Tag Archives: revalidation

105. The Firehose Paradox.

The first rule of psychotherapy?  Never quote song lyrics, even if they seem devastatingly apt. Even if someone says ‘it’s like a jungle out there’, do not be tempted to reply ‘you sometimes wonder how you keep from going under’.

Even if someone says, ‘some people call me Maurice’, as actually happened to me once, don’t be tempted to get out the air guitar and play the riff from The Joker. (No, I didn’t do it.)

Quite likely your client will recognise the words, in which case your authenticity is blown. 

Nevertheless, songwriters are great at encapsulating a feeling. If you must quote, include the attribution. Like, ‘as Leonard Cohen would say, Everybody Knows’. 

I’m a late convert to Leonard Cohen’s music and poetry. Clearly, he should have won the Nobel prize instead of Dylan, just for this song. Everybody Knows. In 5 minutes and 37 seconds the song lists all kinds of skulduggery that passes for normality. The dice was loaded. The good guys lost. And in particular, a concern about Fidelity: ‘You’ve been faithful, give or take a time or two’.

There are lots of lines in the song that sound like paranoia but fall just on the right side of understandability. Everybody Knows gets close to conjuring a ‘delusional mood’, an altered state of experience where nothing seems normal. Everybody Knows creates a resonant view of the world’s main problem, which is Falsehood.

But does ‘everybody’ mean ‘everybody’ or just ‘everybody but me’? 

There are hundreds of words for Falsehood and the list is growing. I like ‘knowing’, but you may prefer terms that allow a little more nuance, like ‘greenwashed’, ‘gaslit’, or ‘spun’. Not to mention, for Bill and Ted fans, the evergreen word ‘bogus’.

I am using ‘knowing’ to describe a situation where deceit is implicit but unspoken. Knowingness describes a situation where people quietly share an awareness of falsehood. Like when the checkout assistant asks whether you found ‘everything you were looking for’ today and you say Yes, but you mean No.  The assistant has been told to say that to every customer, perhaps in case Bono ever visits Eurospar. And is still looking for whatever it was he was looking for in 1987. 

What the checkout operator is really saying is ‘I’m being held hostage in this shop, call the cops’.

In Casablanca, (spoiler alert)  everyone knows that Rick shot Major Strasser, including Captain Renault who was there at the time. Instead of arresting Rick, the Captain orders his men to ‘arrest the usual suspects’. Note, Renault does not actually tell a lie.

How often does arresting the usual suspects resonate with our experiences today?

Take this Guardian article by Rafael Behr*

This followed a Sunak speech pretending that he had cancelled a tax on meat, mandatory car sharing, needing 7 recycling bins and other fictitious green policies.

Behr observes that the speech was ‘delivered without the trademark Boris glint that showed at least some awareness that he knew that you knew that he was bullshitting’. Worryingly that means that Sunak is either a better liar than Boris or the opposite, that he has no insight into his own scam and thinks he is telling the truth. 

The glint, the knowing look, is the sure sign of a ‘knowingism’. But if the glint is not discernible there’s a problem. Knowing who knows and who doesn’t has become a major challenge. At one end of the scale, which we can call Glint Positive, is the account of two Russian tourists who visited Salisbury in 2018 and who were suspected of poisoning people. They claimed when interviewed that Salisbury Cathedral was ‘famous, not just in Europe but in the whole world for its 123 metre spire, for its clock, the first one of its kind ever created in the world, which is still working’. 

This is a clear ‘Everyone Knows’ situation. Salisbury cathedral isn’t even famous in Wiltshire.

At the other end of the scale perhaps, I once had a colleague who left stacks of casenotes on every horizontal surface, so that you could hardly see him across his desk. He complained every time you met him that he was grossly overworked. I never knew if he really was stretched to the limit or merely conducting a strategy, possibly one he had learned on a management course, to stop people asking him to do anything. I don’t think he had a glint in his eye though. He probably just had a terrible job.

What happens when a person has learned to disguise that tell tale glint? Or more likely, when a person has talked himself so well into a role that he has forgotten he’s acting?

Misrepresentation, distortion or outright lying is rife in politics, advertising, in corporations and in the public sector. 

