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Edward: shot in his own interest Technototalitarianism and the fragility of the therapeutic danceDavid Zigmond MB, ChB, MRCGP, DPM Liaison Psychiatrist, Hammersmith Hospital and Principal GP, Bermondsey, London Summary
Eric Hoffer, The Ordeal of Change (1964)
Bertrand Russell, Unpopular Essays (1950) It is well past midday. For nearly four hours I have variously survived a chimeric procession of human contacts that push and crowd a Monday morning GP surgery. I am turning light-headed, retreating with compassion-fatigue, and losing my sharper abilities for convergent thinking. When Edward enters I know I will have to recover my receding faculties, if we are both to feel well-disposed to one another. Edward is a complex man, and has long evoked much frustrated confusion in those who attend him. His large physical frame has carried his 82 years mostly with great reliability and robustness but, I sense, without much expression or pleasure. His physical complaints of mild hip arthritis and angina have been well suppressed by usual current treatments. Not so his 'illness behaviour'. Edward's frequent attendances, over many years, despite his lack of serious illness, had first perplexed, later irritated and finally enervated his previous doctor, Dr T, a man long admired for his good-humoured restraint and diplomatic wisdom. With Edward, Dr T tired from an attrition of his higher powers; his colleagues sighed with relief when he declared an uncharacteristic abandonment of this 'heartsink patient'. They had secretly and individually feared far worse. Edward, removed from Dr T's list, was assigned to mine; a blind and involuntary coupling. Six years later, I have identified and commiserated with Dr T, his travails and honourable self-discharge. Edward has been a 'difficult' man, often experienced as contrary and contradictory, ambiguous and ambivalent: his neediness mistrustful, his responses to attention often spikey and diminishing. Beneath this surface of confused signals and contacts, I have imagined a life of thwarted yearning, of previous struggles, and now, turbulent submission. Edward does not want his private life probed, but he does, somehow, want it understood. He recurrently declined invitations to enter the more directly investigative and interventive domains of psychiatry and counselling. Early on in our encounters I framed these suggestions, I smugly thought, with much skill and artistry. His retort was tart: 'I'm no more crazy or disturbed than you, doctor’. I had insight enough not to contest him. Explicit enquiry remained subtly parried. My interest in explanatory history, or explicit portraiture, would not be met. I was slow to learn that well-travelled approaches of medicine, psychiatry and psychology could not help me to help, or even contain, most of this man's complaints. I was in the world of the shaman and the cryptographer. In the analogy of journeying, I was now confined to the use of narrow winding tracks in poor visibility over uneven, often steeply inclined, surfaces. The steady, even, well-lit, straight, broad roads of 'conventional' medical practice were elsewhere. Off the major thoroughfares, hazards are more numerous and various. To stay on such paths requires vigilant anticipation and attention. With Edward I learned to offer him not just the usual, pre-packaged questions, explanations and reassurance, but also bespoke medical ritual and respectful play. Lingering over a manual (not electronic) measurement of his pulse and blood pressure was usually unhelpful medically, but offered a form of structured, caring touch and contact that was tolerable and safe for this lonely and armoured man. 1 learned, too, of an acerbic and anarchic wit beneath his previously gruff, combative presentations: our banter developed an accompanying, unspoken affection. I was rewarded for taking The Road Less Travelled. He agreed to come every two months for 'routine review', and stopped his more frequent opportunistic, antagonistic attendances. Receptionists reported a baffling patience and politeness. I cautiously enjoyed my brief but regular appearances in a marathon role as secular priest. Edward became less querulously hypochondriacal, his presence in the room was lighter, his gaze softer, he left the room willingly and without a trail of unfinished, unspoken business. He stopped being a heartsink patient. I thought often of the innumerable ways that we humans devise for engineering contact, but ensuring structure and optimal distance between us. Intimacy threatens more dangers than most of us wish to acknowledge. ooooOOOOoooo When Edward enters, I am marshalling the end of my working energies. Not only must I redirect myself to our uneven, tortuous track, but I am running out of fuel. I remind myself of the probable importance of this visit for Edward, and conjure sufficient attention to satisfy us both. As Edward seats himself, there is a brief, silent peace between us. This is punctured by the imperative trilling of the telephone. Yet another distraction: I am aggravated. The practice manager's voice sounds courteously singsong but curt and peremptory: the fresh vigour of new authority, a commissar of the New Contract.
