certainties of statistical norms and retrospect.
At each of these levels the important thing is to recognise the hid- den power of the mechanisms of selection and exclusion which act upon the memory onions, locked up in boxes, deep in the unimaginably- large stew-pot of our minds.
3. Patterns
Identical twins
There were a pair of identical twins in my boarding house at school. For several years I couldn't tell the two apart - presumably my mind only had one pattern for them and they both fitted it. But when I made the effort to learn to distinguish them (and it was sheer laziness that had prevented me doing so earlier) I was astonished to find that I could do so without the slightest difficulty - even by poor light and at a distance. Furthermore, I never thought of them as one person again.
How, I wondered, could something which had once seemed so difficult change and suddenly become so automatic? At first they had seemed so similar, now they seemed so different. And it was such a strikingly one-way process - there was no question of reversing it so that the two merged into one identity again.
The key to splitting my mental image in two, I now realise, had been the finding of one or two consistent distinguishing features and making these into the labels on two separate pattern boxes. From then on observations about the two brothers could be linked appropriately with the new individual boxes and not just dumped carelessly into the old common one. From then on every new ob- servation served to reinforce the separation rather than to worsen the muddle. Details of voice, mannerisms and personality quickly took their places in the correct boxes and I was one tiny step further forward in making sense of the world.
"Come in"
A pale, anxious face appears around the door. It's young Stuart, late in his teens. Hasn't been in recently. Thin. Doesn't look well. A little breath- less. He's telling me the problem as he comes in - "I've got this pain up here." He puts his fist on his chest in a certain way and I've got him labelled as a spontaneous pneumothorax before he's taken two steps into the room.
"Slip your shirt off, let's have a listen"
I check his trachea's central and my hands move to either side of his chest.
"Take a breath, please".
Both sides move equally. I percuss carefully - equal both sides. His breathlessness doesn't seem as bad as my first impression - Provisional hypothesis number two coming up - he's a chest infection.
"Got a cough?"
"Yes"
Treat him as a chest infection. Start to talk about his family as I write the prescription.
An incredibly efficient process
Its fantastic, isn't it! Sitting there, listening to the problems, taking in the story, feeling your mind grabbing the facts into meaningful shapes, testing, rejecting them, slipping straight into the next shape until you find something you can act on.
It's an incredibly efficient process if we let it happen and educate our minds to allow it to happen. It bears the same relationship to working through a formal protocol as a countryman recognising a tree has to a biologist looking up a scientific key. Our minds select with extraordinary accuracy the very features which are most efficient in testing our provisional hypotheses.
The dimple test
Some time ago a pair of identical twin girls joined my practice list. Because I was interested in the question of telling them apart, almost the first thing I did when their mother brought them to see me for the first time was to look for a distinguishing feature. I found it - one of them had a dimple on her cheek and the other did not.
To my delight Mum confirmed that this was her own method of distin- guishing them and so I wrote down "dimple on cheek" on one record - and "sister has dimple on cheek" on the other. Perhaps this acted as an outward and visible symbol of me "writing" the same information in my mind. But anyway, from that moment I have never had any trouble distinguishing them.
A grown-up
A few days ago in surgery I turned around and found a little girl was holding up this model that she had been making out of my Stickle-bricks while I had been attending to her Mother.
"That's nice," I said, "Is it a North Sea Oil Platform?"
"NO it isn't", she said, "It's a GROWN UP"
"I see, then that must be the hat"
"No, those are the EYES!"
"Oh, well those must be the legs"
"Yes. And those are the feet"
A stalled ox
This is a picture drawn by a member of my wife's drama group to illustrate the cover of a programme for a selection of Saki readings, under the title The Stalled Ox. Here again, a few simple lines are all we need to conjure up a com- plete image in our minds
Word pictures
Literature and story-telling exploit this automatic process by which the mind builds complex and vivid mental images from even the scantiest informa- tion. Few people who saw the cartoon film of Watership Down after reading the book can have failed to be disappointed by the shallowness of the characters and the thinness of the plot compared with the mental images conjured up by read- ing.