Top of the list for doctors in the UK is the monstrous carbuncle called Revalidation. Keen to be seen to respond to the Harold Shipman scandal and strangely determined to force as many retirements as possible, the General Medical Council imposed a time consuming and user unfriendly annual charade on its captive audience of practitioners. As an appraiser and as an appraisee, there are glints in both eyes throughout the process. There is even a glint each time you type the nonsense into adobe acrobat, send it a few times between you and your appraiser and eventually ‘lock it down’.

The GMC removed thousands of licences from doctors for ‘failing to engage in the requirements for their revalidation’. It’s not quite a Post Office Scandal level event. But Revalidation has probably accounted for 10% of medical time and 90% of medical exasperation since it was introduced. And everybody knows that Harold Shipman, if he hadn’t been caught, would have sailed through the Revalidation process and probably led appraisal workshops during which people unaccountably died. (Trevor doesn’t seem to have come back from the coffee break…’)

Doctors would probably settle for a much lower pay rise, or even a pay cut, if they were never again forced to fill in a ‘reflective portfolio’. The GMC say they exist to ‘protect, promote and maintain the health and safety of the public’ much as LAPD  supposedly exists to Protect and Serve. 

The psychology of knowingness was famously invoked by Donald Rumsfeld in 2002:

 ‘as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know’

Rumsfeld was ripping off a piece of psychology called the Johari Window, which has been a stalwart of management workshops since its invention in 1955. 

The four parts of the window are Known / Known; Known / Unknown; Unknown / Known and Unknown / Unknown. Leonard Cohen helpfully simplified the four window system into one – just Known / Known. 

You can probably recall those kinds of workshops and remember the levels of knowingness you felt in the room; the facilitator earnestly drawing the four windows on his flip chart, asking people to think of things that he can write in each window. Meetings where people whispered ‘beam me up Scotty’ from time to time.

Even though the song Everybody Knows, from the album I’m Your Man, came out in 1988, slightly preceding the breakdown of the USSR, the Russians got more and more fascinated with disinformation strategies.

For some reason, the capacity to generate and disseminate false information has become regarded as a work of genius. Russia’s ‘Firehose of Falsehood’ strategy has been hailed as massively effective by some psychologists.

Sometimes attributed to Putin or his advisor Surkov, who presumably read ‘1984’ in the Lower Fourth like we all did, the Firehose involves multiple competing and often conflicting streams of information.

It has been observed that Surkov’s strategy was only really effective because he revealed what he was doing. So that everyone really did know that nothing was what it seemed.

After several decades, the question remains, what has it achieved? 72nd place in the GDP per capita league? And Surkov under house arrest? Yes, but is he?  

Like pirates, a few individuals have made fortunes out of chaotic conditions. Some have been lucky, most have not. The armaments industry has done well, even if there never was a real SDI ‘Star Wars’ program, even if Ronald Reagan pretended there was. As though nobody knew he was an actor.

On the contrary, creating and broadcasting falsehoods is neither difficult nor clever and most often results in a negative outcome for the agent. Take Macbeth for instance. His strategy: kill the king, kill both his bodyguards, blame the bodyguards for the murder, make yourself king, then remember your colleague knows you did it, but have your colleague murdered too. What could possibly go wrong? Only getting PTSD, wife going mad and killing herself offstage and finally getting killed after not noticing a forest creeping up on him.

Macbeth’s plan, like the Rwanda scheme, fell apart under the weight of its own complexity.

The basic problem for propagandists is that disinformation is self-defeating. Especially in the case of propaganda whose objective is to stop people believing anything. Although repetitive and plausible disinformation can seem to be effective in the short term, does it really have a lasting effect? Did it really advance Putin’s agenda if, as a result of the Firehose of anti-vax falsehoods, there is a slightly higher rate of measles in Skegness? Or do beliefs just settle back to where they were before? Every action has an equal and opposite reaction. It’s not rocket science – oh wait, it is!

There’s a contrary view. And an alternative definition of Knowingness. Jonathan Lear, in the book Open Minded,  describes it as a posture of ‘already knowing’ – of purporting to know the answer even before the question arises. Knowingness is a false claim to knowledge that makes it impossible to be surprised by anything new.

According to Malesic,** knowingness can also take the form of ironic or cynical distance, of seeming to have ‘seen it all and gotten over it’. Which is pretty much the world view taken in Everybody Knows and perhaps the true meaning of the song, a jaded acceptance of failing humanity, always attempting to punch above its weight.

