‘Cliché: in the printing trade, French cliché was a stereotype block: it was the past participle of the French verb clicher ‘to stereotype’, said to be imitative of the sound produced by the dropping of the matrix on the molten metal … perhaps the wisest comments on clichés were by Christopher Ricks (1980): “A cliché begins as heartfelt and then its heart sinks”.’1
‘Partnership is like a marriage’ had always struck me as one of the worst clichés, never remotely true and, subsequently, overworked to death. Others, however, have pointed out that there are some real similarities: for instance, how it is the quality of the relationship that dictates how everything works (or falls apart). Then again, we use the analogy because we have so few models for long-term relationships between equals, freely entered into.
On page 730, Davies extends the metaphor to describe the newer, more casual relationships that are becoming commonplace among general practitioners (GPs) in the United Kingdom. On page 740 a report on the different preferences between principals and sessional GPs, concludes that it may be difficult to agree a contract that caters for all. Having more sessional GPs is likely to mean more responsibility falling on managers, but the study on page 734 reveals some of the difficulties that will have to be addressed. Managers felt they had little authority to take on real responsibility, and weren't able to deal with strategic issues. Most worrying, Davies feels that the changes will leave those with a chronic illness comparatively disadvantaged.
The shift of emphasis away from the sick to the healthier consumers of health care, and the effects on the integrity of the medical profession as a whole, comes under scrutiny in Mike Fitzpatrick's column on page 795. The frequency of the Fitzpatrick column figuring in this Focus slot reflects my own sympathy with his views, but we should not be surprised if his style is not to everyone's taste. Thank goodness there are still outsiders to remind us of the benefits of working in the National Health Service (page 747). As Davies writes: ‘We can learn a lot … from how others see us’. Echoing Fitzpatrick, one feature of the French system that doctors found difficult was the need to please patients when everything is paid for by fee for item of service.
Although we consider time and again how contracts, working hours, and colleagues affect our work, we often ignore the physical environment and its effects on ourselves and our patients (page 798). Patients have more confidence and satisfaction with their care when the surroundings are calm and attractive, and the benefits can even be measured at a cellular level. For anyone planning changes to their surgeries there is a list of suggestions for the different spaces. That's followed by a piece on page 800 challenging all of us to improve access to our surgeries: ‘… have a look around your surgery and if you cannot see at least three things you could do to improve access then you almost certainly need some professional help’. Really practical and helpful stuff here.
For good measure, the study on palliative care on page 772 also offers simple, practical suggestions to ensure high quality care. Most patients want to die at home, but for that to happen patients and their carers must have access to competent professionals and suitable equipment. We could do better, but we should all take some pride in offering this service at all. Another satisfactory verdict is the accuracy of asthma diagnoses, which, in at least one practice, is commendably high (page 753). But before we all drown in a warm bath of self-congratulation we need to remember to consider the possibility of occupational asthma in anyone developing asthma for the first time as an adult (page 731).
Finally, for a bit of navel gazing there is another extended metaphor offered by Dougal Jefferies on page 793 describing the landscape of the Journal. I'm not sure whether having my monthly scribbles described as a lawn is a compliment or not. What kind of a lawn is this? The scene of decorous, polite tea parties, or the eternal struggle between the gardener and the advance of weeds? Or perhaps a croquet lawn, with ferocious conflict waged under a veneer of impeccably good manners?
- © British Journal of General Practice, 2004.