Category Archives: doctors

Doctors just following orders

Superior orders

Befehl ist Befehl

Dalrymple points out that under Britain’s National Health Service, doctors

are becoming ever less members of a liberal profession and ever more executors of orders from on high.

They have

little leeway to consider whether these orders are good or bad in the individual case before them.

He notes that this is a problem in all systems in which a third party pays for patients’ treatment,

but it is acute in a highly centralised and dirigiste system such as the NHS, in which uniformity is the goal, even if it be uniformity of error.

Increasingly,

it creates an atmosphere of technical, managerial and ethical conformity.

👏🏻Clap for the NHS👏🏻 is to gestures what Jeff Koons is to art

Every Thursday at 8pm, Britishers are required to come to their windows and hail 🙏🏻the NHS bureaucracy🙏🏻. Applause must be long, loud, and accompanied, Dalrymple notes,

with ululations.

He dislikes such actions,

which seem to me empty and shallow. They are supposed to be gestures of gratitude and encouragement, but all that I have seen suggests that doctors and nurses are more irritated than pleased by them. Often they have to work in poor conditions, with essential equipment lacking despite the vast expenditure on the health service.

He points out that thus to genuflect is cheap.

It costs nothing, financially or in any other way.

The Danube of Thought: cheer him to the rafters

There is also

something unpleasant about it. When lots of people make a gesture collectively, there is often the implication that if you refrain from making it—and even worse if you actively refuse to make it—you are in some sense an enemy, in this case, of the people. Whatever your inner conviction, it is safest to join in. By doing so you avoid drawing attention to yourself and you are assumed to think and feel like everyone else, which is always safest.

It reminds Dalrymple, in its tendency to get longer and louder and almost more hysterical,

of the applause after a speech by Nicolae Ceaușescu or any other communist despot, in which everyone in the audience had to show himself to be as enthusiastic as the most enthusiastic applauder, and to continue applauding as long as someone else was applauding, for to be the first to stop might be taken as a sign of disloyalty and dissent from the official line.

His objection is also æsthetic:

I find it to be emotionally kitsch.

The sort of ‘art’ excreted by Jeff Koons: Play-Doh (five versions, 1994-2014)

The Rousseau theory of cancer

Simply stated, it is that

in a virtuous state of nature, man would never get it.

This, says Dalrymple,

raises the question of what man would die from in such a state.

While we’re on the subject of cancer, Dalrymple remembers that when his mother had it,

she demanded that after her operation she be told everything. She had a poor prognosis (the likelihood of recurrence and death within a year was great), and the surgeon, sizing her up, advised against a full disclosure of the facts.

She lived another 20 years, and

I have little doubt that the surgeon was absolutely right and humane in his advice, which was to mislead, if not actually to deceive, her.

A satanic gynæcologist

Dalrymple points out that J.G. Ballard’s High-Rise (1975)

has several doctors as characters: a lecturer in physiology at a medical school, a psychiatrist, some neurosurgeons, and a gynæcologist.

The book

is typical of his dystopian genre. The high-rise of the title is one of four 40-storey blocks of flats built in the docklands area of London (as the novel was published in 1975, the location is an instance of Ballard’s prescience).

The residents of the new development, all of the professional classes,

start a war against each other of a class nature (the higher the floor you live on, the higher your social status).

Eventually there is anarchy.

Everything is vandalised, the services cease to work, rubbish accumulates everywhere, the walls are covered in graffiti, and the residents raid one another for food and eat each other’s pet dogs.

Dalrymple notes that almost every element of Ballard’s fictional horror is visible in less extreme form in the real world today.

Pangbourne, the gynæcologist,

is among the worst characters in the breakdown of order. Rich and successful, he lives on the highest floor, the 40th, and has led a raid with women acolytes to the lower floors, capturing an accountant and a meteorologist.

Dalrymple asks:

Which of us has never met a Pangbourne?

The doctor as production line worker

The GP is no longer a member of a liberal profession but an executor of government diktats or obiter dicta

Ever increasing numbers of doctors: acute shortages of doctors. Such a miracle, writes Dalrymple, is one that

only our government could have wrought.

Dalrymple points out that about 250,000 doctors are registered in Britain,

but it is more difficult now to get to see any of them. There is said to be a crisis in medical manpower and that this necessitates the importation of a further 3,000 doctors this year. Fewer than two-thirds of doctors in Britain trained here. Britain parasites the rest of the world. It has outsourced a lot of undergraduate medical training.

