We seem to have a little hit on our hands. The BMJ published our Analysis article “Evidence based medicine: a movement in crisis?” and within a few days, the social media channels were humming. Returning to the original concept of EBM, which was all about the holistic care of individual patients, seems to have struck a chord not just with us, the authors of the paper, but with readers too. One of the rapid responses said: “This article describes the sort of medicine I aspire to practice.” Aspire to. What a phrase. And in an instant I’m back in the surgery, and thinking about all those times I wished it had gone better.
Not that it was terrible. In many ways, my time of practising was a golden age, with increasing and better services for patients, the introduction of chronic disease registers, proper screening and vaccination programmes, expanded premises, electronic medical records, GP training, and so on. We even managed the odd bit of decent medicine; the parathyroid adenoma diagnosis lives with me decades later.
Twenty years on, repeat requests from old colleagues and their successors for more nagging (cunningly disguised as decision making and EBM workshops) are the greatest compliment. But thinking back, the rapid responder had it. With the best of intentions and in a search for clinical excellence, I sometimes lost sight of the big picture. The one thing I regret is—and it was hidden in plain sight all around—I wish I’d recognised the importance of kindness.
In my defence, I was sleep deprived to a dangerous degree. In those days we did our own on call, and with three young children who were all terrible sleepers, much of my 30s is a blank. Music, films, books—all were strangers to me. Daytime demands increased inexorably too. I’m hopeless in a 1980s pub quiz.
And it wasn’t just me. When we eventually set up an out of hours cooperative, I got letters from spouses saying: “Thank you so much, you’ve given me my husband back.” Gulp. We now know that after a night on call our affective biases kick in and our risk of making an error goes up. Shifts and loss of continuity are of course far from perfect, but I’ll be on the barricades if working a day, a night, and the next day are ever back on the cards.
So, back to kindness. Since we started working on the paper, I’ve discovered a couple of genius American writers: George Saunders (GS) and David Foster Wallace (DFW). I’ve not yet found them covering medicine per se, but they both cover some of the big questions in medicine. GS gets it: “What I regret most in my life are failures of kindness. Those moments when another human being was there, in front of me, suffering, and I responded . . . sensibly. It’s a little facile, maybe, and certainly hard to implement, but I’d say, as a goal in life you could do worse than: Try to be kinder.”
Think back to those times when you were ill or troubled. I bet the bits that you remember are the kindnesses and, yes, the times when kindness was absent. How we deliver care matters, as well as the outcome. I guarantee I never set out for the surgery vowing: “Today, I’ll be unkind,” and neither do you. Why do we sometimes lose focus? There has to be more to it, and indeed there is.
Knowing about ourselves and our own reactions helps us understand more often what’s going on around us. For we are, as far as we are concerned, the centre of the universe. Everything we see happens to us, and cognitively the default reaction is literally it’s “all about me”—if we’re not careful. If we think about it consciously, even briefly, of course we know better, but instinctively we aim to self-preserve, and we see reinforcing self-preservation going on all around us as our colleagues also struggle with work and their own lives of quiet desperation.
Don’t think I’ve gone soft over the years and forgotten the bone aching, brain dead days (and there were many of them), when I should have been the GP wearing lycra and trainers as I ran, literally, from one patient with complex, unsolvable, and distressing problems to the next . . . and the next . . . and the next. But under that pressure it’s all too easy, because of how we are hardwired, for it to become about me. We can forget that, actually, it’s all about them and we have a choice.
As I write this, I’m irritated by the woman next to me on the train, who is crowding my personal space and playing her music too loudly. I could easily get cross and grumpy, because of course it’s all about me. But there is another explanation, perhaps. It’s likely she isn’t doing that to be unpleasant. Maybe she’s had a bad time at work today and is preoccupied with that, or she’s going home to be a carer for her Mum who’s ill, or . . . and then, once we start to think about them rather than me, there are a thousand other more plausible explanations than “it’s about me.”
No one should expect, or be expected, to automatically feel differently about what they feel. Our default settings are just that—our default. DFW, writing about all this, says: “It’s hard, it takes will and mental effort, and if you’re like me some days you won’t be able to do it, or you just flat-out won’t want to. But most days, if you give yourself a choice, you can choose to look differently.” I’m trying David, every day I’m trying.
GS reckons that as we age it gets easier—we naturally become kinder. Big things happen to us, we start to see better what really matters, and what, on the other hand, is at worst a passing irritation. In our own dark, tender moments we receive care with compassion ourselves, and the importance of kindness becomes more obvious. And especially, once the sleep deprivation wears off, we see the unselfishness that comes from having children and grandchildren. Those of you in that happy position know that it isn’t about you any more, it’s about them. If you don’t feel it yet, you will. Ask any parent or grandparent. “As long as the kids are ok.”
Of course we must take our clinical expertise seriously, finding (not knowing) the best evidence, and our many other doctoring roles. These are incredibly important, not just for our patients, but also for the people we work with so our teams and organisations get along as best they can. But if we worship the god of having to know all of the evidence, and think that’s the most important thing, then we ourselves will struggle.
As DFW says: “The really important kind of freedom involves attention, and awareness, and discipline, and effort, and being able to truly care about other people and to sacrifice for them, over and over, in myriad petty little unsexy ways, every day . . . The alternative is unconsciousness, the default setting, the “rat race”—the constant gnawing sense of having had and lost some infinite thing.”
If George is right that over time we’re going to get kinder anyway, let’s “hurry up, speed it along, start right now.” It won’t be easy, but it’s the sort of medicine I aspired to practice.
Neal Maskrey’s early career was as a GP before spending seven years as a medical manager and part time GP. After 12 years as a director of the National Prescribing Centre and programme director at NICE, he is now honorary professor of evidence-informed decision making at Keele University, and consultant clinical adviser in the Medicines and Prescribing Centre, NICE.
Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I hereby declare the following interest: Employed part time by the National Institute for Health and Care Excellence.