It’s become trendy to label such human failings as cognitive distortions, which is a nice way of regarding different ways of lying to oneself. 

As a result perhaps of decades of propaganda, most people’s beliefs nowadays are super shallow – often what the last person they heard told them. Popular beliefs are like topsoil or shifting sand.  

In time perhaps the sands do move and another house in Scarborough falls into the sea. 

In general though, the number of people with views that can be described as ‘fanatical’ stays below 15%, 3% or 1%, depending on where you draw the cut off line and start using terms like ‘far left’ or ‘far right’. For instance, in the UK only about 1.5% of people belong to a political party. This has been falling gradually over the last 70 years.

So, not Everybody Knows. Just 98.5% of people.

Confucious said that real knowledge is to know the extent of ones ignorance.

Socrates said that the only true wisdom is in knowing you know nothing.

Abba, more realistically, just said: knowing me knowing you – its the best I can do.

*https://www.theguardian.com/commentisfree/2023/sep/28/rishi-sunak-success-failure-general-election

**https://psyche.co/ideas/our-big-problem-is-not-misinformation-its-knowingness

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92. Doing without experts, or even people who wear spectacles.

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The CEO presents his new organisational structure, shown here as a Venn diagram.

 

A cat is out of its bag. Not Kevin, the actual cat – he can’t get through Kevlar sacking – but metaphorically speaking.

There’s a book out called ‘Where there is no psychiatrist’. Though the phrase ‘developing world’ occurs somewhere in the description, and the front cover depicts a place where people carry water in stone jars on their heads, so probably not Mexborough, in actual fact this manual is meant for Britain itself. There is no psychiatrist in your town or mine. That fellow with the beard is just a hipster. That guy with the carefully-crafted-designer-vagrancy look you admired so much is just a vagrant. Though some people are pretending otherwise, for better or for worse, mental health is going DIY.

There are exactly ten reasons for this:

  • Very few new doctors are choosing psychiatry as a speciality
  • A lot of psychiatrists are retiring to open artisan cheese shops
  • Psychiatrists who don’t use a medical model are more expensive than social workers
  • Psychiatrists who use a medical model aren’t cool enough at parties
  • Psychiatrists have to wear a T shirt that says ‘in case of disaster I am to blame’
  • People have noticed that the NICE guidelines for mental illnesses are the same ones for every single disorder
  • Illegal drug dealers have got more and better new drugs than we have in the NHS
  • Maplin have got more and better electrical treatments than we have in the NHS
  • The GMC now require you to cut down the mightiest tree in the forest, with a herring, in order to get revalidated
  • Conspiracy theorists have stolen all our best delusions

Now that we have youtube to show us how to do every task, the main constraints on DIY are statutory regulations rather than not knowing how to do things. But where there are severe penalties for unauthorised gas fitting, there is no penalty at all for pretending to be a mindfulness therapist, or for lighting candles in people’s ears.

Surely, before we start selling prozac and zyprexa in Poundland, before we legalise ketamine, before we hang special magnets from our earlobes, there should be youtube videos on how to interpret evidence and follow logic? No mate – this is England. No-one likes an expert round here.  

31. Paying homage to the Empathy Police.

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By all means grab it by the stem and de-root it, but be careful to bend properly at the knees. Above all don’t feel sorry for it.

How did that make you feel?

A question asked by a million news and sports reporters, usually following a tragic or catastrophic moment, such as falling over the first hurdle in the Olympics, having trained for 4 years day and night.

Most people don’t have, or need to have, the kind of vocabulary to describe their feelings on these occasions. The correct British response is to massively understate any emotional effects of such an event, such as saying you were slightly disappointed but otherwise had a very nice day.

A little like Abraham Lincoln’s wife’s theatre review.

Now the idiotic question beloved of crap reporters everywhere, may be asked by surgeons, misguidedly trying to improve their approval ratings: How did you feel when…(you found we had removed the wrong kidney and left two swabs and a sandwich inside you?)

We know that empathy plays a massive part in the quality of relationships. We know it plays a key role in psychotherapy. We also know that some people have very non-empathic personalities, but that doesn’t always stop them from becoming surgeons, or even psychiatrists. It doesn’t even stop them from attempting to run workshops in emotional intelligence.

