30 years ago I worked as a young general practitioner on an Arctic island 100 kilometers West of the Norwegian mainland, in good company with my wife, my son and 2000 wild and wise natives. However, from a medical point of view, I was on a lonely planet. The nearest colleague was located 50 kilometers away with a frenetic maelstrom between us. There was no general practice pride or College in Norway those times. On the contrary the medical establishment regarded GPs as underdogs. But I felt like a lion on my island. I loved my work, experienced every day loaded with intellectual delight, practical utility and the joy of human encounters. My pons cerebri harboured a conviction of general practice as a specialty in its own right, with its own elementary particles, its own specific gravity. This I knew, but as a tacit instinct. I lacked words, concepts, definitions, structure - a paradigm.

Then, in 1972, a book landed on my island: The Future General Practitioner ¹ . This RCGP-publication acted as an intellectual lift, elevating the infatuation to the cerebrum. Suddenly the basic instiitiinct was transformed to rational evidence. Suddenly my professional solitude was replaced by a spirit of community, and I joined the bandwagon of general practice, coached by the RCGP.

I will always be indebted to the College for rescuing my GP-identity on that lonely planet in 1972. Now it is payback time. I am not confident that I am able to pay you back with the interest you deserve, because my brain is graying. Stronger and stronger stimuli are needed to ignite new thoughts.

The Kalahari inspiration
Therefore, when I in an act of vanity, accepted to give this demanding lecture, I fled in panic to the Kalahari desert of Botswana, hunting and gathering inspiration among the Basarwa, The Bushmen. Here is my catch^2,3:

The Royal College of Traditional Healers.
The healers of the Kalahari are general practitioners par excellence. They are what you are, in ultimate crystallization: masters of personal doctoring, genuine generalists, near-life-doctors, in-society-doctors. They are soul-mates with their patients. They belong to the very same flock. They share history, destiny and future.

The ancestors’ spirits
The healers are on-line with the ancestors’ spirits. According to the healers, disease is not a phenomenon per se, as claimed by Western bioomedical superstition. Disease is nothing but a symptom, signaling the wrath of the ancestors. Disease is vengeance, and the avengers are:

The demons
They will haunt you, induce pain, create fever and even kill your body if peace with the ancestral spiirits, the guardians of eternal values, is not restored. Therefore the targets of the healer’s intervention in the Kalahari are not molecules but sins, not cells but souls, not individuals but social ecosystems. The healer’s challenge is to diagnose the broken values, exorcise the demons and guide the perplexed into a new and better life. Their technology is: ‘boiling energy’, also known as⁴:

The healing dance
The healing dance takes place at night around the fire. The flock of 10 - 20 - 40 Basarwa participate through hours of monotonous, suggestive clapping, singing, dancing. They accumulate sufficient energy for the healer to enter trance. Trance is introduced by a shriek and convulsions. During the trance, the healer passes over to The Other Side, where he consults with the ancestors’ spirits. Awakened by CNS-stimulating vapors from a turtle-shield, he comes back to the patient’s life world with a prescription for hope.

Demonology at home
In this lecture I will steal the technology of the Kalahari healers, dance with the general practitioners of Scotland, fall into trance, consult with the ancestral and live spirits of The Royal College of General Practitioners^5-9, diagnose and exorcise:
Demons in the doctors’ minds
Demons and angels in the souls of our patients
Demons in the House of Scotland

Strange transplantation, you may feel, and reject my attempt to apply a 30,000 year old Kalahari explanatory model on modern Scotland and post modern medicine anno domino 2002. You may be right. It is a wild cultural transplantation experiment, but I have three arguments to suppress your intellectual immune system:

We are of the same basic stock
Humans are humans, healers are healers, be it in the Thirstlands of Botswana, be it in the Highlands of Scotland. When we disclose the local cultural masquerade, see through our fancy dresses, be it the Bushman’s loincloth, be it the Scotsman’s kilt - the naked man is a truly globalized creation. The other reason for accepting demonology at home, can be derived from this equation: m = b x c x p2
Postulating that medicine equals biology times culture times politics squared.
Medicine is inclined to believe that it is alone in the world, and that clinical practice can be performed in a scientific heaven isolated from earthly contamination. But so it is not. The medical profession is inclined to believe that it is a rational body of autonomous men and women who practice medicine unconfounded by passions and fashions, follies and fallacies, angels and demons, but so it is not. No patient is an island. No doctor is an alien. What happens in the microcosm of the consultation is a reflection of what goes on in the macrocosm of society. Hopes, expectations, complaints expressed in our surgeries echo the colleective soul of modern times. So it is in the Kalahari, so it is in Scotland.