It is strange, when you think about it, that humble words, compelled as they are to trudge through the mind in a single file, are capable of evoking such rich patterns of ideas. But the strange fact is that it is the "reality" of the film which limits the imagination. Our subconscious seems to say "Well, so this is what it is really like! I can replace that collection of vague, unstructured ideas, feelings and impressions with something concrete. Seeing, after all, is believ- ing."
It's that paradox again: definition and clarification seem to destroy the richness and real nature of living things.
Summary so far:
The mind creates patterns out of everything - not just memories but sen- sory perceptions and abstract ideas. These patterns are much more than mere shapes, they can stretch to incorporate details of every sort connected with the entity which they represent. Sound, smell, texture, characteristic behaviour can all be incorporated and so can subjective feelings. Thus the shape of a spi- der is linked to feelings of fear for many people and the very thought of some in- dividuals will evoke feelings of warmth or love while others evoke dislike or ha- tred.
Every new experience is matched automatically against the existing stock of patterns in the mind. Always looking for the closest fit . Not an exact fit, but the best available. Everything occurs within a shimmering, ephemeral, three dimensional continuum from which relevant elements are automatically drawn into prominence and related to the subject of attention. We are totally unaware of the size and complexity of this continuum and even if we infer it's ex- tent we are unable to comprehend it.
Anyone who thinks he has made a computer that can do these things is like a primitive tribesman who stands back from his carved tree-trunk and thinks he has made a man.
The fact is that ideas in the mind are not very like anything in the physical world.
If you doubt this, let's spend a moment thinking how computers would baulk at an analogy.
4. Analogy
O, my Luve's like a red, red rose That's newly sprung in June; O my Luve's like the melodie That's sweetly play'd in tune.
An analogy has to be a word or phrase of which we know we already share an understanding with the listener.
When Robert Burns says "My love.. is like a... rose", he is taking two concepts that he knows the listener already has and inviting him to allow them to interact. The intention is that the listener will take whatever idea pattern may be evoked in his mind by the words "my love" (presumably a girl whom the poet loves) and expose it to the pattern which is similarly evoked by the concept of a "rose". The automatic functions of the brain will then ensure that the two patterns seek out any aspects which, in the present context, fit together. Countless ways in which the two patterns do NOT fit having been ex- cluded, the mental image evoked by the phrase "my love" is subtly distorted to incorporate appropriate aspects of the "rose" pattern such as scent, beauty, summer, fresh air, femininity, etc. Describing the rose as "red, red..." con- veys further qualities of depth and richness and even links vaguely with the heart. The listener places this new pattern on provisional status whilst awaiting the next line of the poem which may either reinforce these aspects, or alter them.
Sure enough, in the next line the poet goes on to further enhance the im- age of his love by exposing it to further patterns of ideas: "melody.. sweetly played.. in tune..".
How could any listener now fail to understand what makes him so enthu- siastic about his love?
And how much richer a means of communication this is than if he had said "My girlfriend is incredibly wonderful!".
How INFINITELY richer than saying, "My girlfriend is more wonderful than 99.97% of the female population aged between 16 and 34" etc. etc.! But the last method is the one by means of which the reductionist, literal, mechanical, artificial world in which we are increasingly living HAS to commu- nicate its ideas.
Let us imagine a charicature of the modern mechanical man, who so dominates contemporary life, listening to this poem, learning about it, talking about it, until he gets the message. His eyes light up. He starts to smile. He says, "I SEE! He means that his love is like... like a very... an INCREDI- BLY..."
He stops. The idea is there, but he can't define it. Can't pin it down. It is too large, too delicate, too subtle, to fit clearly into his consciousness all at once. He can't BEGIN to communicate it. The danger is that he will retreat into his simple, materialistic world and pretend that he never really had the deeper experience. He will say, "I have it, I will construct a twenty four point rating scale for all aspects of feminine beauty and desirability and then show you how the poet's love measures up". Yes he will. Believe me, he will! I keep try- ing to do it myself. We all do. We call it progress.
A strength, not a weakness
Take the subject of this lecture, the same subject which I tried to address in my book. It is an idea. A large, subtle, delicate, complicated idea. Far too large to fit into my consciousness in one bite-sized, definable lump. You may manage better than me, but not much. People used to ask me what the project I was so absorbed in was all about and I couldn't say - I mumbled things about it being bigger than its parts. I said they wouldn't understand unless they read the book. The point is that this size, this complexity, this subtlety is a STRENGTH not a WEAKNESS. The whole current ethos of our society, that things should be pinned down, defined, recorded and formally described is, in this vitally important way, TOTALLY WRONG.
