I want to express the pleasure, and sense of honour, that I felt when Mairi conveyed your invitation to give this year’s Fulton lecture [1]. Pleasure to be here, because of my long association with so many of you in this Faculty, and the good friendships which we forged. A sense of honour, because of my warm and respectful memories of Willie, and of one particular symposium in 1973 when the two of us went head to head with a somewhat arrogant William Sargent, the then doyen of London psychiatry, and came off best. That’s a story for another time.

Let me say something about the provenance of my perhaps mischievous title. On Saturday mornings I listen to BBC Radio 3. At noon the composer Michael Berkeley invites a guest to illustrate his or her autobiography with music – favourite CDs that resonate with important elements of his guest’s personal and public lives. The programme is called Private Passions.

It is this model that I have adapted for this evening. Of course I wish that I could play you my favourite CDs. Had I been able to do so this would surely have given you much more pleasure than what in fact is now to follow. Instead, I am going to re-play some of my favourite themes, themes that have long been my private passions in medicine [2]. In this I may remind you of some of the star performances given by a number of the general practice prima donnas of my time. I shall also be playing you a few of my own old and cracked records. And because I love music there will be a musical conclusion.

In his book La Naissance de la Clinique [3] Michel Foucault described the 18th century origins of modern medicine. I don’t give the title in the  translation chosen by the English publisher -  The Birth of the Clinic – because in French the term ‘la clinique’ has two meanings. The first is ‘clinical method’. The second, the place where it is practiced - the hospital clinic. ‘La clinique’ refers to both technique and location. I suggest that in our time the term  ‘general practice’ has similarly come to have two meanings, and that these meanings may now be in conflict.

Foucault argues that the two meanings of ‘la clinique’ became fused in the early 18^th Century, and he blames what he sees as the excessive technical rationality of modern medicine, and what he calls the ‘objectification’ of the patient, on this fusion. My case this evening is different. I want to contend that a fusion of two meanings in ‘general practice’, a fusion which has served our society so well in the mid-20^th Century, is no longer sustainable. It is being deconstructed by the march of events.  In the face of this deconstruction, general practitioners must soon decide what they wish to become in the 21^st Century.

The first of my two meanings of general practice concerns our clinical method: how, in the broadest sense, we conceive of ‘what is wrong’ when the patient consults, and ‘how we know it’. I call this medicine's personal agenda. The second meaning concerns the delivery of primary care: the practice as an organisation; its location in the community; the people involved; the interface with other health services. I call this medicine’s political agenda

Each of these two agendas, the personal and the political, has, over long sweeps of time, developed its own distinctive language.  And each of these languages, I shall argue, is peculiarly difficult to translate into the language of the other. By now you may have gathered that a fascination with language, and the languages of medicine, has been perhaps my most abiding private, and not so private, passion.

Three Cultures.

I begin my story with an unremarkable consultation [4]. The patient is a 55 year old man. He is unemployed, - probably now unemployable; separated from his wife; living in a downtown hostel. He’s shabby; his fingers are stained tobacco brown; it is ten in the morning and there is a smell of drink on his breath. The notes read: ‘chronic obstructive airways disease; drinking; depressed; two serious overdoses’. The young woman doctor asks about his symptoms and revises his medication. No mention of cutting out the fags and booze. She knows how meager are his life’s gratifications. What alternative solace does she have to offer?  She is about to go on holiday. ‘I’ll see you in three weeks.’ she says.

Hardly the stuff of grand opera. She hands him a prescription just as he gives vent to a wracking bout of coughing and wheezing. Inconsequentially he says: ‘I saw you with your children yesterday. They’re growing up fast’. His eyes fill with tears:  ‘She’s told me she won’t ever have me back’, he says. This is old news. The doctor is running late. Another banal consultation? I will come back to this later. 

In 1959 the novelist and savant CP Snow lamented that by and large arts and science graduates were ignorant of each other’s worlds, and that thus a deep schism had opened up between the two major components of Western Culture [5]. His use of the term ‘The Two Cultures’ struck a deep chord with academics and politicians, and came to dominate our thinking about higher education. Snow later identified a third culture, the social sciences, which he thought was similarly dislocated from the other two.

Ten years later, when a group of us sat down to write what became ‘The Future General Practitioner’ [6] we were challenged to yoke these three cultures together. It soon became clear to me that the problem was to find a common language.

