‘Thanks.’ Philip’s tone was indeterminate.
‘No but think about it.’ George was suddenly intent and quiet. ‘When she started to need a doctor it obviously couldn’t be me because I was friends with her. Which left you and Sara. And I didn’t think she and Sara would get on.’
‘No.’
‘And then I thought about you, and I thought, first, that she’d enjoy trying to provoke you, and then that you might find her interesting. Because I know I said it was hogwash a moment ago but actually she did have quite a well developed analysis, didn’t she? The problem was it was completely unrealistic.’
‘What’s odd though is that, well,’ said Philip, setting about getting the thing clear: ‘her ideas were pretty much formed in the nineteen-forties, weren’t they, and fifties. And yet they are still relevant now, or in a way they are more relevant. Like patients using the doctor less, taking more responsibility for their own well-being. Oh, I know in a sense it’s old-fashioned. Stiff upper lip, grin and bear it. Given her politics I’m surprised how much of that attitude there is in her, was in her.’
‘Two things explain it,’ said George, with certainty: ‘Age and class.’
‘But here’s the thing – with the internet, it makes more sense. Because with the internet, everybody suddenly knows a lot more.’
‘No,’ said George, with a surprising up-and-down intonation as though he were telling off a child: ‘No they don’t.’ And then more plainly: ‘They have more information. Which is absolutely not the same thing. Especially when most of it is wrong.’
‘No but for instance,’ said Philip, unbowed: ‘a man I saw yesterday. Perfectly ordinary bloke, I’d say he worked as a builder. Came in and sat down and said: “I think I’m at risk of prostate cancer and I need a DRE and a test for PSA.” That’s what he said, “DRE” and “PSA”. And it turned out he was completely right, his interpretation of his symptoms was completely right. So I turned him round in five minutes. Whereas before, well, the consultation would have taken longer, there’d have been a lot of hurdles to jump. But more than that, he probably wouldn’t have realised there was anything wrong in the first place, not until it was too late, till he was pretty much unable to pee.’
‘Yeh but how many’ – George had heard it all before – ‘compare how many times that happens with the number of times you have to say to people, I’m sorry, essence of rhubarb is not going to cure your cataracts. Or’ – he gestured in the air to grab another example – ‘by all means apply feng shui to your bathroom but don’t expect it to have any effect on your arthritis. It’s ten to one Philip, it really is. And then’ – he was miming exasperation – ‘you finish your diagnosis and they resist you. They brandish a printout. They say: “But doctor, it says here . . .” Just because they found it on a computer screen they take it as gospel.’
‘OK,’ said Philip, shrugging, lifting his voice a little, admitting that there were two sides. ‘Still, I think’ – emphasising the ‘I’ – ‘that it’s more good than bad.’
‘Whereas I think’ – George echoed his intonation – ‘people should accept the doctor knows best. That’s why we went through seven years of training, for heaven’s sake. That’s why we spend our whole time looking at sick people and working out what’s wrong with them. It counts for something. And you should realise that too’ – he said, getting up, going to the bar for another drink – ‘what’s wrong,’ he said loudly over his shoulder, and then turning so that he was walking slowly backwards: ‘what’s wrong with actually knowing something, with having expertise? Why’s that something to be ashamed of, all of a sudden?’
As the sound of George’s voice took whatever little time it took to travel through the air towards him, and down his external auditory meatus, and strike his tympanic membrane which agitated his ossicles which vibrated his cochlea, so that the hair cells of the organ of Corti translated this physical wave into chemical-electrical nerve impulses which the brain then could somehow understand, Philip was thinking of Janet Stone. Of the fact that in her case there was actually some truth to what George was saying. Bearing in mind that the whole thing, with her and Albert, was the management of a complex scenario so as to achieve a beneficial outcome. I.e. not worrying too much about whether this or that in itself did or did not have any actual therapeutic effect. Because in this sort of case, where everything was so fuzzy and entangled, where the physical blurred into the psychological which was influenced by the social, the question of what counted as an actual effect was, frankly, impossible to answer. You just had to sit there patiently and focus on the individual concerned. Listen to what they were saying, even if some of it was rubbish. And then nudge them in the direction that was most likely to do them good.