Bureaucratic fatuity

There is a big shortage of general practitioners (i.e. family doctors or primary care providers). Young doctors do not want to go into general practice; training posts go unfilled. This is to a great extent because of the administrative burden. GPs must

spend untold hours filling forms of a soul-destroying and unnecessary kind. This is a slow kind of torture. The demands placed upon them by a bureaucracy composed of people who have little or no understanding of medical practice are immense.

Rules laid down by fools

GPs’ pay

depends on their compliance with rules laid down by fools, and this is not a happy situation for an educated and intelligent person.

Computerisation has been a factor, because for the bureaucratic mentality,

if a piece of information can be recorded, it ought to be. Before the spread of the computer, the bureaucrats’ dream of replacing all other human activity by form-filling was impossible.

Loss of prestige

The more the work

is reduced to algorithms, the less attractive it is.

The GP

is no longer a member of a liberal profession, but the executor of government diktats or, worse still, of its obiter dicta. Eventually the GP will become redundant. What is done by GPs will be done by computers or nursing assistants.

Dalrymple points to the

steep decline in the attractiveness of medicine as a vocation, profession and career.

And no one

who ever experienced an ordinary Soviet hospital will be in any doubt as to what a decline in the prestige of the profession meant to patients.

It has long been the goal of the government, he points out,

to deprofessionalise medicine and to turn its practice into a mere job. An independent profession, with its high standards and old traditions, is dangerous to the government, especially when it is as respected as the medical profession, in a way in which a mere group of shift workers will never be. Shift work dehumanises patients and deprives the work of most of its satisfaction. It is also grossly inefficient.

The independence of doctors

has eroded almost completely, and you cannot expect highly educated people who have undergone a long and strenuous training to remain contented for very long with being harried and reprimanded by people who are of lower calibre than themselves.

A vivid exemplification of the New Hospital Order is the noticeboard in the corridor of the hospital in which Dalrymple works, which

informs the public of the senior staff of the hospital. The senior consultants, all men of considerable distinction, appear on the fifth and bottom row, under four rows of bureaucrats. The impression is given that they are of very minor significance.

The shortening of training,

both graduate and postgraduate, is another straw in the wind. New hospital consultants do not have the breadth of experience that old consultants had at their appointment, and this is because doctors are increasingly regarded as technicians and nothing more.

The spinster consultant

This colleague of Dalrymple’s was in her mid-fifties and her patients

were her family, her recreation, her life. Her devotion to them was absolute.

On her ward rounds

she examined each with minute care, read their notes from start to finish, and ordered long batteries of tests in case she had missed something, even when the diagnosis had been made weeks before.

Although she was a woman of the greatest kindness, her rounds

were an ordeal for all concerned — patients, nurses, doctors – lasting eight to ten hours. By the end one wished to scream, to kick the walls, to smash plates. And the worst of these ordeals was that they benefited no-one. I do not recall a single patient whose life was saved, whose diagnosis was made, whose prognosis was improved, by this minute sifting of details.

The hypomanic Dr Pascal

She had an abnormality on her chest x-ray, but it was something more closely resembling a sexual assault than a medical examination

The behaviour of this locum was, writes Dalrymple, so objectionable that he was barred from all pubs within a mile radius of the hospital. Entering the hospital canteen, Dr Pascal would shout across it in a booming voice and with a salacious leer:

How many times did you have sex last night? You look as though you need it more often.

Dr Pascal would

clap people on the back — hard enough almost to propel them through the adjacent wall — and cross-question them on the details of their private lives.

Once, before he knew Dr Pascal’s character, Dalrymple referred a young female patient to the locum because

she had an abnormality on her chest x-ray. When her notes returned with her from Dr Pascal, they bore a detailed account, scrawled across several pages in writing that clearly betrayed loss of control, of something more closely resembling a sexual assault than a medical examination.

The doctor-writers

screen-shot-2017-01-04-at-22-41-01There has been, Dalrymple notes (from 1:07:09),

a very large number of doctor-writers. This is not surprising: medicine is good training for a writer. The doctor is involved in the most intimate details of a patient’s life, but at the same time, he has a kind of objectivity; he is both involved and observing. This is a good combination if you want to write.

Dalrymple himself has

always wanted to write. I had this desire from an early age.

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Bernard Mandeville

Bernard Mandeville

screen-shot-2017-01-04-at-22-46-34screen-shot-2017-01-04-at-22-48-30screen-shot-2017-01-04-at-22-49-33screen-shot-2017-01-04-at-22-52-59screen-shot-2017-01-04-at-22-54-29screen-shot-2017-01-04-at-22-56-24screen-shot-2017-01-04-at-23-00-17screen-shot-2017-01-04-at-23-02-32screen-shot-2017-01-04-at-23-03-59screen-shot-2017-01-04-at-23-06-31screen-shot-2017-01-04-at-23-08-12screen-shot-2017-01-04-at-23-09-58

Carlo Levi

Carlo Levi

Louis-Ferdinand Céline

Louis-Ferdinand Céline

Peter Mark Roget

Peter Mark Roget

The hope of a dilemma-free world is naïve where it is not power-hungry

screen-shot-2016-12-14-at-19-05-57The problem, says Dalrymple, with a nationalised health system’s

incontinent sharing of risk

is that

it deprives people of one possible motive for behaving responsibly. They believe, not without reason, that someone will always pick up the pieces for them at no cost to themselves. Irresponsibility thrives where there is no penalty for it.

