Has theory blurred the line of practicability? We've become
robots/computers testing theories and/or following erroneous
regulations and codes of inpractical individuals instead of recurring
to common sense and practical approaches.
I am throughy interested in your book, The Paradox of Progress.
New contributions from web-site visitors above this line
"It is true that the gas bill was large for the time of year. It is
possible that the customer has been charged for the large volume of gas
which was used up in the explosion which blew his house to pieces."
Real life means the patient you are so proud of diagnosing as having an
underactive thyroid coming back six months later and telling you that the
Thyroid tablets are making her hair thin and making her put on weight (the
very symptoms that ought to be getting better)
Everything in life is expressed in relative terms, not in the absolute
terms of rules and machines.
To the captain of the Under-Tens, "Did you win?"
"Will it sting?"
"The differences, then, are those we often find when a natural thing and
it's artificial counterpart are compared - the natural is the more
versatile, flexible, adaptable (the four legs of a deer and the four wheels
of an automobile....)"
"It was getting too mechanical"
"Its like a compost heap in my chest that's gone wrong. I'm sorry, but its
the only way to describe it."
Computers make it easy to view the mind as a thinking machine. But the key
to consciousness lies with feeling, not thinking.
"Life doesn't have clear edges"
"There are strong pressures now to compare students, to compare teachers,
even entire countries using one dimension or criterion, a kind of crypto-IQ
assessment."
"The true services of life are inestimable in value and are never paid."
We have to give the lie to the official perception that until something has
been measured/counted/recorded it doesn't exist.
Lists can never be complete and it will always be the thing that isn't on
the list that you will want to know about (-because if you knew about it
already, it would be on the list).
General practice is being judged by the wrong criteria. It is being forced
to justify itself in a language which denies its very nature.
For more than 2000 years philosophers and scientists have been deceived by
the apparent simplicity of perception.
"Mummy, why is she dressed up like a nurse?"
General practice would be easy to organise if you knew everything that was
going to happen in advance.
"Work expands so as to fill the time available for its completion. General
recognition of this fact is shown in the proverbial phrase 'It is the
busiest man who has time to spare.' Thus, an elderly lady of leisure can
spend the entire day in writing and despatching a postcard to her niece at
Bognor Regis. An hour will be spent in finding the postcard, another in
hunting for spectacles, half and hour in a search for the address, an hour
and a quarter in composition, and twenty minutes in deciding whether or not
to take an umbrella when going to the pillar box in the next street. The
total effort that would occupy a busy man for three minutes all told may in
this fashion leave another person prostrate after a day of doubt, anxiety,
and toil."
1,567 press officers are now employed around Whitehall - rather more people
than it once took to run India. Ministers spend more than 100 million
advertising themselves. And what does the Government have to show for it?
The worst opinion poll rating since Ethelred the Unready.
"You're a remarkable chap.."
"... another example of the way that, in the new-style NHS, facts and
figures, even truth, are all subservient to `presentation'."
Everybody looks at you through their small window on your life and they
think that they can judge the whole of it on the basis of that view
"Outgoing NHS chief executive Sir Duncan Nichol wants to see a complaint
system that is as simple for patients to use as returning a product to
Marks and Spencer.
"I'm going to see Dr Cassidy next time"
"What will you do if it's up? Change your diet?"
"I've had all the checks and the well-woman screening done the smear and
breast checks. But a friend had a check recently when the pulses in her
feet were checked - I wonder if I could have mine done sometime?"
A doctor can have a marvellously productive and rewarding life treating
gross diseases in Africa or with the same amount of effort feel frustrated
in dealing with people's never-ending search to be more and more perfectly
healthy.
General practice is sinking under a burden of unrealistic expectations -
not only externally, but self imposed.
Everything is getting more difficult as we get nearer and nearer to
perfection. The cost of further progress becomes increasingly prohibitive.
However high our standards, people will come to judge our performance by
those standards - regardless of the difficulty of maintaining them.
"The only person who did anything near what he thought he did was the one
who thought he did least."
Life is a sub-optimal state of affairs
"The practice of medicine is risky and dangerous and difficult"
Society has abdicated its responsibility for risk-taking to real people
like GPs: and then drops on them like a ton of bricks when things go wrong.
The paradox that although medical care has never been safer and medical
accidents are far less common than in the past, public perception of the
dangers of medical treatment and public criticism of doctors has never been
higher. Certainly, the disturbing growth of medical litigation throughout
the Western world has far more to do with unrealistic expectations of
perfection (and indeed, greed) than it has to do with increased
culpability.