5. Maintaining the background model
Once upon a time an old, failing sphygmomanometer, which I had tended lovingly through many crises, was being particularly troublesome as I checked an old lady's blood pressure. Listening to the air hissing out of the cuff as I pumped it up around her wrinkled arm, I sighed, and gently broke the news: 'Oh dear, oh dear - this poor old thing has nearly had it'.
Context is everything
Everything takes its meaning from the context of ideas we maintain in our minds. It is to that background context, that internal model, which I want to turn my attention from this point on. And to make comparisons, as I have done for the handling of discrete ideas, between the natural and the artificial kinds. The reason that the remark "Oh Dear Oh dear, this poor old thing has nearly had it" is such a good joke (and it is, I didn't make it up, it just happened and I wrote it down) is because the remark fitted two ludricrously contrasting contexts of ideas, in other words two completely different models of the world, so perfectly: mine as I thought about my poor old friend the sphygmomanometer, and the old lady's as she sat there, anxiously waiting for the verdict on her check-up.
The Shared context
There are numerous obvious ways in which a government report might be like "a book", but there is only one obvious way in which it might be like "a can of worms".
The more tenuous the connection, in fact, between an analogy and its object, the better. It is only while one connection is much more likely to be seized on by the mind than any other that the analogy is useful.
"Can of worms" is actually a special sort of stock analogy which it is part of the shared ideas heritage of our culture - part, in fact, of the language. Most of us are familiar with it's use to convey the idea that a thing is full of wriggling nastiness. Somebody from another culture, unfamiliar with the term but aware that it was an analogy and not to be taken literally, might jump to the conclu- sion that it meant that the government report was a costly delicacy. Communi- cation is entirely dependent on a mutually shared context of ideas. In order to communicate effectively within a culture we have to have to learn the language, in the broadest sense of the term. Whereas the purpose of the education of the mature mind is to keep it up to date, the purpose of basic education is to lay down the foundations of that shared context, the ideas heri- tage if you like, of the culture into which a young person is growing. Thus, speech, writing, numbers, arithmetic and the other academic subjects are all part of the language. So are social conventions, games, codes of behaviour and self-discipline. Education is aimed at producing a mind image of the world expressed in a language of literally inconceivable complexity. The thing which is often forgotten is how important it is that this language is common. That is the purpose of language - there is little point in having a personal one for your own exclusive use. So the language contains, along with words, very much more complex structures of ideas. "Classics", for example.
A classic case
We doctors talk about a 'classic case' - of Measles perhaps - in just this way. This is the imaginary pattern which includes all the typical features - a caricature almost - which is used as a shared reference point by doctors. It is part of the doctor's language - he knows what it means because he has been edu- cated to do so. It is actually so unusual to see a classic case of anything that he probably dashes about getting colleagues to come and have a look when he does. Again there is a real buzz of satisfaction when the image he has formed of the patient in front of him and the mental image of the classic case rush together in his mind in a sort of joyful embrace.
Sharing this experience with colleagues, whom he knows have the same ideas context in their minds, adds to the pleasure. It doesn't help the patient much in a direct sense, but it provides one of the motivations which keep us en- joying our extraordinary job.
In just the same way sharing an appreciation of a relatively small number of works of art and literature - selected by a process far more arbitrary than we are inclined to remember - permits a very profound form of communication. That is why it is such a tragedy that so many people opt-out of whole chunks of our ideas heritage by specialising too much during their education and later in life. I have just been reading "Last Orders", the Booker Prize-winner, and not entirely in order to boast about it here. All the discussion in the media is about whether or not it is really THE BEST. That is completely beside the point, in my opinion. It is actually very good, but I expect the others were as well. The nice thing is to be able to share the experience with other people who read it too.
Aren't we brilliant!
In a BMJ editorial last year it was estimated that it would take 24 hours to read a single issue thoroughly. Yet, at a health centre journal club recently we found that a particular article on the treatment of Benign Positional Vertigo had been noticed and ab- sorbed by six out of the ten GPs present.