My parents were immigrants: they came to London from Warsaw via Berlin and Paris. In my mother's kitchen they spoke at least three European languages. Unselfconsciously they would switch between all three in the course of any everyday domestic exchange.  Perhaps it was simply carelessness, but I like to think that they sensed that some things could be better expressed in the inflected meanings of one tongue than in another. Each of the languages reflected something unique in their own history, in their personal migrations, in the stories of their families, in the landscapes of their moods and imaginations. 

As a small child I saw nothing strange in all this.  I simply thought that they were speaking one single language - I imagine that I thought that it was English.  This was not a bad guess. Compare the word count of the OED with any other European dictionary. There is a fabulous richness of words. From Early English onward, we traded grammatical precision for the nuanced diversity of every one else’s words.  The Academie Francaise seeks to preserve the French language behind a locked belt of linguistic chastity. English, in contrast, is a hot blooded harlot of a language: she embraces all the others. Later, I came to understand that this was also true of the language of clinical medicine.

Jacob Bronowski in his 1964 essays Science and Human Values [7], contrasted the language of the sciences and the arts. The language of science is single valued: its terms must be precise and unambiguous. The word ‘mercury’ stands for a chemical element; it refers to its atomic weight, the pre-determined dances of its outer shell electrons. There can be no resonance, for the physicist, with ‘mercury’ the evening star seen at sunset; with the Roman god of merchants who sports wings on his sandals. Bronowski says that such multiple meanings belong to the language of the arts.  In this language the word ‘mercury’ stands simultaneously for all its possible  meanings - physical, chemical, cosmological and mythological.

In just this way the general practitioner’s use of the term ‘chronic obstructive airways disease’, is rich in its references and semantic overtones. It conjures up at one and the same time the cunningly concealed social trap that fatally pinions her patient in its jaws; the changes in his bronchial tree; the self destructive solace that he seeks; the dwindling cardio-respiratory reserve; the dwindling effectiveness of medicines; the look of desperation.

Writing in 1923 TS Eliot [8] lamented that, since the 17^th Century Metaphysical poets, poets like John Donne and Andrew Marvell, something regrettable happened to English poetry. For three centuries thereafter, with few exceptions, English poets either felt, or thought. They hardly ever managed to do both at one and the same time. He called this a ‘dissociation of sensibility’. Here is Marvell on the tantalizingly unbridgeable space between lovers:

As Lines So Loves oblique may well

Themselves in every Angle greet:

Buts Ours so truly Parallel

Though infinite can never meet.

Therefore the Love which us doth bind

But Fate so enviously debars,

Is the Conjunction of the Mind

And Opposition of the Stars....

Marvell employs the 17^th Century new sciences of physics and astronomy to examine 'The Definition of Love’ just as the general practitioner today might employ the new sciences of physiology, biochemistry, pathology, genetics, psychology and sociology to examine the never completely definable ‘what is wrong’ with her patient. And more than this, both the enquiry and the language of the conclusion require something more than the technical. It surely denies the fully human to abjure the disciplines of textual exegesis, of aesthetics, of metaphor and wit, to ‘dissociate our sensibilities’, in coming to an understanding of ‘what is wrong’ with the patient, and ‘how we know it’.

And there is another compelling reason for advocating the poetics of general practice. The writer Susan Sontag writes that what novelists and poets do best is to sponsor reflectiveness, to pursue complexity. ‘Information’ she says, ‘will never replace illumination’. General practitioners know this. It is what they do best.

At school I learned that German nationalist critics carped that because the poet Heinrich Heine was not a pure German, he could not write decent German poetry. Rather, they said, he writes French love lyrics in the wrong language. In similar vein we general practitioners can be thought by our specialist critics to be writing medicine in the wrong language. I have always thought Heinrich Heine to be the patron saint of academic general practice. 

At about the time that I began drafting this lecture, I came across the following by the Palestinian writer Edward Said. In his essay ‘Reflections on Exile’ he writes: “Most people are principally aware of one culture, one setting, one home; exiles are aware of at least two, and this plurality of vision gives rise to awareness of simultaneous dimensions, an awareness that, to borrow a phrase from music, is contrapuntal” [9].  It struck me that Said’s sense of exile, and of a contrapuntal life, are the common and necessary conditions of clinical general practice.

The Public and the Personal.

The languages of the arts and the sciences, both essential in the clinical dialogue, and each carrying its distinctive values, are fused in the expression of ‘what is wrong’ with the patient, and ‘how we know it’. The cultural rift between the languages of what I call medicine’s personal and political agendas, however, is deeper, and fusion here is hazardous.