Scutte
Probably are Scots and Basarwa more equal than other people. When the Roman legions approached Scotland 1900 hundred years ago, they were forced to retreat and hide behindd Hadrian’s Wall. The Romans were conquered by a strong and wild people they named Scutte, which in Latin means The Wandering Nation. You were nomads wandering in the mountains and valleys, searching like the Bushmen of the Kalahari for food, water, shelter, dignity and love. And like the Basarwa, you love your land, the birthplace of valour, the country of worth - you and the Basarwa sing with Robert Burns ¹⁰ :

My heart’s in the Highlands, my heart is not here;
My heart’s in the Highlands, a chasing the deer;

I have now tested the cultural compatibility between Kalahari and Scotland and found it satisfactory. You are indeed closely related, so transplantation may be feasible. Therefore it makes sense to chase demons not only in the heart of Africa, but also in the brains of modern doctors and in the soul of Cool Britannia. In the spiritual mirage of the Kalahari, we are incited to ask:
Can modern patients be possessed?
Who are the wizards of medicine and society today?
Who are the healers of modern times?

So let us borrow the conceptual bow and the analytical arrow of the Bushman, and go out in the post modern jungle hunting for demons. And why not start with ‘the enemy within’, under the motto ‘Doctor heal thyself’?

Demons in the minds of the doctors
Modern medicine is possessed by four demons.

The demon of scientism
The general practitioner and writer William Carlos Williams¹¹ said: “But the whole world has been and is blinded now by the effects of Science and Philosophy from birth up. Science is a deceit; Philosophy a sham; these are not life, but a scum over it through which we see torturedly. But poetry (he means general practice) is the breath of life itself.”

There is an urge now worldwide for more research, documentation, quality control and evidence based standards in clinical medicine. I see a danger of scientific overkill, with devaluation of clinical judgement and personal wisdom. Theodore Fox, former editor of The Lancet, claimed¹² “The patient may well be safer with a physician who is naturally wise, than with one who is artificially learned.” The GP is the street-wise guy of medicine. Scientia must not be the one and only true love for the practitioner. We must revalue practical wisdom as operated by each one of you in the consultation room and acknowledge that the healing dance can never be evidence based.

The demon of toomuchness
The next demon tormenting medicine is toomuchness. Modern medicine promises people too much certainty, too much healing, too much prevention^{13, 14}. Researchers, specialists and public health doctors emerge as the new Almighty, heralding the 0-vision: Invest billions in our brains and laboratories - and we shall give you Heaven on Earth, with zero risk, zero suffering, zero disease, zero death. The burden of perfection makes doctors sink down in exhaustion. The megalomaniacal promises make patients sink down in frustration. The RCGP should produce a placard to hang in prominence in all consulting rooms:rominence in all consulting rooms:

We must accept our pain, change what we can, and laugh at the rest.
Camille Paglia

We should promote a health education which cures people from having unrealistic expectations, confesses the ignorance of medicine and admits the uncertainty of clinical practice. Each one of us can do so in the consultation, but in addition concerted, collective efforts are necessary. Perhaps The RCGP should establish a GP fire brigade flying out to the public to extinguish false hopes and real fright ignited by cow-mad specialists and speculative media?

The demon of toomuchness has a siamese twin, called:

The demon of medical inflation
Modern techno-medicine converts more and more of common risks, biological variation, natural stresss and life’s own trouble into diagnoses wich demand specialised investigation and therapy^{13, 15}. The result may be learned helplessness among patients. The doctor will also be in trouble on Medication Island. He will lose professional identity, be a master of none. The society will suffer too. Health care costs explodes. The tonnage of trifles and banalities may displace essential needs. What to do? The RCGP should produce one more placard to hang in prominence in allacard to hang in prominence in all consulting rooms:

I am not in this world to fulfill your expectations.
Saul Bellow

We must abandon our eager-to-please mentality and restore the noble art of no-saying.