"Mind you, your mustn't be too contented. Progress comes from discontent."
"...To have the state as a servant, not as a master..."
"Characteristically, however, devotion to the free market was combined with
the imposition of unprecedented and ill-judged central controls on the
daily work and priorities of individual doctors."
Management is a good idea which has recently undergone malignant change and
become a disease of society. As such it is by far the most important
disease GPs ought to be trying to treat.
There was once a boat race between a JAPANESE crew and an NHS team. Both
practised long and hard to reach their peak performance but on the big day
the Japanese won by a mile.
We keep on solving problems but the solutions, like Medusa heads, turn into
worse problems than the ones they were designed to solve. Even as things
get better, they get worse.
"How long ago did you have the last one?"
Radical change is a luxury we can rarely afford. If individuals have to
accept constraints on their freedom to innovate - so should the
rule-makers.
One of the problems of the NHS is the illusion it gives that medicine can
be planned. One of its successes is the freedom it allows individuals to do
their own planning
"Regulation has become the fastest growth industry in Britain. The slogans
on the banners of the regulators are 'Hygiene', 'Health and Safety',
'Environmental Protection' and 'Caring' This pervasive regulation of
doubtful value has confirmed the belief of ordinary people that officials
are interfering, prying, probing busybodies and nosy parkers out of touch
with the real world."
The impossibility of defining a point at which a cuddle becomes sexual
abuse. The system can never be really at ease with cuddles.
Central controllers are only human, and make mistakes like the rest of us.
The reason why centralised mistake making is so devastating is that it
inevitably results in lots of people, or even all people, making the same
mistake at once.
"..civilisation', or `the system' or `society' or whatever you want to call
it, is best served not by mules but by free men."
"The most illuminating insight into their (the National Commission on
Education, 1993) mindset is their proposal to set up a new quango
responsible for innovation. This ignores one of the oldest lessons in human
affairs. Because the future is inescapably uncertain, progress cannot be
organised. What will work cannot be put into forms made in advance: it
flourishes only in unrestricted freedom..... Innovations come from
individuals, not from committees; from the free flow of the spirit not from
guidelines, instructions, procedures."
"Bonkers" is the best word I can find to describe the people who devised
the process of quality assessment now forced on university teachers. Take
as an example the University of Edinburgh, where I am a member of the
biological sciences advisory committee, and where the distinguished
vice-chancellor, Sir David Smith FRS, blew his top recently over the matter
at the formal graduation ceremony.
People who live by the book supervising people who have to deal with real
life - the blind leading the sighted.
Contrary to what politicians think, the opposition of doctors to government
reforms may not be due to an objection to the relinquishing of power. A
more enlightening explanation is that it owes more to their desire to
protect their core values against the onslaught of an untested economic
model of public services
Progress does not come by imposed planning from above but by vigorous
questioning and criticism by ordinary generalists, with their feet planted
firmly in the richness of life.
The people who are in power in the modern world have no conception of the
pressures they are putting on front-line workers.
"The deep regard of the people of a local community is at least as
satisfying as the plaudits of a congress. And it takes at least as much
earning."
"I'll do it, `Nan!"
"The two investigations which you have recorded demonstrate that the whole
theory behind PACE (Police and Criminal Evidence Act) is fundamentally
flawed. It rests upon the premise that the introduction of an elaborate
framework of rules will actually change the behaviour of police officers."
Professor McConville, Professor of Law at Warwick University, commenting
during `First Tuesday' documentary on the West Midlands police force. shown
7/7/92
Rules should be safe minimum baselines not impossible ideals. They should
be foundations on which to build, not mountain-tops people exhaust
themselves struggling vainly to reach. People are best left to choose their
own mountains to climb.
"Throughout medicine judgement is being denigrated and replaced."
"What I do is try to find out what has happened and understand it. I
actually believe that understanding is the one genuine human happiness".
I believe that the purpose of education is to produce understanding, both
of various disciplines and of the world we live in.
Unfortunately we must face the bitter truth that most students in schools
all over the world do not understand.
Life is a huge idea in our minds which is a coherent amalgamation of every
single smaller idea which we possess. It is the maintenance of this huge
idea, the fine-tuning of this great hypothesis, which is the true business
of life. Our idea of life is uncertain, it is huge, it is flexible, all its
aspects are expressed in terms of one another. Our consciousness addresses
one tiny, selected aspect at a time and yet as it does so that aspect seems
to be the most important thing in the world.
Training involves the inculcation of doctrines with rigid discouragement of
the questioning of those doctrines. Education encourages people to question
everything. That is why authoritarian politicians distrust education.