Can empathy be learned? What’s your instinct on this one? Having attended (at gunpoint, it must be added) occasional ‘workshops’ designed to improve EI, I would say not. If it’s truly a type of intelligence, which is debatable, then it’s pretty unlikely to change much. Otherwise, why call it intelligence? Asking this question during each workshop made me feel unpopular, maybe hated, I wouldn’t know.

Take this sentence from today’s Times newspaper:

‘Its not very difficult to ask the question next time I have a consultation, ‘How did that make you feel?’ which just makes you a better doctor’.

This question is described as a ‘cultural signifier’ to patients that doctors were taking them seriously.

In the same article we learn that last year the number of ‘serious medical blunders’ doubled, so that there were 299 ‘never events’ such as surgery on the wrong body part. These events illustrate the real meaning of carelessness, which is entirely different from feeling you are not being taken seriously.

I know that these remarks are probably misquoted and taken out of context. Perhaps the person quoted, Prof Ben Bridgewater, is the most empathic person you could ever hope to meet.

Nevertheless, I am lost for words to express my feelings about his remarks, save for the usual, though rather dated rejoinder, ‘beam me up Scotty’.

In fact, quite large numbers of doctors are following the bumble bees and are returning to their motherships. They didn’t join up on the basis of competing against colleagues in a league table, nor do they wish to collect tons of bogus documentation to run past the GMC every five years. So we are set to lose a large number of valued part time and older colleagues, much as we lost a whole generation of experienced ‘old- school’ nurses (and some old school-nurses) when PREP started.

When surgeons start facing the Empathy Police I fear many of them will hang up their gowns and wellies.

All this matters this week because I have hurt my back. In what I now know should be called a ‘never event’, I tried to lift something very heavy in the garden, and felt ‘something go’, way down in the lower sacral spine.

In fact I am not looking for any empathy at all on this one. Not even genuineness, warmth, or unconditional positive regard. I’m hoping not to have to fill in any questionnaires or rating scales. I don’t want the transference or counter transference interpreted.

Also, I don’t want to be taken seriously – lets keep it light should we?

In fact, I’d prefer a rather brusque and disdainful approach. After all it was pretty silly doing what I did. I really wasn’t following my own advice at all, which is to limit gardening activity to occasional chemical warfare against insurgent weeds, backed up by sound diplomacy.

So really, a telling off is fine. But what I want to obtain is a reasonable armoury of painkillers and ideally, an encounter with some kind of scanning machine.

And if I’m asked how I feel I will say I am slightly disappointed.

24. Dangling from the last helicopter out.

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What a lowly position feels like.

Sometimes Depression is a sign that your predicament is poor. Surveys show large numbers of people think about quitting their job, but very few actually do so.

A life-time ago, I can remember spending Monday afternoons in an operating theatre, assisting my boss, who was a vascular surgeon. Every week, at about 4pm, there would be a commotion in the theatre next door, as the very temperamental colo-rectal surgeon working there went slightly berzerk. Sometimes he would hurl items of equipment at the wall. Usually he would announce his resignation and storm out. He was always back next week though.

Remember the last scene in Dirty Harry, where Clint Eastwood’s character, Harry Callaghan, throws his police badge into a pond?

What symbol of your job would you throw into the water if you decided to quit in disgust, as the camera zooms out and the credits roll?

If you are a gynaecologist, perhaps an laparoscope would do, an old style – rigid model, thrown like a javelin. The butcher could throw his white trilby hat like a frisbee. But what about the Timpson’s shoe repair and key cutting man, who looks increasingly fed up? He’s big, but how far could anyone throw a lathe?

I have just the thing, which is a John Major era ‘Chartermark’ badge. The citizen’s charter was a policy intended to elevate the concerns of ordinary folk, like the increasing numbers of traffic cones. The problem was, there were no ordinary folk left. The baby boomers were all special.

The badge is made of bronze and about the size of a broad bean. I could skim it far out onto the river on a calm day. I’m sure though, if I went to the river there would be a queue of disgruntled workers hurling various emblematic work items.

What expression should one choose for the camera, just before the zoom-out? Sad inevitability? A mixture of guilt and relief? Or – it’s video remember – deadpan? As though all the life has gone out of you?

More and more people are fed up with work and a lot of them have suffered ‘burnout’. Neil Young said ‘its better to burn out than to fade away’, but in a sense the two things are the same, just different types of oxidation reaction.