By the 1950s we general practitioners were busy  counting our encounters with patients. Keith Hodgkin [10] in his brilliant 1963 monograph ‘Towards Earlier Diagnosis’ gave us a natural history of medical conditions based on the diligence of the first hand descriptions of what he saw. John Fry was a similar researcher. This was counting of a kind, but it was at the same time also a perceptive recounting. It was work in the direct 17^th Century tradition of Thomas Sydenham, the founder of modern medicine.

Too soon this natural history, grounded in the personal tradition of clinical medicine, was to be abandoned for an epidemiology which rather served the political agenda of public health. Henceforward respectable research enjoined us to ascribe a rubric from the International Classification of Diseases, or one of its daughter taxonomies, to every clinical encounter. Recording the incidence and prevalence of morbidity in general practice became the fashionable field sport, and I personally could not wait to join the game. It seemed innocent enough.

But what were we really recording? The language of epidemiology, fashioned to describe diseases as categories, proved less than adequate when it came to describing the illnesses that we encountered. These were dimensional, and not simply categorical, entities: the messy, untidy, over-spilling rag bag of symptoms and signs; the anxieties and denials, the intricately inter-acting co-morbidities, that constituted our understanding of ‘what is wrong’.

Writing this summer in the BMJ, Peter Tyrer, Professor of Psychological Medicine at Imperial College London, and medical historian Edward Shorter [11],  comment: ‘The firewall between (the diagnoses of) anxiety and depression ignores the fact that the commonest form of affective disorder is mixed anxiety-depression’. They point out that the pharmaceutical industry prefers a ‘disease category’ approach because it slices what they call ‘the diagnostic salami’ ever more finely. Each niche diagnosis is a marketing opportunity. We now have paroxetine for social anxiety disorder, fluvoxamine for obsessive compulsive disorder, sertraline for post-traumatic stress disorder. They claim that the arbitrary label of the disease, rather than the psychopathology, determines how it is to be treated.

This is worrying enough for those who hold that  clinical choices must be based on copper bottomed evidence from good research. But 30 years ago, in the face of similar clinical experience, I had reached a far more radical and more disturbing conclusion.

I mentioned that in 1973 Willie Fulton and I were speakers at a symposium on the prescribing of psychotropic drugs. In those days tranquillisers were widely prescribed to deal with the emotional turbulences of the patients and their doctors. The sub-text of the meeting chaired by William Sargent was a stern criticism of the general practitioner’s prescribing habits. Willie and I were there together to fight the corner for general practice [12].

In my own paper I said that the rational model was flawed [13]. The rational model suggests: ‘I’ve listened to your story, Mrs. Smith, and you are a clear case of anxiety. You had better have some Librium’. I argued for a counter-instinctual model. This is expressed as: ‘I’ve listened to your story, Mrs. Smith, and you are a clear case of Librium. You had better have some anxiety’.

In the face of illness which the doctor recognises well but cannot respectably name, the diagnosis is no longer the rationale for the treatment. It has become the alibi for the treatment. We GPs were offering up bogus psychiatric diagnoses simply in order to be able to defend our appropriate prescription of the benzodiazepines as ameliorators of the mixed innominate nervousness – the condition that Tyrer and others now at last recognise.

One consequence of our 1960s passion for looking at general practice through the prisms of population medicine was a significant occupational migration. A few public health academics were so hot for this field of study that they went native. They became professors of general practice. In Scotland academic general practice was founded by just such asylum seekers from public health. The illustrious names of Dick Scott and Ian Richardson come readily to mind.

In 1972 the traffic in migrants became two-way. Ian Richardson, who was a great personal support, urged me to apply for the Foundation Professorship of Community Health at Leicester University. The appointment of a working general practitioner to this Foundation Chair, in a radical new medical school, caused indecent joy in the College. It caused utter disgust in the Faculty of Public Health Medicine, on whom the irony of my appointment seemed to have been lost. The insult was compounded when, within weeks, James McCormick, a single handed GP from County Wicklow, was appointed Professor of Community Health at Trinity College Dublin.

But behind the spectacle, the fun and the mischief of all this academic cross-dressing, a fault line began to open up in academic general practice. 

The List.

Surreptitiously our gaze was now distracted from what had traditionally been the object of the doctor’s concern – the patient and her illness. Our new and larger object of endeavor became what we were to call the ‘population at risk’. 

