When the going gets tough
Predicting the consequences of COVID-19, intended and unintended, may be best left to those with ready access to tea leaves and sacred entrails. Immediate possibilities spring to mind: the wholesale reconfiguration of practices to telephone triage and video consultation will surely leave its mark and the economic cost will colour politics for a generation. As George Monbiot commented: ‘it may not be true that there were no atheists in the trenches, but there are no neoliberals in a pandemic’.1
The post-pandemic rebuilding could be transformative — but surely the NHS can’t stomach another decade of austerity.
One remarkable moment, among many, was when we graduated our final-year medical students early so they can be tossed into the COVID-19 fray. I had spoken to them a few weeks earlier on burnout. I offered them my best soundbite on surviving medicine, one passed to me by a trainer: When the going gets tough … lower your standards.
This, if I get the comedic pause right, will usually raise a laugh but, I explained, it isn’t a free pass to do a bad job. We do have to be kind to ourselves, and recognise the toxicity of perfectionist traits in a constrained world. It feeds into my warning to them: beware the cult of medicine.
The cult of medicine
In normal times, when our medical students graduate they all recite the Declaration of Geneva. It is undeniably powerful and the emotional response it provokes is strong. It makes the hairs on the back of my neck stand up. And that makes me suspicious. The Declaration of Geneva was first adopted in 1948, was last amended in 2017, and is a general declaration of the humanitarian principles of medicine. One can’t argue with the words but I find the group-chanting creepy, if not outright sinister. It is a technique beloved of populists (and the Boy Scouts). It is the medical profession’s version of the Trumpian ‘lock her up’ incantation. Welcome to the cult.
The cult of medicine is exclusive and it is about power. Proud parents, friends, and the non-medic staff that taught those students are excluded from the Declaration of Geneva. Intentionally, it reinforces the specialness of doctors. It is a powerful psychological lever that few of us are willing to stop pulling, like addicted rats in a maze starving themselves for a dopamine hit. One might argue it is a piece of theatre, a harmless ritual. Yet, who benefits? We don’t need to drop the principles; we just need to abandon the initiation rites, as these may harm more than help.
Re-shaping the profession
Cults have strong identities. It’s hard to get in and it’s also hard to escape. The cult of medicine sets unrealistic personal targets, stops medics seeking help when they need it, and we shun those who deign to leave. The cult of medicine discriminates against women who shoulder the burden of caring responsibilities in society and still face the ‘second shift’.2 We may not have a single charismatic cult leader but we have our substitutes: typically a white male, privately educated, intimidating and bombastic, he may be wearing a bow tie, and he’ll rail against part-time working or portfolio careers. It’s a caricature but I’d wager we can all name a doctor or two who springs to mind.
COVID-19 has shown how we can bring people back into the profession and we need to strip back barriers to entry, re-entry, and retention. We need to address the 7% problem and recruit more widely across society.3 We need training and working patterns that work for all. NHS and care workers are, quite understandably, being lionised in the time of COVID-19 but we can’t be excluded from the consequences of coronavirus.
The pandemic could herald a radicalisation of the GP model but the real societal gain would be if we grasp this opportunity to be a more inclusive, and ultimately less cultish, profession.
- © British Journal of General Practice 2020