He points out, however, that the problem with individualised insurance is that

it may place intolerable or unsustainable burdens on people through no fault of their own.

In short,

incontinent sharing of risk is unjust: too little sharing of risk is inhumane. Since both justice and humanity are desirable qualities, but not always compatible, now one, now the other, will be the more important; but the tension between them will remain.

Dalrymple writes:

That ethical decisions sometimes cannot be made that are indisputably correct, that entail no injustice or no inhumanity, is difficult for rationalists and utilitarians to accept. They want every division to be without remainder. They want a formula that will decide every question beyond reasonable doubt. They want a universal measure of suffering, so that the worth (in units of suffering averted) of every medical procedure can be known and compared. There is a cognitive hubris at play, according to which information will resolve all our dilemmas; and if our dilemmas have not been answered, it is only because we do not have enough information.

As for the doctor,

he cannot be so limitlessly compassionate as to deny patients’ responsibility where it exists, nor should he deny his patients his compassion by blaming them even when they are to blame.

Surely no human existence can be as empty of meaning as this

screen-shot-2016-09-10-at-13-28-10From time to time Dalrymple receives invitations to attend conferences on something called medical leadership. The invitations ask,

Do you want to be a leader?

The answer, in Dalrymple’s case, is

No.

The latest conference on medical leadership, Dalrymple reports,

has 80 speakers and lasts three days. The organisers seem to believe that the longer the conference and the larger the number of speakers on so patently dull a subject, the more impressive it is, no doubt in the way that a big box of chocolates impresses a greedy person more than a small one. All things considered, I’d rather stay at home and read the collected works of Kim Il-sung.

screen-shot-2016-09-10-at-13-25-28Dalrymple looks at the biographical details of a couple of the speakers, taken from the list at random.

Mr R.

is founding Director of Harthill Consulting. His extensive practitioner background includes working with senior leaders from organisations such as Fujitsu, Danone, Shell, Hewlett Packard, Volvo, Eli Lilly and Microsoft. Co-author of HBR’s award-winning article ‘Seven Transformations of Leadership’ (April 2005) it has since consistently been named as one of HBR’s ‘Top 10 Must Reads’ on Leadership. He recently co-authored and contributed to the large-scale 2015 PwC study on leader transformation and retention. His expertise is exploring leadership as a process of evolving ‘wisdom’ — enabling individuals to integrate discernment, courage, power and compassion.

screen-shot-2016-09-10-at-13-31-37Ms A.-M.

is a Chartered Occupational Psychologist and Chief Executive of Real World Group (a University of Leeds spin-out company). She is also Adjunct Associate Professor at the Centre for Sustainable Business and Enterprise, University of Southern Queensland. She has been working with Real World Group for the past 15 years, supporting leadership development with both individuals and groups up to Board level globally. She has a particular passion for a focus on positive psychology and diversity & inclusion in leadership. She has helped establish Real World Group’s approach to Engaging Leadership, based on uniquely proven research involving tens of thousands of people across the world, and has authored or co-authored most of Real World Group’s diagnostic instruments. The research she has been involved with has established the common sense but often missing behaviours that distinguish leaders from managers, and effective leadership among teams and organisations. They are factors that drive productivity in a sustainable way, even when resources are diminishing. As a result of her research and experience in working with organisations, she has been invited to speak at international and national conferences, and consults on behalf of Real World Group with organisations from the UK, North America, South East Asia and the wider Asia Pacific region. She has worked extensively in Higher Education, including at leading Universities and with the Leadership Foundation for Higher Education. She has authored and co-authored a number of articles in practitioner and peer-reviewed journals, as well as book chapters in academic books by leading publishers on leaders’ career development. She is Co-Chair of the Steering Group of the government sponsored Engage For Success movement (www.engageforsuccess.org) and the editorial committee of the International Congress on Leadership, Management and Governance. She has an MSc in Occupational Psychology from the University of London, Birkbeck College and an MSc in Positive Organization Development and Change from Case Western Reserve University, Ohio.