The sociologist David Armstrong has traced the evolution of doctors’ premises [14]. It began with the closing off of a private room at the back of the 19^th Century apothecary’s shop. Later there were set-aside spaces in the doctor’s own home. In the second half of the 20^th Century purpose built premises for groups of doctors changed everything.

Armstrong  observes that as the complexity of these spatial realignments evolved, the result was  ‘...the separation of the illness from the domestic and its subsequent fragmentation.’ The more elaborate and differentiated the social spaces of the new buildings, the more possible, indeed necessary, it became to ‘map’ the patient’s illness onto the building - the spaces of the receptionist, the doctors, the nurse, and eventually the extended primary care teams. Illness, says Armstrong, was no longer located in ‘separate domestic bodies’.

In place of this domestic space, and the location of the illness in the patient, a new larger territory was claimed by general practice - the community  described as the practice population.  As the bio-technologists explored the internal spaces of the patient’s body, and the health psychologists explored the internal spaces of her feelings and family relationships, the medical sociologists were directing the general practitioner’s ‘gaze’ outward to the community, and once again redefining ‘what is wrong’.

But our lists were in fact neither communities nor even populations. ‘The practice list’ had no natural boundaries; it was an ad hoc collectivity made up of persons who either by chance or choice were contractually affiliated to a particular doctor. The demography of most [non-rural] practice lists reveals a patch work of overlapping groups split between families, households, streets, and neighbourhoods. Precisely because our ‘lists’ had for the greatest part no geographical nor cultural nor community coherence, the expression of the new political agenda was restricted, force majeur, to the epidemiological.

In contrast, writing in 1996 about advocacy in public health, two of its leading doyennes, June Crown and Louise Gunning-Schepers [15] felt themselves un-self-consciously able to employ the language of the personal agenda. They wrote: ‘Public health practice...sometimes needs to go beyond the evidence. There is a place for ‘intuition’ – the public health equivalent of ‘clinical acumen’. They advanced the view that, as advisors in health governance, the public health doctor should function as ‘a poet in residence’. Later I will suggest that in future the general practitioner should function as ‘the poet in residence’ for clinical medicine.

Since the 18^th Century a central preoccupation of public health thinking has been the search for causes, and hence the primacy of prevention over cure. This pro-active agenda was now to be hijacked from its origins in the political arena and incorporated into the personal one. Attention shifted from the patient who feels ill, to the well person at risk. It became manifest in the enthusiasm for developmental assessment, opportunistic screening for hypertension, diabetes, cancer of the cervix and breast, and latterly for unhealthy behaviours - smoking , excessive drinking and eating, and sloth.

This quest for early intervention - the diagnosis and treatment of the still well - had strong philosophical and historical links with another key precept of public health medicine: the pursuit of social justice.

In 1971  Julian Tudor Hart [16] had published an article in The Lancet on health care inequalities. He coined a ringing phrase of immense political sensitivity - The Inverse Care Law.  What was important about this article by such a respected general practitioner researcher and influential thinker was the articulation of the two linked themes of public health - prevention of excess morbidity and pursuit of social justice. Indeed all our evidence about the relationship between poverty, ill-health and premature mortality, pointed inexorably to one remedy: equity in health could only be achieved by the redistribution of wealth. But this was essentially a socio-political, not a clinical solution.

17 years later, in 1988, Julian published his more fully worked out programme for general practice. He called this the ‘fusion of epidemiology with primary care’ [17].  Crucially he wrote: ‘...to be consistent with science, (medicine) must serve whole populations according to their needs, rather than be merely available to individual demanders or purchasers of care...’ 

I fretted that ‘individual demander’ sounded to me like a synonym for ‘patient’. Here Julian represents patient as the usurper of a superior client, the community. This profoundly political view of the medical task, from the radical left, had strong roots in the great 19^th Century European tradition of Public Health. Then the German pathologist Rudolph Virchow averred that medicine was a social science and politics nothing but medicine writ large.

What emerged from these arguments was the relocation of the patient’s illness from ‘in here’ (in the body-mind of the individual), to ‘out there’ (in the socio-economics of the community). However, once ‘out there’, the identity of the patient, the difference between patient and person, and between person and class of people, became problematical. In 1976, at a colloquium to debate with the extraordinary Ivan Illich, I warned that it was  ethically hazardous to fail to distinguish between being a person and being a patient. I said it was repressive; that like all idealisms it would end in coercion.

