I have to confess that it is not often that reading anything in the BJGP changes my practice or even arouses more than a flicker of curious interest. However James Willis's review1 of The Master and His Emissary by Ian McGilchrist2 inspired me to read the book, which has in its turn set me thinking about much that I encounter both as an individual and as a GP in a new light.
McGilchrist's thesis is that our brain has two complimentary halves which approach the world in different ways. The right cerebral hemisphere is more concerned with connection and the bigger picture, while the left hemisphere is concerned with the technical, the detailed and the straight line. These two functions need to go on separately, but also need to be integrated and there is no sense in which one is better than the other. However the left hemisphere is unable to appreciate anything new unless it has been presented to it by the right. Information processed by the logical left needs to be returned to the right side for it to be integrated into the bigger picture. Now whether this is functionally and anatomically correct or not (McGilchrist provides ample evidence that it is), the point is that is how human thought often proceeds. He also demonstrates that while the right hemisphere appreciates the existence and function of the left, the reverse is not the case. So patients with right hemisphere damage are dependent on the left hemisphere. They do not recognise the problem nor do they acknowledge the existence of the part of the body served by the right hemisphere (for example, left side of the body).
The second half of McGilchrist's book goes on to draw parallels between this and the way civilisations have behaved and thought. Sometimes we have been dominated by interconnections, the world of intuition and even superstition; at others logic alone prevails, and the heads of saints and monarchs roll in the gutters. Currently the left brain is in the ascendant and while we are not currently decapitating our rulers, we are destroying much of value for the rationalist goals of economy or progress.
So why has this made such an impact on my everyday thinking? Principally because it allows me to understand in a new way some of the things that seem to be going on unchallenged, and which provoke a reaction in me that is known by family and partners as Grumpy Old Doc or GOD for short.
We have recently been visited by the infection control team. Various suggestions, or rather imperatives have been delivered, many of which make perfect sense, but some appear to be totally one sided without any recognition of a counter argument. So we are no longer allowed a pillow on the examination couch or a blanket to give a near naked patient both warmth and modesty, something not achieved by what amounts to an overgrown loo roll. Now I am as keen as anyone to reduce the incidence of infection, and particularly the ‘super bug’ infection in my patients by all means reasonable, but I do not think it is reasonable for an 80-year-old kyphotic lady with abdominal pain to have to lie near naked on a couch without support for her head. Nor do I think it reasonable for a small rural practice to have to launder blankets and pillowcases every time they are used. Good medicine is practised by making individual personalised decisions on a case-by-case basis with due regard to the evidence, not by sweeping statements and dictat that ignore the bigger picture. To my knowledge there is little or no evidence of the role GP premises and couch pillows play in the spread of infection. However, this view is not heard. Similarly, toys in the consulting room are now discouraged due to the spread of infection. How are children going to educate their immune system if it is not by shared toys? Isn't that why they go to play groups?!
Is it too far to extrapolate from McGilchrist's learned work to the rumbling of a disenchanted GP about being told what to do? Let's try another example. Jean is a sad lady in her mid 70s with a dog, COPD, and an alcohol problem. When she is at home she smokes and drinks herself to the edge of death, falls over and calls an ambulance, which then takes her to hospital. There she gets better and is reasonably happy because she is being looked after, as long as she still gets her gin and the neighbours look after the dog. She won't go into a home because when she is sober she denies there is a problem, and because she would have to give up the dog in the home. She is costing the PCT a fortune and although she is getting good care in hospital it is dependent on her being in crisis and it is not appropriate. When assessed for continuing care she is always in hospital, sober and on the up, and consequently does not qualify. The left brain straight lines of logic are: crisis = 999 = hospital; homes paid for by the state don't take dogs. Human rights and a belief in individual autonomy = we can do nothing to stop an individual who continues to drink themselves silly and expects the emergency services to pick them up. Anyone looking at the situation knows it is crazy. Why can't we pay for her to go into a home where she can have her dog and her gin in moderation? It may be paternalistic but she would probably be happier, we would be using far less resources, and delivering better personal care.
Now you can argue until the cows come home about whether that sort of paternalism is morally right, that is the nature of right hemisphere stuff; there is no simple yes/no answer. However there can't be a single GP reading this who doesn't know at least one Jean on his list and probably half a dozen.
According to McGilchrist's thesis we are often locked into a left hemisphere view that denies the possibility of there being another perspective. Consequently we in the NHS go on creating more and more cumbersome logarithms and pathways to deal with imagined clinical situations, all based on single diseases or problems, while the reality is that our patients are complex individuals, and are part of a complex and interconnected social web. As practising clinicians we know that these models can only take us so far, and then we need to offer our patients care and help that relates to the individual facets of their lives, based on experience and humanity with a good dose of common sense.
- © British Journal of General Practice 2011