The phrase burn-out, which was hyphenated in those days, apparently derives from Graham Greene’s book, The Burnt-Out Case, which features an exhausted celebrity architect who goes to work at a leper colony. The parallel is between architecture and leprosy in terms of their effects on people, which is to make them quite interesting and very thin.

The ‘Whitehall’ studies looked at sickness in various groups of workers within the civil service. They seemed to show that the more lowly paid the job, the more stressful it turned out to be, which is the exact opposite of the commonly-touted belief that high-flying jobs are the most vexing.

Nevertheless, even in medicine, which is quite rewarding in many ways, my impression is that an increasing number of people are walking away, sometimes after a dozen or more years of training and dedication.

I tried to research the number of doctors who are qualified but don’t work in medicine, but it is hard to get these statistics.  A sizable number are still registered and licensed by the GMC but will quit as they come up for revalidation (or to give it its proper name, The Cull.) Many more work part time or intermittently, via agencies.

Whatever the number in work, if you look around your locality, ask yourself: are there any more GPs than there were 20 years ago? And: how easy is it nowadays to sign on with a GP?

As far as I can see, the answers are, ‘No’ and ‘as easy as getting through Tintwistle’. I’m not sure where the GPs are going, but its probably the same place as the bumble bees. Studies have shown that GPs have the highest burnout rate of any professional group, up to 40%, at least in Holland.

Not been to Tintwistle? Let me explain:

The giant industrial cities, Manchester and Sheffield sit about 35 miles apart on either side of a small set of hills called the Peak District. Because they are in the north of England, there is no proper road joining them up. Things start well enough, as you leave Manchester on a fine new highway called the M67. After five miles, the M67 ends abruptly and you are frozen in traffic, as though liquid nitrogen had suddenly been sprayed over the road from a giant cartoon airship flown by Mister Freeze.

During my time at Tintwistle, which was longer than many prison sentences, I reflected on the notion of helplessness, and how it affects the nervous system. The most accurate description I can think of is that helplessness hits the human organism like a rubber hammer. There are no wounds, no broken bones, not even ruptured internal organs. Just a sense that something deep inside of you is broken.

I can remember similar effects from going on fairground rides with inappropriately high and sustained circular motion. What initially seem to be expressions of happiness on people’s faces turn out merely to be rictus grins caused by G force.

Getting stuck at Tintwistle has much in common with being in a low paid job in the civil service. You have little control over your destiny. And its too late to wonder what you were doing there in the first place.

The truth is, no-one gives much advice about the really important choices in life. Things like which partner to choose, what career to follow, or which team to support. These often start out like the M67, wide and promising, and then, suddenly, the road just runs out.

It’s easy to see people who have chosen completely the wrong jobs. There’s the lollipop man who attacked someone with his lollipop. There’s the science teacher who battered a pupil with a 3kg dumbbell, shouting ‘die, die, die’. There’s Tony Blair as peace envoy to the middle east. And there’s the man at Tesco who prints the yellow price stickers, who should be a master villain in a Bond movie.

In Thinking, Fast and Slow, Nobel prize – winning psychologist Daniel Kahneman reveals that he and his team of experts were quite unable to predict who would succeed as army officers, despite all kinds of aptitude tests. So it seems unlikely that the school careers teacher will succeed in putting everyone on the right path.

Perhaps people are more likely to change job nowadays in mid life, giving a chance of redemption.

Otherwise I think I have a solution, based a bit on Prime Ministers’ cabinet re-shuffles. My idea is to put someone like the town mayor or an official psychologist in charge of employment. He would be able to shuffle people from one job to another if they are looking burned out.

So the Timpson man becomes the science teacher. The butcher becomes the gynaecologist. The science teacher gets to cut keys. And the gynaecologist gets to kill serial killers in San Francisco.

The civil service can be moved to Tintwistle, so that everyone is always late and the activities of the government will be frozen, like in Italy.

There was no scene showing Harry Callaghan with a snorkel and flippers, retrieving his badge for the sequels, but he returned several times. Even worse, none of the sequels allowed him to move to a less bureaucratically-frustrated role, such as running the police pottery workshop, and the body count continued to rise.

Perhaps the GPs will return for a sequel one day, or even turn up at the end of the movie, like the old naval warriors in Battleship.

Or, just as all hope is abandoned, the bumble bees will swarm back over the horizon in giant black clouds. They have made enough honey not only to feed us but to run our cars too.