As she rings off I experience a flush of impotent, irritated resentment. Instantly, and without design, I amplify and caricature my instructions; a contagion of uncoordinated authority. I speak to Edward with unprecedented suddenness; firmly, clipped and without compromise: 'Stand up, take your shoes off and stand over there, with your back to the wall'. Edward, startled by abrupt change, involuntarily winces, stops his breath and jerks back in his seat, as if struck by a sharp stone. With silent obedience he stands, shoeless, where instructed in front of the measuring rule. He looks frightened and gulps.
Fortunately, my relationship with Edward has survived this (partly) comedic convergence of mistiming and misperceptions. I never established how much Edward's notion of his 'execution' was transient fantasy, and how much it was darkly surreal humour, mocking our relationship and my job. Aside from such idiosyncratic factors, more general and important themes can be perceived. As with many executionees, Edward was haplessly caught in a cross-current of two very different approaches, occurring at a time of rapid change and reorganisation. The first represents my efforts in the art of medicine: consultations that are private, individually crafted and attuned, often using data which is personal, transient and unquantifiable. This approach is at the heart of empathy, creative (more than 'satisfactory') dialogue and healing. Its language may be rich and varied, but correspondingly inexact or ambiguous. The second represented the practice manager's endeavours to impose a publicly formulated science to my consultation. The activity here is standardised, quantifiable, mass-produced; heedless of unprogrammed individual variables, and conveyed by language which is neutral, exact and deliberately restricted in vocabulary. Such lies at the centre of 'hard' research, treatment procedures and public health measures. Between individuals it can garner very particular knowledge, but it is unlikely, unaided, to lead to a growth of emotional or experiential understanding. The tale has other valuable, metaphorical pointers. The practice manager's executive intrusion into, and redirection of, my multi-layered and fragile dialogue with Edward is a microcosm of many dilemmas posed to contemporary healthcare planning and provision. That systematic data-collection, measurement and 'evidence-based practice' should be a cornerstone of safe and effective practice is now axiomatic. But a cornerstone, crucial as it is to a building's integrity and stability, can only function purposefully if securely attached to walls running in different directions, which are themselves attached to other cornerstones. A cornerstone not thus related has little useful function. Asking for Edward's height was a redundant cornerstone of activity, but one which involved team effort. At 82 years, his height can only change by amputation or involutional shrinkage. Otherwise it is a stable bit of data, of no use or interest diagnostically or therapeutically. The systems, which automatically and rhetorically demand such data, and the mind-sets and social-structures that develop in response to these, are of greater significance. ooooOOOOoooo Sheila is the locality-manager for general practitioners in my area. More than a decade ago she had several years of various nursing experiences, and has since equipped herself for her executive role with further training in organisational management, and a wardrobe of demure, but sharp, dark suits. She is a pleasant, intelligent, open-faced woman, focused and efficient in her work. I imagine she is ambitious for promotion and will soon succeed. Currently, a large part of her job is to ensure conformity to the burgeoning requirements of the 'New Contract'. She comes to meet with my manager (Kate) and I, to 'encourage' such compliance. Our meeting is brisk and mutually respectful, the agenda completed rapidly. This yields an unprepared and unstructured hiatus of time. I want to describe my recent story of Edward's 'execution', partly for light relief and partly because, beneath this small-scale surreal drama, larger themes and forces have aroused my curiosity and unease. The light relief comes with a gust of shared laughter. We are laughing, I think, at the improbable and the absurd. We are laughing, also, for some respite from our own burdens, fears and spectres. The fear of harm-through-care is especially dark and universal. So, too, is the awareness of our tinsel-like autonomy, evident when we perform acts, knowing them to be futile, even harmful, because a 'higher authority' demands and monitors compliance. The example of the mandatory measurement of Edward is small but instructive. He is an intelligent, alert 82-year-old with a vigilant awareness of his bodily processes, and the kind of care he is receiving. Measuring and weighing Edward makes no sense to either he or I. It is the