How is this possible?
The fact is that mature doctors do not attempt to read every word of the literature. Even though they go on feeling that they really ought to. What we do is SCAN! At incredible speed and with incredible selectivity, our minds homing in with devastating accuracy on the incongruities, things which clash, things which surprise, things which fill a need.
It is time we generalists stopped making apologies for ourselves, we are brilliant! It's time we started saying so.
Broadsheet newspapers, designed to be read by intelligent people, (although with the current emphasis on politician's hair-styles, you wonder) are the size and shape they are because they are scanned. If they were meant to be read like books they would be like books.
Sieving out the nuggets
We spend our lives fine-tuning our models of the world by exposing them to reality. From the vast wash of information that pours through our minds we sieve out the nuggets - the valid contributions to our pictures of the world. From thousands upon thousands of ideas our minds pick out the few that are incongruous and bring them to our attention so that we can use them to up- date our model. Ideas which do not fit with our existing ideas are automatically selected for attention as we scan newspapers and journals, attend meetings and watch television programmes. The maintenance of our model is like the pruning of a plant, strong branches are selected and weak ones are removed. As a path through a forest becomes more clearly marked with the passage of many people. As the paths that are not used disappear.
So we carry our collection of concepts throughout our lives, continually maintaining, renewing, polishing and improving them. Like a proud mother constantly adjusting her child's dress before a big occasion - we are never satis- fied that they are finished and perfect.
Maintaining a living understanding of medicine and of our patients is the essence of what it means to be a doctor. Even if society has forgotten this, the patients haven't. They expect modern doctors to use tools, to look things up, to take advice, to involve them in the discussion and decision-making, but in the end they look for something far beyond "working to rule". When they say "you're the doctor" they mean they want a judgement based on understanding.
Understanding the shared model
I can now perhaps explain a little more clearly what I meant earlier when I said that society's shared understanding of the world - the shared model - is made up of three different components This natural understanding of individual people (the maintenance of which I have just been describing) The natural understanding held in common in many minds. The artificial, recorded, codified understanding which has recently be- come so dominant in the technologically advanced world.
The second of these three, the natural, shared understanding, means, as I have said, things like language, tradition, classical art which are held in common by society. I include it in the category of natural understanding be- cause, as it is held in human minds, it is subject to very much the same mainte- nance mechanisms which operate in human minds.
Proverbs make a good example. Proverbs arise, are selected by the sieves of generations of men's minds because they are meaningful, and they fall into disuse when they no longer express something valuable. There is an old saying; "Who understands ill, answers ill" which, though nobody knows its author, has been repeated down the years because people have found it is true, and that it says something that needs to be said.
Off into the stratosphere
One of the underlying reasons for the problems and paradoxes I am trying to address in this lecture is that the third kind of understanding, the structure of rules and definitions which is now increasingly used to try to describe life and as a basis for the future actions of society, has broken the feedback loop. This is something my colleague, Christopher Everett, once said when we were chatting about these things. We have isolated the model from the flood of feedback from reality which is so essential to maintain it. Increasingly that maintenance is left to people who have stood back from the front line of life and who bask in an arti- ficially restricted viewpoint and an illusion of certainty whose extent they, of all people, are the least able to comprehend . What's more they have made a virtue of doing so.
In fact, there is a great deal of virtue in doing so. Provided that they open their minds to the possibility that they may occasionally be wrong. All too often they do not do so. They view the front line view as inherently less valid, instead of more valid as it actually is. And they soar off into the stratosphere, feeding back their preconceived ideas into their model and seeing that it is good. Meanwhile the people down below with their feet on the ground stare up at them with wondering eyes and tear their hair in impotent frustration.
5. Higher Functions
I'm afraid that isn't the end of the story. Even if we could solve these problems and if everybody, specialists and generalists alike, started to respect one another's view points and put it all to- gether into a balanced synthesis, based on a better understanding of the way we maintain our internal models of the world, there are functions of the human mind that we would still be nowhere near replacing. The machine would still need people.
There would still be things like Judgement, Integrity, Morality, and Trust (giving the word trust its proper meaning) which the technological phe- nomenon has somehow led us into doubting that we need. And if, in this aca- demic setting, you will allow me to use the last-remaining taboo four-letter- word, I would mention Love. Which makes the world go round.
