Current issues in the care of older people:

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Find the Gap Doubt and Freedom in General
Practice
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• Between what we know and what we think we know
• Between the map and the territory
• Between medical science and human suffering

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The imperative of doubt
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- in politics, in philosophy, in theology, he was
a doubter and a seeker yet in matters of art and
poetry - and, above all, of music, of which he
was totally devoid of understanding - he had the
most definite and decided opinions.

• Leo Tolstoy
• Anna Karenina

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He was not without that particular confidence
that arrives unencumbered by the need for thought
-

• Richard Flanagan
• Gould's Book of Fish, 2001

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- assuming he has been wise and prudent enough
not to believe blindly in what he thinks he
knows, because this rather than ignorance is the
cause of the greatest blunders.

• Jose Saramago
• The History of the Siege of Lisbon, 1989

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None of us - generalists all, working in an open
system of human interaction can afford the luxury
of certainty, or even near certainty.

• Stevens J.
• Brief encounter.
• J Roy Coll Gen Pract 1974 24 5-22.

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- a dominant discourse that preens itself as
unanimous wisdom -

• Pierre Bourdieu
• The Progressive Restoration
• New Left Review, March - April 2002

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- I was bearing witness to the only sure thing
that was in me (however naïve it might be) a
desperate resistance to any reductive system.
For each time, having resorted to any such
language to whatever degree, each time I felt it
hardening and thereby tending to reduction and
reprimand, I would gently leave it and seek
elsewhere -

• Roland Barthes
• Camera Lucida, 1980

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He carried into his writing the classroom
principle that stating any proposition without at
least a hint of doubt about its validity is a
form of bullying. His only dogma was that,
pending further thought, all claims ought to be
provisional

• Andrew Delbanco
• Review of Trilling L. The Moral Obligation to Be
  Intelligent Selected Essays
• New York Review of Books, 2001

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no one who reads thoughtfully...will ever again
be certain

• Trilling L. The Moral Obligation to Be
  Intelligent Selected Essays
• New York Review of Books, 2001

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For any particular problem, we need a solution
that sorts out the particular complications that
puzzle us, not one that ignores them because they
are untidy.

• Mary Midgley
• Science and Poetry, 2001

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- modest doubt is calld the beacon of the wise -

• William Shakespeare
• Troilus and Cressida, Act 2, Scene 2, line 16.

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just distinction between certainly knowing and
clearly knowing Our ignorance, with all the
intermediates of obscurity, is the condition of
our ever-increasing Knowledge.

• Samuel Taylor Coleridge
• Notebooks, 1804-6.

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Negative Capability, that is, when a man is
capable of being in uncertainties, mysteries,
doubts, without any irritable reaching after fact
and reason -

• John Keats (1795-1821)
• To G and T Keats, 21 Dec 1817
• Letters (ed MB Forman 1935) 32.

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Alfred Korzybski (1879-1950)
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A map is not the territory it represents, but,
if correct, it has a similar structure to the
territory, which accounts for its usefulness.

• Alfred Korzybski
• Science and Sanity an introduction to
  non-Aristotelian systems and general semantics.
  1933.

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All theory is grey. The golden tree of life is
green.

• Johann Wolfgang von Goethe
• Faust
• 1808/1832

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- the key interests of the clinician the exigent
and difficult reality of illness as a human
experience and the core relationships and tasks
of clinical care.

• Kleinman A.
• Patients and Healers in the Context of Culture,
  1980.

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- absolute truths are ideology and are the
opposite of language and the opposite of using
the intellect and the intelligence.

• John Ralston Saul
• Power versus the Public Good
• the conundrum of the individual and society
• 1996 Hagey Lecture

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- the search for an escape from the dismay of
living investing oneself in things, recognizing
oneself in signs, transforming the world into a
collection of symbols a first daybreak of
culture in the long biological night.

• Italo Calvino
• Mr Palomar, 1985

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The urge to tell a story is the oldest of human
impulses, for it clarifies and orders the
relationship between the private and the public,
our inner and outer worlds, and it records the
dissonance between these two spheres of
existence.

• Caryl Phillips
• A beacon in dark times, The Guardian Review
• Saturday 22 November 2003

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To know and not to speak.In that way one
forgets.What is pronounced strengthens
itself.What is not pronounced tends to
non-existence.

• Milosz C. Reading the Japanese Poet Issa
  (1762-1826) (1978)

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With time, dealing with contradictory narratives
in this way has come to me to seem a dynamic
process. Out of it came the energy to refuse and
reject, to learn to hold on to reservations. Out
of it came a way of accommodating and taking
account of difference, and of affirming the
possibility of more complex ways of knowing.

• Abdulrazak Gurnah
• Small World, The Guardian Review
• Saturday 11 September 2004

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Adding decades of immobility to a life formerly
organized around action will for them leave a
narrative wreck with no structure or sense, a
life worse than one that ends when its activity
ends.

• Ronald Dworkin
• Lifes Dominion An Argument About Abortion,
  Euthanasia, and Individual Freedom, 1993

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These stories are told in conditions of fatigue,
uncertainty, sometimes pain, and always fear that
turn the ill person into what Ronald Dworkin
describes as a narrative wreck, a phrase
displaying equal wit and empathy.

• Arthur W Frank
• The Wounded Storyteller Body, Illness and
  Ethics, 1995

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- he, like anyone facing serious illness, had
suddenly lost the central resource that any
storyteller depends on a sense of temporality.

• Arthur W Frank
• The Wounded Storyteller Body, Illness and
  Ethics, 1995

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- some sense of being shipwrecked by the storm of
disease -

• Arthur W Frank
• The Wounded Storyteller Body, Illness and
  Ethics, 1995

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Stories have to repair the damage that illness
has done to the ill persons sense of where she
is in life, and where she may be going. Stories
are a way of redrawing maps and finding new
destinations.

• Arthur W Frank
• The Wounded Storyteller Body, Illness and
  Ethics, 1995

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Ethnography, biography, history, psychotherapy -
these are the appropriate research methods to
create knowledge about the personal world of
suffering. These methods enable us to grasp,
behind the simple sounds of bodily pain and
psychiatric symptoms, the complex inner language
of hurt, desperation, and moral pain (and also
triumph) of living with an illness.

• Arthur Kleinman
• The illness narratives, 1988

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