Yet in that same year we have Denis Pereira Gray [18], hardly a scion of the radical left, asserting that: ‘...the introduction of doctor-initiated consultations for symptom-free people has made the old definition of the word patient inappropriate’. I thought this quite shocking! Surreptitiously the fine boundary between being a patient and being a person was crumbling. For Denis, and for so many of our generation, we had become a nation of patients in waiting. ‘What is wrong’ was being transformed into ‘what may happen’.  There were echoes here of Alexander Browne’s chilling definition: ‘a healthy man is someone who has been inadequately investigated by a physician’.

The Doctor & the Patient.

In the early 1960s I was engaged in a self important but ill-fated study of the way in which members of families might, in the patterns of their consultations, reveal some sort of meta-family-pathology. This almost mystical hypothesis was too far out to be mentioned in polite academic society. More in hope than expectation I was employing some of the bog standard typologies of epidemiology – age/ sex/ social status/ morbidity and so on. In the end my data were meaningless. They were like the cast in the Pirandello play – characters thrashing about looking for an author who would give their story some meaning. I was about to discover my author.

Some time in the late 1930s Michael Balint arrived in England as an émigré from Hungary, where a fascist regime had made the professional life of its Jewish intellectuals, and by association the practice of psycho-analysis, all but untenable. I joined Balint’s group in 1963. It was a secular epiphany.

To be accepted into his research group we were obliged to undergo a preliminary hour long interview. As I left his room he put an arm around my shoulder: ‘Marinker’, he said, ‘this will be your kind of work’. He smiled: ‘After all, you are little bit crazy’. I was flattered. Only later in the day did I reflect that this was a diagnosis by the then President of the British Psychoanalytical Society. I was to spend the next seven years in weekly thrall to his intellect, his wit, his uncanny understanding of human nature, and his merciless honesty.

Let me give you a flavour of those days. Quite early in the research, I recounted the case of a sixty year old bank clerk who presented with dramatic stroke-like symptoms for which no physical cause or consequence could be found. In the course of very many hour-long consultations I performed the most spectacular archaeological dig into his personal history. I uncovered a destructive relationship with his father, an unconsummated marriage, and many other treasures. Throughout all this my patient’s symptoms were gradually getting worse. He was sinking slowly into a depression.  My psycho-therapy was clearly meeting some pretty determined resistance, and I was now looking for guidance.

I spoke for twenty minutes. The group, impressed by the depth of my psychological archaeology, heard me in awed silence. Balint’s comment, in an accent as rich as any Hungarian goulash, was laconic: ‘Marinker has engaged us’, he said. ‘with his usual thoroughness, his eye for detail, his search for the  significant. And he has, how shall I say it, he has bored us all sick’. He turned to me: ‘Perhaps this is what you are doing to your patient’.

Years later, when I left the practice for the university, this same patient came to say farewell. He wanted to thank me. “I couldn’t face things then.”, he said. “But now, your words come back to me, and I can move on”. I couldn’t resist touching for a moment, and at long last, the pure gold I must have stumbled upon during my long voyage in his unconscious. “What was it ?” I asked. “It was the way you said “Come on now Tom. For God’s sake man, pull yourself together”.

Throughout Balint’s classic text The Doctor, His Patient and The Illness [19] there is no reference to  Freudian terms or theories – apart perhaps from his signature tendency to prefer sexual explanations. He thought that generalist clinicians should steer clear of diagnosing or postulating psycho-pathology.

In his 1982 study 'Freud and Man's Soul', Bruno Bettelheim [20] describes a serious inaccuracy in translating Freud's work from the original German into English. His English translator, Ernest Jones, had rendered Freud's use of 'Psyche' as 'mind'. As a consequence, in the anglophone world, psycho-analysis was captured by psychiatry. But the intelligentsia of Vienna and Budapest, for whom Freud wrote, would have known full well that Psyche was the lover of Eros: that she was a beautiful young woman with the wings of a butterfly. ‘Psyche' means both butterfly and soul in classical Greek culture, as it does in many others. It does not mean mind.

Bettelheim’s thesis - that Freud was concerned not with psychiatry but with Man's soul – throws a clearer, I would say a healthier, light on what I argue has been the positive Freudian influence on our clinical thinking. When we seek to make a so-called triple diagnosis, the general practitioner’s compilation of ‘what is wrong,’ we are simply exploring ‘meaning’ - the sense that the patient is making of the illness in the context of her life. This is what Sontag called ‘illumination’.