When it came down to it, his role was, on the one hand, to encourage Janet to stick with the parenting tactics she had finally consented to learn; while also helping both of them to keep seeing the benefits of the CBT that Albert was being put through; while also getting input from the SENCO at school; and monitoring the recommendations of the dietician; and staying in touch with the hospital specialist – i.e., to keep this whole complex structure of approved care more or less in place; and on the other hand also to stop Janet getting sidetracked by the stuff she kept reading about online. But in fact there too the trick was to listen to her with respect, i.e. crucially not present yourself as the One Who Knows Everything in the way George thinks you should. Take for instance Synaptol, the natural homeopathic remedy concoted in an oligotherapeutic base. I.e. basically just water. Dual-action symptomatic relief designed to lead your family back to daily wellness. I.e. absolute complete and utter wank. Still, when she tells you about it, you listen. Because she quite reasonably wants to feel she is contributing to the way forward, and also importantly because she wants to find something that connects to her sources of identity and understanding of the world, all of which are in the mystico-natural bucket, the Ash-bucket, haha. So you listen with an attitude of careful attention, and you say “it can’t do any harm to try” – and you get her trust. So that when she is tempted by something worse, like neural feedback, she comes and asks you about it, rather than keeping it secret, and believes you when you say it’s absolutely pointless. As though ADHD kids can be helped by playing more computer games – everyone knows they are good at playing computer games. Neural feedback is a perfect example of the phenomenon of the techno-placebo whereby people think that if they are connected to a computer with wires then it has to be doing them good. The ADHD kid has too many theta waves and if you replace them with beta waves then bingo, it’s much better. Absolute Star Trek mumbo-jumbo. Pure magical thinking. Because an EEG on its own is a terribly blunt instrument. Because the whole question of how the recorded trace relates to what is really going on in the brain is unimaginably complex; as is the whole other question of how it relates to people’s behaviour.
Though actually it didn’t take much to put Janet off that one: not really her sort of thing. It was just because it existed that she felt anxious: is this something we should try? And probably it wouldn’t have done any actual harm. It’s the cost that is criminal. Absolutely something that Janet shouldn’t be made to feel she had to struggle to afford.
Though anyway, Philip ended up thinking as George came back with two fresh drinks, Albert’s doing pretty well. The whole rickety structure of different bits and bobs, all coming together and focusing on him and making him feel safe and loved and important – it was all working pretty well.
‘So how’s Graham Epsom?’ – asked Philip, as George raised his glass and said ‘Cheers!’
‘Oh, he’s alright,’ said George, accenting the ‘he’ as though Graham Epsom would always be alright, there would never be any doubt about that.
‘Not set back by the changes to the bill, the future forum, the health and well-being boards and all that?’
‘It’s Stalinist,’ said George. ‘What I can’t stomach is that the whole idea was to set us free so we
could do more good more effectively; and in fact it’s ended up now as an enormous amount more bureaucracy . . .’ Philip’s phone was buzzing. ‘And this has happened,’ George carried on as Philip looked to see if it was Sue, ‘because of our own campaigning. It would be much better’ – he blustered – ‘if it had been left the way it was.’
It was Janet.
‘Well,’ Philip said, tapping Decline, ‘you know’ – he brought his attention back to George who was in front of him – ‘you know that’s my opinion.’ Philip sat squarely on ground he had staked out many times before.
But he was also thinking: Christ, what can she be calling me for now?
‘But, yeh’ – George went back to the question he had been asked – ‘Graham’s OK. He does systems and data, so for him, well, the more complicated it is, the more he’ll be in demand.’
It was really getting too much – Philip was thinking – ever since he’d gone out to see the three of them on the barge . . .
