There are some quirky books around — I read one recently about ‘worst-case scenarios’. There were chapters about how to fend off a shark in the water or how to escape quicksand. It left me wondering what to do if I were attacked by a shark while stuck in quicksand! I think these books are supposed to be light-hearted but a part of me wonders if people might actually use them as reference books.
In today’s society ‘what if’ and ‘catastrophe thinking’ are everywhere. Worse perhaps are those poor modern parents, where thoughts of the worst outcomes seem to dominate their whole consciousness. The fear of not breastfeeding until the child is 5 years of age, the fear of gluten in bread, the fear of germs, the fear of not tutoring your kids, the fear of not going to university, the fear of contact sports, the fear of eggs, sausages, pies, sugars, skateboards, McDonald’s, the fear of not being popular, etcetera, etcetera. (Here’s an insight though: perfectionism is a parental disaster.) Society is caught in the headlights of fear — fixed, paralysed, and terminally indecisive. This is no more true than for health fears where said fears are supercharged by Google and all clicks lead to cancer or, at the very least, chronic incurable disease. The media offers no balance because fear sells. But here’s the truth: absolute poverty is banished (though maybe not relative poverty), we have all but eradicated infectious diseases, we offer screening programmes for all major cancers, smoking is on the wane, and vascular disease is in terminal decline. So what’s all the worry for?
But of course, medicine is different: rational, considered, and balanced. Surely we are not infected by this modern scourge of irrational fear and constant catastrophe thinking? Of course we are — perhaps we are the worst fearmongers of all because we are trained to think this way. The undergraduate education is hospital-bred and fed a constant diet of fear and blame from specialists who see the merest tip of the illness pyramid. Medical students are taught always to think of the rarest of illnesses, seeking smaller and smaller needles in bigger and bigger haystacks. Medical students are blind, with no perspective, no generalism, and, frankly, largely devoid of common sense. They have no knowledge of the natural history of illness and no concept of probability. They encourage testing, but all tests are insensitive and non-specific, leading to more insensitive and non-specific testing, which no one seems able to interpret. On and on it goes, picking up patients and families in a twister of fear and escalating rather than de-escalating every concern, ‘reassurance’ only coming from pain investigation and not experience. But this reassurance comes at the cost of anxiety for all. Today, doctors are pale, quaking, shivering professional wrecks.
We have a duty to the sick but an even more important duty to protect the well and we are spectacularly failing in this duty. But here I am being nihilistic; it’s not going to change because GPs used to unpick much of their training with concepts and phrases such as: ‘Common things occur commonly’, ‘The power of nothing’, and ‘Time as test’. But this is no longer happening and GPs are increasingly aping hospital care in the name of best medicine and fear of not following guidelines, which is disastrous for low-risk populations.
Overtreatment and overdiagnosis are the new norm. Catastrophe thinking is hardwired into doctors and this is truly bad medicine for all of us.
- © British Journal of General Practice 2017