Health Services.

I want now to turn to quite an other of my private passions - to the future of health services. Fundamental changes are afoot in specialist medicine. As a consequence both of a galloping technology, and of the established link between volume of cases and quality of outcomes, specialist doctors are being driven into ever narrowing fields. In the new treatment centres, surgical techniques will finally be fully industrialised. I failed last year to find a general cardiologist in London. They were, to a man and woman, described as specialists in valvular or electrophysiological or myocardial heart disease. But while this narrow focus doubtless increases technical mastery, there is a loss of a sensitive peripheral vision of the patient’s wide ranging and more complex clinical condition.

In 1993 Robert Myerburg [21], writing in the New England Journal of Medicine, already noted ‘Faculty members in departments of medicine are having increasing difficulty communicating with each other’. The problem of language again: there was no longer a lingua franca between specialisms.

Paul Beeson [22], presciently writing some thirty years earlier in the Annals of Internal Medicine, observed ‘...specialties thrive in situations where something can be offered, but where that something is complex, and only partially effective...I am impressed by the evidence that the introduction of simple curative treatments means trouble for a practice specialty’.

As for general practice, the changes are no less radical. Both clinical triage and the monitoring of chronic conditions, key elements of 20^th Century general practice, will in the 21^st fall to health professionals from the traditions of nursing and pharmacy. Continuity of care, perhaps the iconic claim of the general practitioner, will no longer be an individual but an organisational responsibility. The patient’s life record will no longer sit in the practice filing cabinet, but, encrypted on a smart card, in the patient’s pocket and the public domain. The consumerist patient will become the final guardian and arbiter of her own continuity of care.

Deconstruction.

I have argued that over the past fifty years there have been two distinct but mutually confusing agendas in general practice. Can we now begin to think about separating them? And what would be the implications of such separation for the organisation of care?

In her 1992 monograph Systems of Survival the philosopher Jane Jacobs [23] creates what she calls ‘a dialogue on the moral foundations of commerce and politics’. She suggests that man has developed two, and only two, systems for survival.  The first, she describes as taking - making use of what we find around us.  Man as hunter gatherer developed this system, based on the territorial needs of the tribe. She calls this system The Guardian Moral Syndrome. In the modern world it translates into the morality of government and the public services.

 The second system of survival, Jacobs describes as trading.  Early on man learned to exchange goods, to produce surpluses for exchange, and with this came the growth of manufacture and the mercantile society.  This trading system came to be equally well served by a different set of inter-dependent moral precepts.  These she describes as The Commercial Moral Syndrome.

The moral precepts, the virtues, in each of the two syndromes, she says, are paired.  And the pairs seem always to contradict one another.  In the Guardian Syndrome the virtues include respecting hierarchies, adhering to tradition, dispensing largesse, deception for the sake of the task. In the Commercial Syndrome  the virtues include dissent for the sake of the task,  thrift, honesty, enterprise, and openness to novelty.  Each group of precepts, says Jacobs, is internally consistent. Both work in their own spheres. 

Jacobs thinks that the danger lies in carelessly mixing them.  The examples she gives from North America are the intrusion of Government into business enterprises; the attempt to organise public services as though they were private companies; and the attempt to mix up clinical and public health medicine. I think we may have been carelessly mixing them up in general practice.

In the 20^th Century the qualities of mind so prized by Renaissance man, the intellectual and emotional richness of horizontal thinking across disparate disciplines, seemed irrelevant to the needs of an emerging technical mastery. In my 1994 Bayliss Lecture, The End of General Practice, I predicted that the next generation of practitioners would have to be created against this grain

 The new GP, I argued, will be a Renaissance Physician; ‘the poet in residence’ for clinical medicine. She can no longer be confined to the front line of medical care. She will be consulted by her specialist colleagues so that their technical interventions can be located in a rounder clinical context; and by the individual patient who will want to come to a deeper understanding of ‘what is wrong’, ‘how we know it’, and ‘what can be done’.

But where would she be placed in the complexities of the NHS? Gareth Morgan [24] in his 1986 monograph Images of Organisation argues that organisations can be best understood in terms of their metaphors. Metaphor illuminates the familiar by casting it in an unfamiliar light, revealing what habits of seeing have previously obscured. The commonest metaphor of organisations, he says, is that of the machine.