‘But for me, and Sara and Adam and Isobel and Paul,’ George was continuing, ‘it’s going to be intensely frustrating. It was going to be tricky enough getting together with eighteen other practices as it was.’
. . . he’d stupidly given her his private number and now, every little thing, she called him . . .
‘But now we have to form a Clinical Commissioning Group including representatives from blah blah blah it’s too boring.’
. . . and he couldn’t tell her to fuck off because she had this hold over him . . .
‘And run everything past the Commissioning Senate while taking account of the NHS Commissioning Board and doffing our hats to Monitor.’
. . . it was like blackmail . . .
‘Can you believe it, “Monitor!” You couldn’t make it up.’
‘I know,’ said Philip.
‘But Graham’ – George’s eyes were focused on the table top where his fingers were pinched together – ‘What Graham’s after is the data. Basically because he thinks he can make money out of it.’
‘He can’t sell people’s records?!’ Philip locked back into the conversation.
‘No, it’s all pseudonymised. This is one of the big things. Proper pseudonymised data about conditions and treatments and outcomes. I think it’s very exciting. That’s why I give Graham the time of day. Because this is real knowledge about people and their illnesses. This shows us what’s really going on. And it means we can properly target whole populations, not just the patients who happen to come to see us. It means we can make a real difference.’
‘Medicine on an industrial scale,’ said Philip, mildly. He saw Janet’s vehement worried face. All it was, was probably that Albert had had a bit of a tantrum. She’d only need some reassurance.
‘Oh for Chrissake Philip. You really need to get beyond this old way of thinking about it as one person being nice to another person.’ George was exasperated. ‘How many of your patients do you see a day?’
‘About 30.’ Philip’s feelings softened as he imagined the calming tones of his own wise voice solving the problem . . .
‘Of whom about half are ones you see all the time and . . . for heaven’s sake, you know how it adds up.’
. . . telling her it would be fine, making the stress vanish from her eyes . . .
‘About half of our patients we never even see.’
. . . she just needed to carry on with the agreed programme of management.
‘We never reach them.’
‘Right.’ Philip’s phone pinged as a message arrived. Irritation gripped his throat again. He didn’t look.
‘And that doesn’t mean there’s nothing wrong with them. It doesn’t mean they’re not in need of help.’ George was messianic, unstoppable. ‘Then factor in ethnicity. Who are the people most at risk of peripheral arterial disease? The black population. Who are the people most at risk of CFS? The Pakistani population. Who are the groups least likely to go to see their GP? Those ethnic groups, among others. What do we do about it? As a single GP you can do absolutely sod all. But as a consortium’ – his voice rose into upland calm – ‘then you can put in place targetted measures to reach a whole population and really make a difference. Save more lives.’
‘All I know,’ said Philip in an empty voice, ‘is that I went into this job as a human being, wanting to help other human beings. And what that means’ – his voice rose to cover George’s interjection – ‘is one human being talking to another. Listening to them. Viewing them as a whole person. Because’ – he stopped. Astonishingly a feeling of being about to cry was gathering around his eyes. ‘Because . . . that . . . matters. Looking at the person in front of you as one person. As an individual. As . . . a unique person. In a particular body. And a’ – for some reason he was smiling through his unhappiness – ‘particular smell, and clothes, and voice . . .’ he was trailing off but as George seemed about to speak he again spoke over him: ‘No, here’s what I want to say. The fact of being a person, who does the crazy stuff we do, who is there, ready to listen to anyone who walks in, to give them the time of day, treat them as someone who isn’t a fucking number’ – he spat the word – ‘but’ (quietly) ‘a person with dignity. That’s worthwhile. It’s about being human.’
‘No. That’s right,’ said George. ‘Fair enough. I didn’t mean to. Anyway, let’s leave it.’
He rattled the little rounded remainders of ice-cubes in his glass.