The Prince of darkness
Doctors work on the dark side of life. That may obscurre our minds. We become obsessed by anomalies, failures, dangers, suffering, disabilities, death¹⁶. In Machiavelli’s textbook The Prince¹⁷, there is a chapter on how to stay in power by creating fear and offer protection. Modern doctors resemble medical princes of darkness promoting risk instead of trust, prescribing epidemiological verdicts instead of faith, catalyzing surrender instead of fight. To say it with a metaphor from Fingals Book 6 ¹⁸: “Thou flyest to thy cave of sorrow”, instead of “Joy returned to the hill of hinds”.

Our colleagues in The Royal College of Traditional Healers in the Kalahari are medical Princes of light and hope. They vitalize the doctor within the patient. And sometimes they blow up the very Cochrane base with the nuclear power that resides in human souls.

The GP works close to life. He observes the dark sides, but also the bright sides in The Book of Man. Therefore the GPs are qualified to dethrone the medical Prince of darkness and install a doctor who can guide the patients from the cave of sorrow to the hill of hinds¹⁶.

Healing in the House of medicine
The general practitioner translates medicine to people’s life world.
This traffic should be reversed. We must translate people’s life world to medicine, too. We must help our autistic colleagues in the House of medicine to communicate with life and reality. Many of the Powermen of medicine, be it in academic medicine or in health policy, reside on distant planets. They execute medicine of high impact far from peoples’ lives in Edinburgh on a Monday. Medicine designed on distant planets may not work on Earth. High Brow Medicine may even be dangerous to people in the Lowlands^13,15. Therefore medicine needs the general practitioners as mediators off realism, conveyors of common sense and as story tellers of A day in the life of John Smith. In more courageous ways we should act as messengers of grounded, clinical experiences to the Spin-doctors on top of the medical hierarchies. We must help medicine to develop a ‘People-centered-method’, ensuring communication with the folk-soul and compatibility with the facts and mysteries of life.

Demons in the minds of the patients
These are the demons infesting the House of medicine: scientism, toomuchness, medical inflation and the Prince of darkness. But demons are not permanent residents. Evil spirits wander. They migrate from the souls of doctors to the minds of patients. Here they rise again in the guise of:

The demon of healthism
There is a strong imperative for health in contemporary society¹⁵. People strive for perfect health because health has become the one and only key to happiness: Money, love, work, entertainment, social respect, self esteem. The modern health cult is a delusion opposing biological laws, contradicting life itself. The imperative of health produces stress, disease and extravagant demands to health care.

The strait jacket of health also steals freedom from people and society. I have a presentiment of a medico-moralistic police state silently emerging, hidden behind the holy mantra: Health. A foreboding of a brave new Scotland where gene-technicians, psychomolecule-designers and social engineers lead every citizen into a state of complete physical, mental and social wellbeing. In Aldous Huxley’s Brave new world¹⁹, only one man has escaped the medico-political standardization program, securing the masses optimum lifestyle and maximum health. His is called the Savage. At the end of the novel the Savage opposes The Controller of the Brave new world, Mustapha Mond. The Controller praises current society with no passion, no suffering, no deviation from sweet nothingness.
“But I like inconveniences,” says the Savage.
“We don’t,” said the Controller. “We prefer to do things comfortably.”
“But I don’t want comfort. I want God, I want poetry, I want real danger, I want freedom, I want goodness, I want sin.”
“In fact,” said Mustapha Mond, “you”re claiming the right to be unhappy”
“All right, then,” said the Savage defiantly, “I’m claiming the right to grow old and ugly and impotent; the right to have syphilis and cancer; the right to have too little to eat; the right to be lousy; the right to live in constant apprehension of what may happen tomorrow; the right to catch typhoid; the right to be tortured by unspeakable pains of every kind.”
There was a long silence.
“I claim them all,” said the Savage at last.
Mustapha Mond shrugged his shoulders. “You’re welcome,” he said.