In such organisations the emphasis is on central control, rules, hierarchies, discipline, uniformity, specialisation of functions, and predictability. Think of a registrar training programme driven by behavioural objectives, and their relentlessly iterative assessments. This 19^th Century mechanical metaphor, Morgan argues, still dominates our industrial economies. It is this metaphor that most powerfully describes the National Health Service.

Morgan offers a number of competing metaphors: the organisation as ‘church’, as ‘school’, as ‘laboratory’. All of these, I believe, throw light on different facets of general practice. None more so than Morgan’s most chilling metaphor - the organisation as ‘psychic prison’. Here the participants appear trapped by half-suppressed memories of the organisation’s real or imagined history. Drawing on Jungian imagery, he posits that this organisation’s life can be understood in terms of the relationship between fools, magicians, warriors, high priests, lovers and other symbolic characters. The psychic prison, as you will all have instantly recognised, is the perfect metaphor for the general practice partnership.

The political agenda of primary care will henceforward be appropriately pursued by the new professionals of the Primary Health Care Team. It  will be ruled by the virtues of Jacob’s Guardian moral syndrome. And of course I recognise that there will be many general practitioners who will feel their talents best deployed as the Medical Directors of this new Primary Care.

The Renaissance Physician, at once scientist and poet, would then be set free to practise as a clinician, both in our sense of panoramic generalism, and in fidelity to the patient’s personal agenda.

But there are political trends, endemic in our health governance, which threaten the return to this personal agenda. Ivo Mosley [25] in his troubling monograph this year, Fascism, Communism and The New World Order, argues that the corporate state now robs us of our natural inventiveness, diversity, civic responsibility and compassion. Successive governments have marched far beyond the bourns of Jacob’s Guardian moral syndrome, to invade almost every human activity, industrialising it for the purposes of the corporate state. We now have a football industry, an entertainment industry, a countryside industry. The advent of the health, and education, and criminal justice industries already seems imminent.

The political tasks for my Renaissance Physician are therefore daunting. I hold that she must be faithful to the concept of a health service designed for fairness and solidarity – not as a party political preference, but because fairness and social solidarity are virtues intrinsic to policy and governance for health in a civil society. Yet at the same time she must break free from the organisational metaphor that has until now has seemed necessary to the pursuit of these key virtues of fairness and solidarity – Morgan’s monstrous machine. 

She will need to transcend the constraints of both private and public corporate medicine: and she can not be imprisoned within any of Morgan’s metaphors of organisation, not least because her generalist perspective will be equally vital to the patient in all the settings of medical care. Her emerging role will provide us, finally, with  a delicious historical irony! Mediating between powerful new technologies, as her patient’s advocate, advisor and collaborator, and as mentor to her specialist colleagues, she will become, in the full meaning of the original 19^th Century term, a general medical consultant.

Of course I may be wrong! Iona Heath, who so perceptively describes the Mystery of general practice [26], assures me that it is the context and tasks of general practice that alone determined the peculiar skills and values that I have described. If we change the context and tasks, she argues, the skills and values will simply degrade. Alas, we agree that our different hypotheses can’t be put to the test of experiment. You see, our futures are not so sensibly and rationally constructed. We build them politically; we build them by the exercise of our private passions.

Conclusion.

In concluding I want to return to the most enduring of my private passions - the art and science of the consultation - and to the consultation with which I began this evening.  You will recall the somewhat thin information – a man coughing and wheezing, no job or likelihood of one, no loving companionship, a penumbra of beer and cigarettes and sadness. I asked ‘Another banal story?’, and commented ‘Hardly the stuff of grand opera’.

Let me tell you another banal story. Two young Neapolitan officers boast about the fidelity of the two sisters to whom they are engaged. A cynical older friend taunts them. ‘The fidelity of a woman’ he says, ‘is like the Arabian phoenix; everyone believes in its existence; no one has ever seen it’. He offers the young men a wager. If they pretend to embark for duty overseas, and then return disguised as Albanian soldiers, each will be able successfully to seduce the other’s fiancée. He wins his bet, but in the end, all is revealed, all forgiven, all restored. What a piffling and silly scenario!

The patient takes the prescription, stands to go, pauses, and says: ‘Doctor, may I touch your hand?’. Until this moment, the consultation seemed quite unremarkable: the deteriorating symptoms; the expected small talk. But - ‘Doctor, may I touch your hand?’. This is one of those off the wall happenings for which no behavioural objective can ever prepare you. And medicine is full of such surprises, such sudden intimations, letter drops, encrypted secrets, semaphores, text messages across the deep space between the patient’s world and the doctor’s. Time for a Hail Mary pass.

