“I don’t know how you do it,” says one friend, trying to sympathise. “I don’t know why you do it,” says the other. He has always been more cynical. “Spending all your time with sick, scared, angry and ungrateful people. Not to mention all the negative media coverage. And all for a fraction of what I get paid.” He works in the City. “You must be mad.”
He has a point. Several points, actually. Doctors have always dealt with the sick and the scared. They are our constituency and that will never change. And anger comes with illness as surely as pus comes with bacteria; it is the anger of impotence and fear, a gnawing, non-specific anger that as often as not finds its target in those who are trying to help.
But what about the ingratitude, the widespread mistrust, the feeling that doctors are no longer valued as much as in the past? These feel more recent, products of fundamental shifts in society and its mores. Yet these, too, have deep roots that run back to the distant past. Healers have always been feared for the power they possess to alter the natural history of disease, for good or ill. The ethical provision of both Western and Eastern traditions – of the Hippocratic Oath and the Charaka Samhita – are attempts to circumvent those fears and reassure patients of their doctors’ good intentions.
“Wait a minute,” says my cynical friend, “why are books with titles like The Trouble with Medicine or What Doctors Don’t Tell You so successful? Why are the osteopaths and the aromatherapists and acupuncturists raking it in?”
Again, I explain, this is nothing new. The first flowerings of experimental physiology were contemporary to the first stirrings of homeopathy. Both had their origins in disillusionment with 18th century polypharmacy. Thirty years after the publication of Ivan Illich’s Medical Nemesis, the appetite for books and television programmes exposing the limitations and failings of modern medicine appears undiminished.
So, yes, there is, and always has been, plenty of material to load on the negative side of the scales. But, equally, there have always been sufficient positives to ensure that we carry on doctoring. Certainly it is true that some of the compensations and comforts of the past no longer apply. The financial rewards of modern medicine (in Britain, at least) rarely match those of the era of the gold-headed cane or the top hat and morning coat. Being a doctor does not carry the social cachet it once did, though we are still better regarded than lawyers, journalists, and the like. Nor can we take refuge in scientific progress: Illich, McKeown and their contemporaries effectively deflated the confident assertions of scientific medicine that sustained us through much of the 20th century and which, for all the proselytising of its supporters, Evidence-Based Medicine will never be able to replace. So why do we do it? What gives us hope, inspiration and protection? What can we put on the positive side of the scales?
Start with the practical things. Simple jobs well done. A pain-free cannula. A first-pass lumbar puncture. A clear history extracted from a rambling informant. A clean, steady ECG. Truly informed consent. A dignified but thorough examination. A central line or nasogastric tube in the right place. Basic life support. Diagnosis and prognosis explained and understood. Successful defibrillation. The relief of salbutamol, frusemide or oxygen. Accurate notes. A nearly invisible appendicectomy scar. Weaning off the ventilator. Writing the death certificates and cremation forms without delay.
Add in the times when, however briefly, everything comes together and fits. The unifying diagnosis. The pathognomonic physical sign. The collateral history from the relative or partner that makes sense of the disparate stories spun by a delirious or demented patient. A brief word of thanks. Complex changes in drug regimes achieved because you took the time to explain them and write them down. The searching look in the eyes of someone hoping for comfort or a cure. The comradeship of colleagues. And last, but not least, the glorious uncertainty of it all. The knowledge that tomorrow will never be the same as today. That death can be cheated and joy can come as often as despair. These are small victories, insignificant in themselves. But together, they tip the scales. And so it happens that each morning I offer up a prayer (admittedly an agnostic one) to the God of Small Victories to sustain me through the day. And that God (indulging my agnosticism) has never let me down.
“That may sustain you,” says my cynical friend, “but what about your patients? Don’t they need you to have greater vision or higher ideals? Shouldn’t you offer them a bigger picture to sustain faith in the profession?”
I don’t know the answer to that question. But if the history of medicine teaches us anything, it is that grand designs and bold promises lead, almost invariably, to failure and disillusionment. They offer hope, but unrealistic hope. If we ask our patients to recognise our small victories, we keep our relationship with them on a human scale. Then, if we fail, as we often do, we only have to cope with human failure. That, to answer my sympathetic friend’s question, is how we do it.
I wrote this short piece twenty years ago for a writing competition run by the British Medical Association, the doctors’ trades-union in the UK. I can’t remember what the brief was, but I do remember that it didn’t win. I suspect the tone was not quite what they were looking for.
Some things have changed in the interim. The critique of medicine has perhaps evolved from philosophical concerns regarding the inappropriate medicalisation of society and the role of doctors as agents of social control, to more concrete problems, such as the scandals relating to the retention of children’s organs at Alder Hey Hospital in Liverpool, or the poor care and high mortality rates at Stafford Hospital, which became the subject of the 2013 Francis Report.
Some things remain the same. Doctors continue to be among the most trusted public servants, and the NHS continues to be held in high regard across the whole of British society, even while the amount of the non-clinical work done in the Service being outsourced to private firms has continued to increase rapidly.
The small victories that I listed are very much those of a junior doctor in training. They are predominantly practical achievements, arising from the daily activities of life on a hospital ward. Were I to list my small victories now, they might revolve more around the exigencies of life in outpatient clinics and administration (though I still perform lumbar punctures and continue to derive inordinate pleasure from a painless crystal clear tap). But the principle point of the essay – that the frustrations, irritations, and inadequacies of life in medicine are on average outweighed on a daily basis by the joys that it brings from minute to minute, and hour to hour – remains as true for me today as it did then.