Music hath the power to charm the savage beast that I am after a hard day at the coal face, and I'm relaxing, listening to the delicately beautiful piano playing of Bill Evans. In films I've seen of him, he sits hunched apologetically over the piano, in sharp contrast to the usual flamboyant style of most jazz musicians, but what he draws out of the keys is haunting and sublime. Rich and original harmonies that complement sparse melodic lines with not a note wasted. I can't imagine anyone not being moved by its understated beauty. Evans' music has a lot of links with classical music, there are influences from Chopin and especially the impressionist composers such as Ravel and Debussy, yet it is fundamentally different and the difference has its own coherence, meaning and structure. Not weakness, but adding to the quality of the music.
It reminds me of something that a past President of WONCA said — GPs are the jazz musicians of medicine. This expresses more to me about being a GP, about our strengths, our purpose and our uniqueness than any number of policy studies, focus group documents or working party reports on the nature of general practice. What we do is different too. A lot of our work is classical medicine, just the same as our hospital colleagues, but we are not general physicians in the community and what we do also has to be instinctive and improvised. Those who haven't experienced the complexity and uncertainty, that is routine for us, may see this as a weakness, but often it's our strength.
All of us have stories about times when things didn't quite add up in a consultation, something that stirred a sixth sense, that we weren't able to explain rationally to a hospital doctor at the time, but later turned out to be significant. I never learned about the ‘bag sign’ in medical school, but if I visit a patient and notice a bag already packed for them to go into hospital, it instantly tells me a lot about their ideas, concerns and expectations, and I ignore it at my peril. I spent many anxious nights as a hospital doctor worrying that a patient would die on me in the night, but now with terminally ill patients sometimes my worry is that they are going to survive in pain or distress, despite me having done everything I know to try and relieve their symptoms.
Some argue that focusing on the softer side of medicine is a cover that allows mediocrity and bad practice to remain hidden, but I think it is something that takes effort and experience to develop fully. Many of the best jazz musicians would practice for hours and hours to hone skills that would appear effortless and instinctive when they were playing, and we need to spend time learning, reflecting and discussing to enhance this side of our work as well.
Another parallel I see is that although Bill Evans was classically trained, he would have trouble playing back transcriptions of performances he had created spontaneously. Similarly, I think there is a danger of missing out if we try, or are persuaded to try, and codify everything we do and assume that only what can be codified and reproduced is important.
When I read in the medical or lay press, or wake up to an item on the Today programme saying that GPs are missing this or not diagnosing that or need more training in some area, I think of jazz and how what seems to someone outside as a fault, can be a skill. Many of us have an instinctive concern that evidence-based medicine has the drawback of medicalising more and more areas of life and that Illich may have been right about the more subtle and hidden harms we may be storing up. For many years, specialists and pressure groups criticised us for not being liberal enough in prescribing HRT and that women were losing out on all its medical and life enhancing benefits. What other good practice is waiting for major revision?
Listening to Evans helps to remind me that quality has many different forms, forms that are equally valid, but not always comparable or reproducible and sometimes even contradictory. But ignoring them will rob our work of its full meaning and richness.
- © British Journal of General Practice, 2004.