Training is for performance
People who have succeeded without any training at all in their field:
There is a constant dilemma that you want to let the ideas that are forming
in your mind take their own form but at the same time you have to impose
some discipline and structure or you don't make much progress. So, you have
to strike a delicate balance in imposing structure upon your ideas and
remember that the ideas are always more important than the structure.
"It is no accident that many important judicial decisions in our society
are not vested in experts, but in a jury."
JS McCormick, The Personal Doctor 1975 JRCGP 1976,26,750-753
"People who behave like computers will inevitably be replaced by computers"
The simple message is that the people who understand a job best are the
ones actually doing it
Working to rule does more harm in Medicine than it does in industry. The
practice of medicine requires a fresh judgement for each patient.
The potentially disastrous consequences of encouraging people to
decommission their common sense and their integrity by slavish adherence to
externally imposed rules. The real object of rules should be to help people
to educate their common sense and their integrity.
We are witnessing the culmination of a process which has been going on for
many years - the gradual replacement of individual human judgement by a
structure of external rules.
"You could be right Doctor, you see more of it than I do."
"The division of medical work darkens understanding".
To assess the profits of a company, or improvements in one parameter of
medical care, there is no question that measurement is an incomparably
effective tool - but when you combine the innumerable unquantifiable and
variable parameters of the real world, common sense wins every time.
The human mind is the best machine we are ever likely to have for modelling
reality and automatically throwing up incongruities.
Many of a GP's greatest achievements are negative ones (e.g. Supporting a
potentially unbalanced patient over many years) and negative achievements
don't show.
If you really want to remain a generalist, you can't succeed as a
specialist as well. But in the present world you have to be a specialist to
influence things.
Being a generalist involves integrating everything into a manageable whole.
The overall, general view is every bit as important as the specialist view;
both are necessary; neither is inherently superior or inferior to the
other. Both are perfectly valid. But the generalist view has been
persistently neglected.
Each specialist is sure he knows the answer to the generalist's problem of
having too much conflicting advice: Obviously, conflicting advice from
other experts should be ignored. Busyness:
Christopher Wren
"Do you plant them at any particular time?"
The suddenness, completeness and lack of hindsight with which we change
from longing for rain to longing for sun. It is so difficult to remember
that what we really want is a balance between the two.
General practice is full of problems which have no correct answer. This is
what makes it seem to be a woolly, vague and inherently less valid
discipline than a restricted specialist field within which certainties can
be seen to apply much more directly.
Throughout history, it has always been recognised that the human mind is
capable of two kinds of knowledge, or two modes of consciousness, which
have often been termed the rational and the intuitive, and have been
traditionally associated with science and religion, respectively.
"Can I have a motorcycle when I get old enough?"
-Norberto T. Espmndola
I find more than a specific paradox, the entire concept of paradox as
intriguing. A paradox is defined as a statement with two opposing and
contradictory concepts that seem to be in contradiction but in fact have some
simultaneous truth. It appears to me that paradoxes are on the increase in
all areas. I don't know whether it is an increase in technology or
information flow. It might be due to the quantification of our surroundings
with a subsequent loss of wonder.
Whatever, the old modes of thinking just aren't working anymore. We have
somehow not been able to hold the opposites at the same time, forcing us to
take extreme positions. The result is that there seem to be more extremes
and less middle ground than ever before.
We are inundated with paradoxes. Simply the way we use everyday language
creates paradoxical situations. Take your time, but hurry up about it.
Relax as intensely as you can. Prepare to be spontaneous.
-Bob Gerold
Gas Board reply to enquiry.
"No, we were up against the Under-Elevens"
"Well, it might sting a bit, but you won't mind too much"
"Well, actually, I would mind if it stings"
Five year old being offered eye-drops.
The Oxford Companion to Music Comparing the human voice with the organ.
Professional golfer - describing a problem with his swing.
Nicholas Humphrey The private world of consciousness New Scientist 8 Jan
1994
David Hockney
Howard Gardner Psychologist, Harvard Graduate School of Education
R L Stevenson, Lay Morals
Colin Blakemore, The Mind Machine
"She IS a nurse, sweetheart."
Conversation in treatment room
We have to worry just as much about all the things that don't happen!
C Northcote Parkinson, Parkinson's Law or The Pursuit of Progress, opening
para
Andrew Rawnsley Observer 30 Jan 1994
"Everybody's remarkable if you look closely enough."