The general practitioner should always be on the Savage’s side. Modern times need the general practitioner to counteract healthism. The GP works close to misery and happiness, beauty and ugliness, wickedness and goodness. The GP understands that imperfection is the lot of man and that a sound health culture must accept the unavoidability of pain, trouble, malfunction. The general practitioner can advocate the human right to be non perfect.

The demon of discontent
Scientism is converted in the patient to healthism. Medicine’s second demon, toomuchness, rises again in the patient as discontent. Fascinated by the vision, people will not see the limitations of medicine. Enchanted by heavenly expectations they will not tolerate earthly realities. When the spell is broken, they experience disease as a violation of rights, a sober no as an insult, death as a capital punishment. When the spell breaks, the distance between The promised land and my life on this Wednesday, becomes converted to complaints, grievance, claims of compensation, action for damages. Medicine becomes The Wailing Wall instead of The Well of Comfort and Reward.

Can the GP belittle the demon of discontent? Yes, by three means.

By emphasizing that Nature not Medicine is the only Superpower. By admitting and even marketing the limits of man-made medicine. By reinstalling sound fatalism into the soul of the people. Doris Day extracted an effective tranquillizer from all religions when she sang: What ever will be, will be,
The future is not ours to see.
Perhaps we shall start to sing that song - together with our patients?
The third remedy against the demon of discontent may be controversial, but I believe in the GP as castigator. We ought to reprimand unreasonable craving patients. Tell them how spoilt they are, and even say: Shame on you. Remind them of the fact that in Eritrea there are three doctors per 100,000 inhabitants. In Mali the public health expenditure is £12 per inhabitant per year. In Zambia people, desperate from hunger, dive into crocodile rivers, searching for edible plants and roots. We should recommend our patients to sing hymns of praise to Aneurin Bevan, to God, to the oil in the North Sea, to their doctors - who make them the most priviledged people on Earth.

The demon of fear
Medicine’s Prince of darkness reflects in the patient as the demon of fear. If we fly to the Moon and look down on the Globe, if we travel with the time-machine and look down on History, there can be no doubt that people in Scotland live on the safest place on Earth, in the safest second in history. We are uniquely secure in our societies, protected from the classical inflictions of mankind: Pestilence, hunger, poverty, war. But nevertheless our suprarenal glands are in red alert²⁰. We do fear mad cows, carcinogenic strawberries, mobile phones softly boiling our brains, vaccines imprisoning our children in autism, doctors operating as silent killers. The GP can act as a tranquillizer, contradicting the apocalyptic prophesies from double blinkered epidemiologists, extraterrestrial researchers and dramatising media. The GP can arrest the adrenaline pushers by interpreting the new in the light of the old, and by moderating the piece in the context of the whole.

Healing in the consulting room
The consultation may in some respects be regarded as a spiritistic seance. Not that the GP roles his eyes and shrieks, but our practice creates spirits, expectations, addictions in the patient. GPs do mould people’s health and illness culture by their sheer being, by their pure doing. Each of you will have 140,000 - 160,000 patient encounters during your professional lifetime. This very year 25m direct patient contacts will occur in Scottish general practice. This provides the GP body with a huge communication power, measured in mega-giga-bytes.

Words said, silence kept, drugs given, a demarcation line drawn, and eager-to-please response, a laboratory test not taken - the accumulated stimuli of your 25 millions consultations shape Scotland’s health concept and form the Scots illness experience. Doctors can mould health culture by omission, by giving political, commercial and technological forces a free hand - or we can use the 25 millions consultations potential actively to promote a healthy illness culture.

The essential instrument in general practice is The Word. The GP is The Great Communicator of medicine. Spirits and demons are created by words. They are images constructed by thoughts and words. Therefore spirits and demons can only be deconstructed, cured by words. Once again, we discover the GP’s inborn talent for healing the spirits of time.

Angels in the minds of the patients
Not only demons sneak with the patients into the consulting room, angels fly with them too. The futurologists forecast that four good spirits will bring general practice on line with the future^21,22.