A patient of mine was once in the terminal stages of a very aggressive breast cancer. She was the mother of three young children. She had shown me the little lump only eighteen months earlier and although we hadn't missed a trick (there had been no delays in treatment and everything had been done ex- actly as it was supposed to be done) it didn't seem to have made the slightest dif- ference.
I called to see her about ten o'clock on the evening of the night she died. I remember sitting by her bed with her husband, one of the daughters and the district nurse, when her little son came to the door of the bedroom and held up a pair of socks. Making an excuse to be there, I suppose. "Have I got shorter or have these socks got bigger?" She sat up and looked, and said, "Those aren't your socks, yours are in the other cupboard." Then she smiled and announced to the room, "You see, I'm still in charge here." She died in her sleep a few hours later.
There were details which it would not be appropriate to mention here which made this story particularly poignant but her husband has given me per- mission to tell you about something that did happen, about three weeks before she died. For some years she had been trying to enlist my help in getting him to take up the threads of the singing they had both so much enjoyed as students in Oxford.
In the way that some things happen as though they are "meant", it was just when her illness was obviously moving into its final phase and I was casting around desperately for something positive to suggest that the lady I go to most weeks for singing lessons rang me up and asked me whether I would mind if, for once, she came to my house for the lesson. So I suddenly had a crazy impulse to ask my patient and her husband to come and join us as well.
And that is what they did. They were a little late, but when they arrived we helped her in from the car and sat her on the sofa with a pot of tea. Then we each sang a few songs. Just as she had expected and in spite of his exhaustion and his croakey voice from a cold his potential was immediately confirmed. Any fears that my unconventional management might have been misjudged were completely dispelled by the radiant happiness of her face as they left with some- thing to think about which transcended the present gloom. Afterwards he told me that the evening had been an "oasis in the desert" for both of them. A few months after she died he began to have his own lessons from the same teacher and about eighteen months after that the three of us decided to do a little concert together. And that is exactly what happened.
Not, as you see, in some remote, idealised past when people had time and freedom for that sort of thing, but just over two weeks ago, right in the middle of my preparations for this lecture. Here is the final phrase of one of the songs he sang on that occasion, "E'en as a lovely flower". Another analogy you see. The slide is of the words he chose for the programme note, and probably account for the slight wobble in his voice. The wobble wasn't there at the re- hearsal, which I recorded as well, but I thought I'd play you the real thing, so that you can hear the silence of a hundred and twenty people in the audience.
F.Bridge:E'en as a lovely flower The loveliness of the beloved inspires wistful longing. May God keep her lovely, pure and fair.
So What?
Did I say life is full of coincidences? I did not quote ADAMS, Douglas - Hitchhikers Guide to the Galaxy and ADAMS, Richard - Watership Down at the beginning of this lecture just because I was starting at the beginning of an al- phabetical Dictionary of Quotations. It worked out that way entirely on merit. Douglas ADAMS, for one, said it all, long ago. Thanks to him we all know the ultimate silly answer to the ultimate silly question - the answer, in fact, to Life, the Universe and Everything.
42!
Was anyone else listening to Radio 4's, Today programme last Thursday morning when they announced that space physicists were a little embarrassed to find that the most recent calculation of the value of the Hubble Constant - upon which depends the rate of expansion of the Universe and therefore its ultimate destiny - had turned out to be, of all things, 42. I haven't pursued the matter for fear of spoiling the story, but that is certainly what they said. Anyway, Douglas ADAMS was right. There isn't AN ANSWER and there never will be. Life is not a simultaneous equation and it does not have one so- lution. It has an infinity of different solutions depending on a infinity of view- points and situations. Nonetheless, the illusion that there ought to be one so- lution for things like the minimum level of competence in general practice is ex- tremely powerful.
I am the last person to suggest that everything has a simple answer BUT I do think a lot of contemporary problems arise from the illusion that things to do with life can be PRECISE. And our failure to understand that they are actually bigger, more complex and more subtle than we can conceive.
This means simply, that the world is much more complicated than it seems to be and that jobs which involve dealing with the real world are much more difficult than they seem to be.