group's submission to the diktat of a distant planner. In themselves, these activities are neutral and unlikely to harm, but enacted in an industrialised or authoritarian manner, any procedure risks eclipsing or extinguishing more personal reflection or communication. It is hard, then, to combine mass-production with mutuality; corporate compliance with fertile dialogue. The seismic effectiveness of applied science and mass production in the last century is matched closely by the reciprocal decline of individual craft and non-performance art. Generally, occupational activity is said to make 'progress' when individual dexterity, judgement or intuition are replaced by mechanised or electronic precision and speed. In medical practice there are areas of diagnosis and treatment where such 'progress' is hardly to be questioned: the intensive care unit, the lithotripter, the MRI scanner, are clear examples. These cumulative medical triumphs are the evolved legacy of Newton and Brunel; a medical model of applied and empirical science; biological engineering. Here 'diagnosis' is made objectively, by observation and measurement from the outside. Similarly, 'treatment' is mediated by a manipulation of 'external agents': chemicals, lasers, radiation, scalpels, stents, sutures and so on. This kind of medical model assumes engineering principles, and operates from outside the person's subjective experiences; such experiences may be dealt with courteously, but are usually thought of as distractions from the 'real work'. As with other forms of engineering, it is readily conveyed by authority, instruction, management, hierarchy, flow-charts, pie-charts and algorithms. It has its roots in scientific determinism, and has been ineluctably successful in our 'control' of many serious and demonstrable physical illnesses. But there have always been a large (the larger?) proportion of people who seek help, but are not so afflicted. These sufferers of dis-ease, dis-equilibrium or dysfunctionality often cannot be understood or relieved by such objectively conducted bioengineering. If we are to have any success in these areas, we must somehow address the inner psychic and experiential world of the other; not just their fears, conflicts, fantasies and dreams, but also their positive, self-generated resources for immunity, growth and repair. Such (re)generative capacities operate at both psychological and physical levels, and are sensitive to many influences. The importance of these factors is not matched by their poor accessibility to biometric sciences. Even psychoneuroimmunology, a sophisticated sounding mouthful, often manages little more than attempts to define, in pathophysiological terms, micro-mechanisms for larger pictures, such as ‘people who feel hopeless are more likely to get ill, from both trivial and serious illnesses’. It remains the art of attunement that helps the hopeless person feel that there can be positive possibility in contact, and to wish for a wider empowerment in their fate. It is the art of conveying faith, hope and charity* that can catalyse the other to heal and grow. This is a world more of induction that conduction: an inter-subjective realm of energy fields, transponders and eco-systems. Here a person's illness or difficulty may be understood and influenced by attention (not always directly) to their personal inner-world and relationships.
In this dimension of medical practice, the art of the consultation itself may become a powerful source of understanding and change. Like any art, it cannot always be applied, and thus cannot be mass-produced. Often it evolves by dancing in the dark; a coded bond, an improvised choreography – such activities are akin to living organisms that are delicately environment-specific. Attempts publicly to illuminate, transplant or formulate are likely, inadvertently, to distort or destroy As in the world of agri-business, the industrialisation of living processes in medical practice can offer high yields, but there are serious dangers. We have to take care not to mutate adversely, not to poison in the process of our crop's provision and protection, not to obliterate bio-diversity in our engineering of monocultures. This latter consideration is not merely important for our aesthetics and souls; casual destruction of other life forms – 'collateral damage' – may have an amplified echo through surrounding eco-systems. Hedgerows and trees are not just sources of beauty and wonder; they also prevent soil erosion, thus enabling our crops. Politicians, health economists and service planners necessarily make decisions for thousands or millions of individuals; their task-view is like that of the owner of an intensely-farmed vast prairie. The individual practitioner's view is much smaller, his understanding more intimate. On this scale the hedgerows can be preserved and tended; human idiosyncrasy is here both familiar mystery and essential currency.