Conversation with a patient
Michael O'Donnell Monitor Weekly 16 February 1994
Giving evidence to a House of Commons select committee last week, Sir
Duncan said he saw no difference between the service offered by the
national health service and the service offered by a large company such as
Marks and Spencer."
PULSE, 19/3/94
Jonathan (3) ...after not getting a 'scripshun from Dr Willis
"No, change my doctor."
92 year old ex-1920's Gaiety Girl, wanting to have her Cholesterol checked
Dr Roger Hillman ..conclusion from his study of how well doctors' real
performance matched up to the rules they thought they applied to themselves
James McCormick
Elderly widower, in his tiny room, after saying how wonderful the NHS is.
Margaret Thatcher naming her objectives on first becoming Conservative
party leader.
Ian Gilmour Dancing with Dogma - Britain under Thatcherism
The NHS team became discouraged and morale sagged. Senior managers decided
the reason for the crushing defeat must be found and set up a working party
to investigate the problem and recommend action.
They concluded that the Japanese had eight people rowing and one steering
while the NHS team had eight steering to one rowing. They immediately hired
a consultancy to look at the team's structure. Millions of pounds and
several months later the consultants concluded that too many people were
steering and not enough rowing.
To avoid losing again the team structure was changed to give three
assistant steering managers, three steering managers, one executive
steering manager and a director of steering services. A performance and
appraisal system was also set up, to give the person rowing the boat more
incentive to work harder.
The Japanese were challenged to another race - and won by two miles. NHS
managers responded by laying off the rower for poor performance, selling
the oar and cancelling orders for a new boat. The money saved was used to
finance higher-than-average pay awards for the steering group.
Story doing the rounds
"Four years."
"Oh WELL! They've changed it all since then!"
Auxiliary nurse in postnatal ward, officiously showing a Mother how to
change the nappy of her fourth baby.
Kenneth Baker, reviewing The Mad Officials by Christopher Booker and
Richard North
Robert M Pirsig, Zen and the Art of Motorcycle Maintenance.
Robert Skidelsky Professor of Political economy, Warwick University.
In July 1993, the university was visited by three auditors for three days.
That may not sound much, but to prepare for the visit the science faculty
of this top-quality university, was required to submit over a hundredweight
of documentary evidence (that's more than 50 kilograms if you're lodged in
the metric system). Over 200 people were involved in producing it,
accounting for the equivalent of eight years of staff time. The bill for
photocopying alone was 3,500. Edinburgh reckons that once quality
assessment becomes fully operational, the cost will be 500 staff days a
year. And this does not include the time that will have to be spent by
university staff in assessing other universities - estimated to take up
another 400 staff days.
For pity's sake, let us trust the universities to deal with the few
slackers in the system, and let the assiduous ones get on with teaching and
research.
Tam Dalyell New Scientist 30 October 1993
Part of Laughlin and Broadbent's thesis is to question whether a
fundamental change in the values of professionals (health professionals,
teachers, civil servants) was ever necessary. They doubt whether it was,
believing that the "financial management initiative" that the British
government has been attempting since the early 1980s, has been introduced
into the public sector at vast expense and with little evidence that it has
improved services.
Jane Smith BMJ 26 March 1994 p. 812
T F Fox The Personal Doctor and his relation to the hospital
Observations and reflections on Some American Experiments on Gen. Pract by
Groups
Lancet April 2 ,1960
3 year old, rushing up to his Grandma who is struggling to open the
"childproof" lid of her medicine bottle.
"This, then, seems to be the underlying trend of change in the NHS _
cynical analysis leading to distrust of judgement and its replacement by
procedures and markets."
Bruce Charlton Personal View BMJ 20 Feb. 1993
Brian Redhead, Guardian obituary by Sally Weale 24/1/94
Howard Gardner Psychologist, Harvard Graduate School of Education
Education is for understanding
Useful remark.
Sir Theodore Fox, Harveian oration 1965: PURPOSES OF MEDICINE
Patient, told he has 'flu.
James Mackenzie
Most things are done by busy people
Busy people do things quickly
Doing two things is often easier than doing one
It isn't the unemployed you see out jogging
...also rather a good architect!
"Yeah, I sticks `em in any-when. I stops when I can't go on no more."
Hilda Stevens, 83 year old gardener, on roses.
But general practice is a much better model of life than is a medical
speciality because life is full of woolly uncertainty.
F Capra, THE TAO OF PHYSICS
"If you take care of it."
"Is it hard?"
"Not if you have the right attitudes. It's having the right attitudes that
is hard."
Robert M. Pirsig, Zen and the Art of Motorcycle Maintenance.
Jaques Ellul, The Technological Society Vintage
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