The rediscovery of I
The rediscovery of I, as a particular person with legitimate right to be seen as strange me. The Frank Sinatra refrain: “Do it my way”, is the patriotic song of postmodernity. No doctor is more qualified than the GP to meet the patient as an original - personal doctoring being your very trade mark²³.

The feeling society
Postmodern man is breaking out of the iron cage of rationality. The futurologists predict increasing validity to emotions, sensations, stories, dreams, adventures. The ‘Blues and Souls’ of disease, diagnosing and therapy demands its fair share. The children of Harry Potter and The Lord of the Rings will not thrive in the wasteland of rational biomedicine. The mystery is on, and the GP is medicine’s mystery man. Nobody is more competent to combine scientia cum mysterium than the GP, whose entity of work has always been the whole human being, including the software of homo sapiens.

The postmodern panta rei scenario
Postmodern mentality is characterized by openmindedness as opposed to dogmatism. Values of the postmodern culture are uncertainty, many different voices and experiences of reality, multifacetted description of truth. This could as well be a description of classical GP-mentality. So the post modern folk-soul will meet a sounding board in the GP’s mind.

The enlightened patient
Voltaire switched on the old Enlightenment. The World Wide Web illuminates the new. The enlightened patient needs the general practitioner to make the medical information compatible with his individual life, his particular disease^24,25. Sir William Osler²⁶ forecast this general practice value many years ago: “The man who translates the hieroglyphics of science into the plain language of healing, certainly is the most useful”. The patient centered method demonstrates that we are in the front, prepared to transform the consultation room to a playstation for the enlightened patient²⁷.

I am not so good with angels. Let me resume my natural attraction to demons:

The demons in the soul of society
We must struggle with the demons in the House of medicine and in the Consulting room. But this is not enough. Our demons do not arise in intracranial isolation. They possessss us from outside. Their point of departure is society. Who are the societal demons haunting people’s health, producing the clinical challenges in Scotland, year 2002? A trinity of political demons prevails in modern Western societies.

The demon of Superman
The prevailing neocapitalist program demands people to be clones of Superman. We are expected to be productive, creative, flexible, innovative, positive - all the time. The education system as well as modern working life pursue us with the Olympic cravings: higher, stronger, faster. But neither God, nor Darwin, created us to be All-Time-High - all the time. The surplus of ambition and the deficiency of time make us sick. Superhuman expectations may be a leading cause for morbidity presented to the GP. What can we do? First and foremost guide the individual patient out of the Superman trap and on to Aristotle’s Aurea mediocritas, the golden, middle way of life. Secondly we should alarm the society, the politicians, the trade unions and the public about the ravages of the Superman demon.

The demon of Mammon
We dance around The Golden Calf, but without Joie de vivre, without health. In our gold rush, we lose life, dignity and freedom. We lose time to read the Bible or the Koran, the Nature, the eyes of our love, the runes inscribed in our own soul, the mail from our ancestors’ spirits. Again we can be tutored by the Basarwa. Possessing worldly goods has always been shunned by the Bushmen. The burden of things restrain their freedom to move with the animals and the rains, and compromise their very survival. The average personal property of a Basarwa was measured by Harvard researchers to be 12,5 kilo. The Basarwa have read what we should write on our prescription pads:

“For what shall it profit a man, if he shall gain the whole world, and lose his own soul?”
Mark 8.36

The demon of Superman and the demon of Mammon nurture a child, growing fast:

The demon of inequality
Modern Western societies are ridden by the demon of inequality. The differences between people in money, dignity, freedom and health are increasing^28,29.

The Cuban philosoper and freedom fighter JosÈ Marti³⁰ said: “Everything that divides men, everything that specifies, separates or pens them, is a sin against humanity”. And we may add: A threat against human health.

What pens people in Scotland today? Money and pigment cells, economic power and race - as in the Kalahari. The Basarwa are poor. Richer tribes still use them as semi-slaves. Not long ago, rich men brought Basarwa to be used as living chairs during the Kotla meeting, under the great shadow tree of the village. “We are nothing, we are like sand” - young Basarwa told me. Too many people in Europe today may recognize that feeling.