A final squeeze on this metaphor; the practice-manager was like a 'beater', harrying creatures concealed and protected in the hedgerows out onto the open plains for dispatch. Edward's stark fantasy, ‘I thought you were going to shoot me', may refer to the vulnerability of both his own life, and the few relationships that he believes sustain him. ooooOOOOoooo My friend, Charlotte, gazes glumly to the bottom of her glass. The last drops of a mellow, fine claret. In her early 50s, she is an attractive, accomplished example of contemporary professional womanhood: bright, candid, warm, funny, compassionate, resourceful and strong. She is surprised, she says, to hear herself talk of giving up her job as a general practitioner and trainer. For years it had been a love of her life; the investment high, the rewards deep. She had not imagined changes that would so deplete her motivation, her hope.
I offered her simultaneously more misery and commiseration: a sampling of my own experiences and concerns. She became encouraged by our joint gloom
ooooOOOOoooo Sheila seems a willing recipient of my lunchtime panorama. I describe the two metaphors of Edward's shooting and Charlotte's ants’ nest. They usefully capture a zeitgeist, an emerging world of paradoxes where the 'ordinary citizen' is increasingly restricted and controlled by the same technology that is designed for his benefit: a high-tech cuckoo in the nest. A new totalitarianism. Not framed by grand and dangerous ideologies, nor delivered by evil demagogues as had so shattered and terrified the earlier twentieth century, this current totalitarianism is administered by such apparently benign beings as Sheila, Kate and myself – conscientious officers in a democratic state. On reflection, all participants agree that the weighing and measuring of a healthy 82-year-old man makes no sense to any of us, but diverts us from things that do. It is the computer program that increasingly decides what we should do, and how we are performing. The individual's judgement or wish – however well-intended, designed or considered – is simply irrelevant to the computer's executive demands and monitoring. This is technototalitarianism; electronically coordinated mass-management. The enthusiasts and advocates of this regime are likely to talk, realistically, of increased efficiency through compliance, clarity and precision. What they do not talk about are the unwanted side effects. At their most mild, these are manifest as superfluous and redundant activity and data; this is akin to the current over-packaging of groceries, creating waste and clutter. The more serious side-effects are those common to many command-and-control systems; they tend to run counter to flexibility and creativity. For the IT-saturated practitioner, this can easily lead to a production-lined and humanly impoverished degradation of contact skills, where individual faces are not remembered, important stories not listened to, voices not heard – the institutionalised and narrow-gazed behaviour of healthcare factory workers. Such command-and-control mindsets are inimical to the types of encounter likely to induce autonomous growth and healing. These inductions are fragile processes that require communications often more resonant than explicit, more artful than automatic. Imaginative receptivity here is crucial and cannot be pre-programmed. In the realms of general medical practice and psychiatry in particular, consultations generated in this way lie at the heart of ancient forms of how we may best understand and help others. Many difficulties currently arise through this genus of activities being dys-compatible with mass-production, statistical research and electronic-management technologies. For all this, they require our special protection, rather than extinction through neglect and destruction of natural habitat. Treatment can be readily mass-produced; healing rarely so. Ensuring co-existence of these approaches requires much corresponding imaginative receptivity from our planners and managers. ooooOOOOoooo It is time for us to stop. Sheila must return to debrief with her own managers; reporting on her management of me, our 'progress'. She frowns, and then purses her lips as she gathers and packs the vast scattering of data-dense papers that guided the earlier part of our meeting. She gazes at the heavy pile, symbolically I think, before turning to me, a smile intelligent with sentience and sympathy.
This tease-in-the-tail is her offering of consoling irony, not hierarchical sarcasm. She sighs with both fatigue and, I imagine, undisclosed complicity. Her voice is less resolute now.
We are both, for now, too tired and busy to attempt an answer.
Nigerian Proverb
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