Robert Browning was once asked the meaning of one of his more difficult poems. ‘Madam’, he replied, ‘When I wrote that only God and I knew what it meant. Now only God knows’. In the Guardian Review on August 23^rd  this year James Fenton, Emeritus Professor of Poetry at Oxford, notes that in American football the term Hail Mary pass describes a long pass thrown nearly blind, in desperation, that you hope will be caught by someone on your side, and not intercepted [27]. He comments that in poetry there are a lot of passages like that.

In other words, he says, ‘the poet is working in a state of uncertainty, hoping for the best. He thinks up a line. He hasn’t the foggiest notion what it means. But he sends it out any­way into the big wide world in the hope that it will prosper.’ This is the poet’s Hail Mary pass.

The doctor pauses for a moment and then: ‘Of course’, she says. She stretches out her hand and takes his. ‘You are going to promise to keep taking the medicines’, she says. ‘Let’s shake hands on it. And you’re going to promise me that you won’t try to kill yourself. I will see you again in three weeks time.’

I referred earlier to the first of our ten goals in ‘The Future General Practitioner’- the so-called ‘triple diagnosis’: it states that the doctor should be able “to make diagnoses about the patient which are expressed simultaneously in physical, psychological and social terms”. I was responsible for the actual drafting of these goals of training, and it was I who, crucially, insisted on inserting the word ‘simultaneously’ into the text.

As far as I am aware, in the thirty years since publication, this goal has never been challenged. Yet I have to tell you that to this day, I’m not precisely sure what it means. But I still hold it to be valid and crucial. How can this be? Of course it was a Hail Mary pass.

In Tom Stoppard’s problematical play Jumpers, George is a professor of moral philosophy. Throughout the play George tries to use logic to prove the existence of God [28]. Stoppard has him say “The fact that I cut a ludicrous figure in the academic world is largely due to my aptitude for reducing a complex and logical thesis to a mysticism of staggering banality”.

Varying Stoppard, I have concluded that in asking for that simultaneous diagnosis, we authors of ‘The Future General Practitioner’ were seeking to elevate a mysticism of staggering complexity to the banality of a logical thesis. We need constantly to remind ourselves that real education, true professional development, moves us far beyond the fashionable confines of behavioural objectives, protocols,  algorithms and those obsessive assessments.

This was certainly a contrapuntal consultation – shorn of all the psycho-babble and behavioural bollocks that pass today for educational and managerial sophistication. It reveals what the declared curriculum of the medical school and of registrar training, by which we live and torture ourselves, cannot comprehend – the melding of science and art, the aesthetics of the encounter, the intuitive improvisation, the very spirit of clinical medicine. They belong to our hidden curriculum.

In Lorenzo da Ponte’s scenario for Cosi Fan Tutte, Don Alfonso, the cynic, stands on the shore with the two heart broken young women. He points at a boat on the horizon, and says ‘Look, can you see your lovers waving goodbye’. He is lying of course. The sisters sing ‘Lie calmly thou ocean; blow softly ye breezes’.

If this had been a lecture in which a rational argument had been developed in a linear sequence, at this point you might have expected a summary. But I have not presented my private passions about medicine to you in this way. Perhaps you would not have expected anything so reasonable of me.

Rather, I have presented them as a collage of fragments of general practice, leaving you to make such sense of my canvass as you will. A palimpsest might be a better metaphor. A palimpsest is a canvass or parchment on which each new image is superimposed on its predecessors, so that the old images show through, co-exist as ghosts haunting the new. My favourite contemporary water colourist, her name is Jenny Franklin, paints like that [29]. My favourite doctors consult like that. So, no definitive summary from me; you must imagine your own summaries.

Willie Fulton played you some music at the opening of his lecture. I promised you some music at the end of mine. What Mozart does with this silly scene, the mischievous wager, the make believe voyage, the lies, the little tragedies concealed in broad farce, is to transform the moment so that now, and when the dénouement is complete, it is love, not cynicism, that has triumphed. Just as in the consultation I have just described, the moment between the doctor and her patient is transformed by a clinical artistry beyond mere managerial artifice.

Would that our private passions could match such public performance. (fade in ‘Soave sia il vento’ [30]).

Marshall Marinker.   11 October 2003

Delivered at Glasgow Medical School, Wednesday 22 October 2003.