‘What I meant’ – George was hauling together some joviality – ‘to do was say: sorry. I mean I hope I’ve said it before but I wasn’t sure I’d said it clearly enough. I didn’t know that Grace was going to be as much of a . . . problem patient as she turned out to be. I’m sorry it landed on you the way it did.’
‘Oh that’s alright.’ At the bottom of Philip’s glass was a viscous pool.
‘How are things’ – said George – ‘looking for next year?’
‘Oh,’ said Philip, with mild surprise. ‘I’m just gonna do some locums. With Sue, it’s not entirely clear what her situation is going to be next year, where she’s going to be. So I’ll wait to see about that.’
‘She’s been living with you here this year has she?’
‘Yes, that’s right,’ said Philip. ‘I owe her. Anyway.’ Philip drained his glass: ‘Time to go. I’d better go.’ But he sat there still.
‘Yes you’re right,’ said George, looking at his watch and then rising, smiling. ‘I’ll see you Monday.’
‘I just need to make a call,’ said Philip, pulling out his phone and tapping Messages.
‘Philip,’ said George, turning back towards him in the doorway and staging a significant pause: ‘You are a good doctor.’
Philip lifted his head from the one-line message and saw George’s broad, well-meaning body dark against the bright light of the street where buses lumbered and people hurried past. Then he looked back at the one line which said:
‘Albert gone. Help me! Help!’
As Philip thumbed the message to call back, Sue, 54 miles away, was contemplating the stack of glass-fronted wooden, laminate and grey plastic boxes. They were a bit higgledy-piggledy and the wall of them was curved but that worked, it was good, because it was a bit like a bank of surveillance monitors but also a bit like a pile of stuff you might find in a junk shop. So it mingled those references which was exactly what she wanted.
As Philip stood, making the light aluminium chair scrape on the floor-tiles, Sue was thinking: there is something almost Serra about the way it dominates the space.
Not all the streams were running at that moment but, as Philip stepped out into the early-evening summer brightness of the street, Sue was watching Tahrir Square, one screen down and one to the right from the top left corner of the display. It was amazing, flooded with people again, clotted with banners, flags, tents and an enormous, numinous sheet of plastic which must have been for shade before the dusk began to gather, as it was gathering now, creeping in among the people, softening them into a mass of shadow. Above
, blobby streetlamps hovered in the air. Whereas yesterday the square had been fulfilling its prescribed function, cars circulating and dividing, hunkered down and crawling, business as usual, noses to the ground. People sitting obediently in their cars, separated into different channels by dotted lines and following the arrows around the gyratory with its ornamental planting. Now all that structuration had disappeared again beneath – what? – human beings, and a litter of basically just cardboard and plastic and cloth. So random and fragile. And you could crush it with a . . .
Except they weren’t crushed. They were there again, not letting go, keeping up the pressure about something or other, for instance putting ex-President Mubarak on trial. So somehow, was it somehow the fragility that had made them strong? Say, right back at the beginning, if they had had proper defences, if they had been armed – then they would have had to be crushed, but, as it was, nobody had been able to bring themselves to drive a tank over this efflorescence of life that was so fragile and breakable and – alive.
Sue’s eyes skipped across the wall of tellies to other images. The looped video of an eye (middle of the top row), framed in close-up and slightly side-on so that you saw the fluffy eyelashes and the crinkled skin and the gleaming alertness of pupil and iris, twitching as the light changed. The undulant, iridescent river surface (right-hand corner, one up from the bottom) where orangey late-afternoon light rippled and spread, a bit like the headlights in Tahrir Square, a bit like the shine on the iris. The clutter of grasses and flowers – poppies, clover – from Philip’s flowerbed that was going to appear on the screen just below the river as soon as he switched his laptop on again tomorrow morning. Which he was going to be able to do with a smile, hurrah, since his court thing had gone so well. Even though it was always obviously going to, or rather, always obviously ought to – only of course he had been worried about it, how could he not be given the, well frankly the trauma that had started it off. But still he did understand she had to be here today, not there with him: he could see she had no choice.
The World Was All Before Them Page 22