We deal in Wholes not in Parts
Parts: Artificial beats Natural Technological progress has resulted very largely from the spectacular successes of specialisation and reductionism. We have broken the world into parts which can be analysed, defined and improved. There is no question, when you are dealing with parts, artificial understanding is the tool to use. There is no question about it because we can prove it so easily.
Wholes: Natural beats Artificial
The corollary, however, that when you are dealing with wholes, we need
the natural understanding of the human mind, can never be proved. It can only
be inferred in the kinds of ways I have been attempting this evening. If we ac-
cept that the purpose of the human mind is not do sums like a computer but to
model the world, and when we consider the pitch of perfection to which evolution
has brought the movements of an Olympic gymnast, the extravagance of a pea-
cock's tail or the interrelationships in a tropical rainforest, it is not too unrea-
sonable to suppose that the human mind is also as close to perfection as any ma-
chine we could ever hope to make.
The Blind leading the sighted
I say to anyone, beware of opening your mind and taking the broad view. It does not make for equanimity. It would be very much easier for us all if we could just concentrate on the details of a restricted field, such as audit, in which everything could be defined and precise and certain. But life isn't like that, to deal with life we have to take the broad view and deal with the infinite uncer- tainty at the cutting edge of time.
Taking the broad view means looking up from your actions and taking re- sponsibility for their consequences.
It means looking up from the short term gain and thinking of the future. It means the manager looking up from the league-table of his salesmen's figures and thinking of the consequences to society if the pressure he is putting on them destroys their families.
It means the law looking up from the fact that a GP didn't completely un- dress a patient with a facial injury and considering the reality of trying to work to that level of detail all the time.
It means looking up from the details of the individual things I am saying in this lecture and opening your mind to the idea that lies behind them. It is a tall order indeed, and people who are not used to doing it may need some help. But it is what we (and a very wide range of other front line workers) are doing all the time. And to put it crudely, we are fed up with being patron- ised by people who either never did the real job or who found they couldn't stick it and who have far less idea than we have what they are talking about. It doesn't mean that you haven't got sympathy and respect for blind people to say that you don't want to be led by them. It is time we brought the era of "the blind leading the sighted" to a close.
I would like to finish with four quotes from people I admire. First Alan Pattison, the headmaster who caused such a sensation with his address to the Paradox of Progress session of the RCGP Spring meeting in Portsmouth in 1994.
"Teaching is very much a matter of having enough freedom, within a rea- sonable structure, to exercise gifts and judgement. Surely that is what you as GPs must retain; the freedom to exercise personal judgement and to relate to each patient in a personal way."
Second, James McCormick, who wrote in September this year in the Lan- cet about the Death of Personal Medicine. But this extract is from the last page of his book, The Doctor, Father Figure or Plumber, is just as true today as it was twenty years ago.
"The doctor can still aspire as his forefathers did to mediate between the patient and his illness.
This demands more than knowledge of disease; it demands concern and aware- ness of people as individual, unique, human beings. It requires both wisdom and judgement, virtues seldom praised in the seventies."
And Iona Heath, who has done so much to promote the understanding of the true nature of general practice. This is from her 1995 John Fry Trust Fellow- ship monograph: The Mystery of General Practice
General practice is a power for good but it is threatened by the process of accelerating change and will only have a future if it can explain and justify itself. Without sharing that understanding, we risk losing something immensely pre- cious.
And Willie Fulton, who said so much of this in his inaugural lecture on 6 March 1990:
"In this age of political madness the most vital role of the college may be to help us hold on to the relationships of general practice based on mutual trust and the professional ethic, despite the emphasis of the all-pervading materialism of our society, which measures everything by the financial return, knowing the price of everything but the value of nothing."
"As we hunt around, more and more frantically, for ways to describe and control the world more and more perfectly, we find that the problems don't get less, they get more. Daily, we encounter the consequences of our failed percep- tion. And all the time the answer we are seeking is there, not actually under our noses, but an inch or two above and behind our noses."(From the Paradox of Progress)
Dr Fulton, Ladies and Gentlemen, colleagues, I have probably talked far
too much. Thank you for your patience. Thank you for inviting us to Glasgow.
Back to the homepage