2.1 'Let's open this chest fast'

The television programme 'ER', surely a major definer of the image of medicine in the year 2001, portrays the doctor's life as one of action. However, even surgeons, who epitomise action, rarely spend more than a quarter of their time actually in the operating theatre.

Research, education and, increasingly, management reduce the time the clinician spends in direct patient care. Even within the time identified as being preserved for clinical work, the act of treatment, either initiating it, operating, or providing long-term support to a patient with a chronic disease, occupies only part of the time spent on clinical duties - for many clinicians a minority of their time. A much larger proportion of time is spent on the steps leading up to treatment, namely:

• making a diagnosis
• appraising the option of 'no treatment'
• comparing treatment options
• tailoring the information to the individual patient
• communicating information without framing
• decision-making
• decision-taking

Furthermore, all these activities involve not only thinking but also feeling, and for many clinicians the steps leading up to treatment can be at least as difficult and stressful as carrying out the treatment itself. In some ways the need to act without thought when a patient arrives in ER bleeding profusely is, although stressful, less problematic for the doctor than acting as decision-maker when time pressures are not so great.

The best account currently available of what doctors do all day is provided by Jerome Groopman in his book Second Opinions. His book is a moving account of a number of cases, including that of his own child, illustrating how agonising and difficult clinical practice can be.

2.1.1 Overt and covert operations

The doctor carrying out the clinical duties described above is acting like a watchmaker, looking at the mind or body problem brought by the patient and seeking a solution to that problem. The watchmaker analogy only goes so far:

• because the human being is more complex to deal with than the watch: watches do not have anxieties and cannot sue
• because the doctor's function of watchmaking is only their overt function

The doctor also performs three covert functions while they are watchmaking and these may not be recognised either by the patient or the doctor even though they are important drivers of the consultation and clinical practice. These three covert functions are:

• the doctor as a witch doctor
• the doctor as St Peter
• the doctor as a drug

Furthermore, the doctor, like other clinicians, has an additional function - that of healer. However, the principal reason why patients consult doctors is for the doctor to act as watchmaker.

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