“How do you think of something to write every week?” someone asks.
Someone helpfully replies for me: “He doesn’t. He just rearranges the same one.”
Many a true word said in jest. But the themes of medicine are constant in time and geography. They are important but abstract, and completely ignored in medical education: doctoring is about reading people, knowing when to listen and act but also knowing when not to listen and not to act. At its core, doctoring is the willingness and requirement to accept responsibility.⇑
Balint’s concept of “the collusion of anonymity” is about medical responsibility. When many people or agencies are involved in care then responsibility becomes fractionated. The more professionals involved the more fractionated it becomes. Everyone is involved but no one is responsible, and the buck stops nowhere. Traditionally this was considered a problem from the 1950s, when patients became anonymous after they were admitted to hospital.
But this is a bigger problem today, and now the collusion of anonymity infects general practice. Continuity is a broken, forgotten, rusting hulk for simple reasons. General practitioners are opting out of weekend and out of hours duties, with part time work becoming the norm. This is increasing the total numbers of general practitioners. They simply know their patients less well. The coming corporatisation of general practice will see continuity all but washed away. Hospitals have the same difficulties but an additional problem too. The vast archipelago of new specialties (medical and nursing) comprises small, separate, distant islands with fiercely insular medical tribes. And despite huge expansion in consultant numbers regrettably they seem no more accessible. More resources, paradoxically, have made the problem worse.
Generalism has been dismissed as inferior, has been left fatally undermined, and is dying, if not already dead. Anything encountered that is outside the modern telescopic specialist training programmes results in referrals to other specialties, choking the system in needless referrals. But we can’t blame modern medicine because it only reflects modern society, which is risk averse, unable or unwilling to accept uncertainty, and left in a paralysis of indecision. There has been a homeopathic dilution of medical responsibility, and patients are increasingly anonymous and faceless in the NHS. The goal of personalised care is but a delusional myth. Today, there is no mere collusion but a systematic conspiracy of anonymity. This demonstrates another medical truism—developed societies get the health systems they deserve. So how do we make it better?