screen-shot-2016-09-10-at-13-22-57In case, says Dalrymple, the above

should be insufficiently enticing to prospective attendees,

it is explained why they should attend the conference:

Be a part of the first Leaders in Healthcare conference, which will bring together both the future generation and most senior of healthcare professionals and managers. The event aims to focus on the leadership challenges all nations face in healthcare to improve the care we deliver for our patients. Learn about and be part of widespread discussions including standards, professionalism and the opportunity for a step change in quality, the leadership challenges facing healthcare on a national and international scale and how we, as a profession, will face these, and contemporary leadership theory from international experts. Attend interactive workshops and hear from inspiring speakers exploring the essentials of what you need to know to continually grow your leaderships skills, how innovation in healthcare can change the way we work, and how medical education can improve leadership, clinical performance and patient safety. Represent the voice of medical students by planning your leadership skills development at an early stage of your career. Explore sessions to understand the essentials of leadership and how to take charge of your own development, and network with peers and senior medical leaders. Develop essential skills for being an effective leader who can motivate and inspire others in the team, influence the way care is given, ensuring it is high quality, compassionate and responds to individual needs, and network with the full spectrum of healthcare leaders from all professional backgrounds. Network with a broad range of healthcare professionals, develop a shared understanding of what good leadership is and how working together can benefit service delivery and patient care, consider how we can encourage greater involvement of healthcare professionals, service users, communities and the general public in shaping healthcare services that are fit for purpose, and network in a unique multi-professional healthcare leadership event embracing all levels and sectors. Leaders in Healthcare 2016 welcomes other professionals who share our passion for excellence in leadership and management.

screen-shot-2016-09-10-at-13-38-20After reading a few lines of such prose, Dalrymple’s mind

goes fuzzy as if I were suffering from a hangover, or as if an almost physical shutter comes down in my brain, just as it does on reading a paragraph of Kim Il-sung. The prose destroys my capacity, even my will, to concentrate or fix my mind on anything. My remaining thoughts are fleeting and desultory: ‘Can anyone really have a passion for diversity and inclusion in leadership?’ or ‘What can the life of someone who does have such a passion be like?’ I try to imagine it, but nothing comes to mind. Surely no human existence could be as empty of meaning as that.

screen-shot-2016-09-10-at-13-23-09Then Dalrymple begins to wonder what Alexander the Great or Napoleon would have made of the conference on leadership.

Would they have been able to reach a shared understanding of what good leadership is? If Alexander had only been better able to integrate compassion into his discernment, courage, and power, would he have found new worlds to conquer? If Napoleon had learned about leader transformation, would he have crowned himself emperor earlier in his career than he did?

Who would pay good money for such a conference?

The taxpayer. He would not attend the conference himself, of course, but he would pay for employees to attend it who needed or desired a three-day break from their work in a public hospital or as part of their mandatory continuing professional development. He would also pay the fees of the speakers, some of them flown in from distant lands.

screen-shot-2016-09-10-at-13-40-36The attendees, Dalrymple notes, would learn about something called lean management, one definition of which is as follows:

If someone tells you that ‘lean management is this’ and not something else, if someone puts it in a box and ties a bow around it and presents it in a neat package with four walls around it, then that someone knows not of what they speak. Why? Because it is in motion and not a framed picture hanging on the wall. It is a melody, a rhythm, and not a single note.

This, says Dalrymple, is

the mysticism of apparatchiks, the romanticism of bureaucrats, the poetry of clerks. From my limited observations of management in public hospitals and other parts of the public health care system, it seeks to be not lean, in the commonly used sense of the word, but fat, indeed as fat as possible; nor are large private institutions very much different.

screen-shot-2016-09-10-at-13-43-08We have entered, writes Dalrymple,

gradually and without any central direction or decree, a golden age of langue de bois or of Newspeak. Langue de bois is the pompous, vague, and abstract words that have some kind of connotation but no real denotation used by those who have to hide their real motives and activities by a smokescreen of scientific- or benevolent-sounding verbiage. Newspeak is the language in Nineteen Eighty-Four whose object is to limit human minds to a few simple politically permissible thoughts, excluding all others, and making doublethink — the frictionless assent to incompatible propositions—part of everyday mentation.

Langue de bois and Newspeak

are no longer languages into which normal thought must be translated; rather they have become the languages in which thought itself, or rather cerebral activity, takes place, at least in the upper echelons of the bureaucracy that rules us. If you ask someone who speaks either of them to translate what he has said or written into normal language, it is more than likely he will be unable to do so: His translation will be indistinguishable from the words translated.

screen-shot-2016-09-10-at-13-49-41It is therefore clear that,

where culture is concerned, the Soviet Union scored a decisive and probably irreversible victory in the Cold War.

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