Exculpation via medicine?

“Full willing was he to give penaunce

There as he wist ye have a good pittaunce”

With these words Chaucer damns the Pardoner in Canterbury Tales. In this essay I want to damn his latter day followers who in this secular age indulge their patients by supplying them with that modern equivalent of indulgences, the doctor’s note.

Indulgences were sold to achieve expiation and exculpation from sin. Convenient for the sinner, and profitable for the Church. Unfortunately they came to be sold widely and cheaply for profit, and eventually there arose scepticism as to whether St Peter would read them at the Pearly Gates Clinic for Reformed Sinners. Indeed there even grew up a view that he might treat such papers with contempt, as showing a lack of integrity and no effort at all at any kind of thinking, let alone the hard thought needed for repentance. Shakespeare described it thus

“I knew one Devil, that could equivocate in either scale, against either scale, but still could not equivocate to Heaven”

How many of us poor medical devils, the modern world’s secular clergy, are trying to equivocate in various scales against various scales to various outside bodies on behalf of our patients? What notes do our medical notes strike?

The main function of our medical notes is exculpation, to get someone else off the hook about deciding about something. Should I let this lady into the Jacuzzi? Better ask the doctor, just to be safe. Eric Wilkes pointed out that GPs are ideally placed both to be reassuring and to take blame when reassurance turns out unjustified. Better safe than sorry and you cannot be too careful nowadays can you? Actually yes you can, and if this is the way the public behaves, then patient empowerment as a goal of policy is an utter delusion.

The drive in our times is to avoid consequences, avoid responsibility and to be reassured. We seek to avoid our own version of the Garden of Gethsemane, and to have every cross taken away from us. “Ooh you might get splinters,sir, and there’s a tetanus risk from those nails. It is rather a heavy burden to carry isn’t it?”

Yes it is, and that is precisely why it matters to carry responsibility, to learn to handle consequences. Life, health, vitality, and empowerment all depend on accepting the responsibility to accept consequences. Accepting feedback is the way of learning, and achieving growth. Anything which stops us from doing this is acting against us achieving our potential and is fundamentally unhealthy to us.

Our current culture is discouraging us from doing any of those things, and this diminishes us as people, diminishes us as a society, and leads to a general feeling of helplessness. This feeling of helplessness then drives another round of seeking advice just in case, more avoidance behaviour and return for extra reassurance. Have you wondered how the more reassuring you are the more people return to you for more reassurance? Of all disciplines medicine is the least reassuring. It describes tens of thousands of diseases by which you can die and no way of being healthy. Why does anyone come to a doctor for reassurance? We cannot give it with conviction, we know too much, and present fears can easily turn into horrible imaginings. To all the neurotics who are worried they might have a disease, don’t worry as one day you are sure to be proved right.

The drive for a doctor’s note is the symptom of this epidemic neurosis in our surgeries. The demand for secondary confirmation of every statement shows just how afraid we have become of other people and our judgement as to whether they are honest or not. We trust neither ourselves nor others and instead we turn to the doctor to bail us out.

What doctors haven’t told you yet is that they don’t believe half what they hear in their surgeries. We repeat what the patient has told us to outsiders. (with patient consent of course, but confidentiality seems of very low value when someone might get an insurance payout or more benefit by telling all and sundry about their dreadful disease!)

We have no independent means of knowing whether the patient is telling us the truth or not. So our comments about a patient’s capacity for anything should not be taken as pure truth. The doctor cannot act as honest broker about illness and its effects and we need to step back from accepting this role that society is trying to thrust onto us.

At a time when we are being scrutinised to provide ever quicker access to the doctor we really need to ask the question “Access; for what?” These note requests are absurd, and a misuse of doctors’ time and energy. They are increasingly common and taking up a lot of appointments unnecessarily. They distract NHS staff time and energy away from clinical and organisational priorities (e.g. NSFs, diagnosing and managing illness) and squander it on useless paperwork that really achieves nothing for anyone. Is this really the kind of service Gordon Brown thinks he is buying with all the billions he is pouring into improving the NHS? Is this what the treasury and DOH want to achieve? A service that acts as universal excuse generator for patients, employers and councils? Another cog in the great bureaucracy of British life.

“These things must not be thought of after this way. Methinks it will make us mad” So said Macbeth, and I think he was right. We need to get out of this idiotic dance of asking doctors to arbitrate on things they know next to nothing about. Stop asking us to make decisions for other people and organisations who could, should, and actually do know better than any doctor what they need to know.

And where medical information is needed it must be requested formally by the organisation that wants it with a named contact, and an assurance to pay the appropriate professional fee for provision of information.

A doctor’s note may get you out of some problems in this world but I am sure that ultimately, at the Pearly Gates, St Peter will look at your doctor’s note and laugh. I am sure that some of his good sense will percolate down into this world.