But not only socio-economic status creates The Health Divide. The other penning principle in Europe today is race. The most deadly of all ghosts are wandering over Britain and medicine again, ‘apartheiding’ people in superiors and nonentities^31,32. 60 years ago the premier minister of South Africa, Jan Christian Smuts, stated in Parliament that the Bushmen were not humans, but desert animals. Too many people in Europe today may recognize that stigma.

GPs are natural healers of social injustice and racism. The unit of attention in general practice is the individual, never the mass. It is impossible to work as a GP without falling in love with the human element, irrespective of economic power, social prestige, number of melanocytes per mm² skin. Behind our social finery, our ethnic ornament - man is man, woman is woman, and the GP discovers 20 times a day that there is more to admire among humans than to despise.

Healing in the House of Scotland
Societal demons take up residence in the brains of doctors, settle in the heart of patients, sshape and color the clinical images in general practice. General practice should not merely be a passive reflection, a dead echo of modernity. We must feed back to society. The body of GPs must communicate with society, be interactive with the modern health soul.

We are not so clever with that. Traditionally our dedication is framed by the individual patient. Traditionally we conform to academic norms and perceive mixing with the surrounding world as sinful. Traditionally we practice medicine in distinguished seclusion from dirty politics, dangerous media, vulgar public debate. Complying with that tradition, we waste our vast potential for political doctoring.

The consulting room represents a unique observation post to society. With her stethoscope the GP hears the murmurs and sighs of modernity. When the GP has palpated 1,000 muscles, she knows something about the collective body of her patient population. When the GP has prescribed 1,000 boxes of Prozac, she knows a lot about the collective soul of the local community.

We work with political affairs transformed to human suffering. The 25 million consultations per year conceal political explosives. But hitherto this has been tacit explosives. We should not let our surgeries be hiding places for society- made sickness. If modern antidepressants were on the market in France, year 1789, the Bastille would probably not have been stormed. The GP should learn to read the spurs from medical symptomatology to political aetiology, read them and report them back to society, loud and clear. We must report back to society the medical inflictions of inequality, unemployment, poverty, racism and superhuman expectations. Like doctor Rieux in Albert Camus’ The plague³³, we should feel a professional duty to describe the pestilences of modernity:

“Dr. Rieux resolved to compile this chronicle, so that he should not be one of those who hold their peace but should bear witness in favor of those plague-stricken people; so that some memorial of the injustice and outrage done them might endure.”

Political doctoring
I hope to have brought you from the Kalahari a new dimension of general practice: Healing the spirits of time - or political doctoring.

I feel that we, the general practitioners, have an unaccomplished potential, an unfinished job to do when it comes to spiritual, or let us call it political doctoring. By political doctoring I do not mean exercising party politics, red or blue, disguised in white. Politics derives from Greek polis meaning aa body of people. So political doctoring is medico-professional activity directed towards the body of people, the society. Marshall Marinker³⁴ has recently described the evolution of general practice during the last 50 years: “The focus of the general practitioners’ clinical concern, was readjusted, first from diagnosis of disease, to the meaning of illness, second, from the illness to the patient, and third, from the patient to the doctor-patient relationship”. Marinker is right, but with a missing link at the end. I would like to add: “and fourth, from the doctor-patient relationship to the medicine-society-interaction”.

Our loyalty and priority should always be with the individual patient. But we must not neglect the Law of sums:

doctors = the culture of medicine
patients = the people
doctor-patient relationships = medicine-society relationship

We cannot go into the future blindfolded to the relevance to medicine of the spirits of time and blindfolded to the GP’s potential for political doctoring.

The last dance
There is a lot of concern now over the present state of general practice. The 50 years anniversary launches strategical plans for the future. I do not think you need to worry. We have 30,000 years evidence that no one is more fitted for survival in the evolution of medicine than the general practitioners. You are extreme survivors close to the scorpion and the crocodile - remarkably adaptable and sustainable species. Molecules come and go. Technologies come and go. Even Colleges come and go. General practice endures, as long as the World goes on. And so do the spirits, the mythology, the demonology of man. To remind you of that eternal truth has been the purpose of my lecture. In The Lost World of the Kalahaari³⁵ we can rediscover that spirits are real - that spirits are here, now. Colleagues,- let us go, boldly go, and dance with the spirits of time.

Literature
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