It's all in the timing


Since retiring I've had more time for my hobby, songwriting, and last year my musical friends and I returned to the Edinburgh Fringe with a mixture of humour and history. A sense of timing is essential for both songs and jokes, and ours was, mercifully, still just about intact. Comic timing is age-related: youthful comedians rarely pause for breath because their noisy young audiences have fast reactions – something that my wife and I noticed when we became midweek theatregoers. Busloads of schoolchildren certainly liven up Shakespeare, and as we recently discovered, intense contemporary drama is much more fun when its sex scenes are accompanied by slurping sounds from the stalls.

The skill of slowing down comes with age. Its supreme exponent was a music-hall comedian whom I saw in London in the 1970s after I attended a MRCOG course. His name was Max Wall and he had become, in his late sixties, a darling of the smart set. What I remember most about his very funny one-man show was the long silences. “Not a bad house … for a Tuesday,” he remarked, watching us intently, like a matador, ready to skewer us at any moment. In the second half he came on as Professor Wallofski, a grotesque parody of the pianist Franz Liszt. Come to think of it, he may have sowed the seed of our recent Fringe show, which was all about Frederic Chopin.

Ask me later

A sense of timing is also important for doctors, as we ask our intrusive questions and give our unwelcome advice. General practitioners say that a patient often mentions the real problem only when the consultation is nearly over: this requires another, longer, appointment. One of the benefits of private practice, I'm told, is getting to know a patient properly, something which is almost impossible in the NHS. I've been an NHS patient from time to time, very grateful for the efficiency but aware of being on a conveyer belt. Each professional, however courteous and well-trained, has one eye on the clock. We patients sympathise but it's a shame that we need the hide of a rhinoceros to mention a problem that isn't already on the computer.

From my days in practice, one of my most memorable patients was a woman with abdominal pain that had led to some major operations, not all gynaecological. No pathology had been found but for some reason I found it hard to discharge her from the clinic. She answered no to all my questions but eventually phoned to ask for an urgent appointment, at which her history of childhood sexual abuse slowly emerged. An extreme example, yes, but it illustrated that however cordial your handshake, a patient may need a long time to decide if she can trust you.

A long time in politics

Timing is even more important at the medicopolitical level. I can remember when decisions about running a service were taken by consultants (yes, really) but even in those days achieving consensus was no easy matter. I admired my senior colleagues who had mastered the art. During most of the debate they kept quiet, and then they chose exactly the right moment to intervene. Suddenly we found ourselves agreeing, grateful that they had summed up the mood of the meeting and rarely realising that they had got what they wanted.

Today the big decisions are made, not by doctors or managers, but by politicians, whose timing extends only as far as the next election. They know that any worthwhile project to improve the nation's health takes a couple of decades but they need instant results. In the game of political football the teams change ends every five years and key players are substituted more frequently than that: England has had 12 Health Secretaries in the last 23 years. Sadly, their short-term gimmickry makes real change all the slower.

This must be why the introduction of relicensing has taken three times as long as the Second World War. Somewhere in our attic are drafts of the first RCOG working party report on revalidation, which I helped to write in 1999. We proposed a process that was essentially the same as the one now due for completion in 2016. What happened during those 17 years? The websites became slicker, the entrepreneurs moved in and some of us suffered terminal disillusionment. Imagine the uproar if the response times of the doctors soon to undergo revalidation matched that of the people in charge of the process.