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Br J Gen Pract. 2007 May 1; 57(538): 426.
PMCID: PMC2047042

On dissonance

For the past couple of years I have been trying to learn the basics of jazz guitar, and providing part of the rhythm section of our local 16-piece dance orchestra. Not only has this provided me with the novel experience of wearing a white tuxedo — as far from my self-image as I could ever imagine being — but it has also given me plenty of experience of dissonance. Of course in jazz, dissonance, an auditory sensation experienced as a state of unresolved tension or suspense, is half the point, and a multitude of strange chords — diminished, augmented, suspended and extensions thereof — has evolved to meet it. In the old dance standards that we play the dissonances are usually resolved by a comforting, good old-fashioned major triad, but more modern jazz seems to thrive on dissonances left unresolved.

Back in the day job, I am finding myself increasingly uncomfortable with much of what passes for modern general practice, experiencing this as a state of cognitive dissonance. The term was coined by an American psychologist1 half a century ago, and its continued currency attests to its value as a conceptual tool to help in analysing conflicts in an individual's behaviour, values and beliefs. Roger Neighbour made use of the term in his book, The Inner Apprentice,2 showing how potent a force it could be for learning.

For example, last week I saw a middleaged man with a painful red eye, with a raised nodule beneath the sclera. I felt uncomfortable: the belief that I should know about ‘causes of the red eye’ clashed with the undeniable fact that I didn't know enough about this particular condition. It was fairly easy to resolve this dissonance by a combination of consulting a textbook and ringing the ophthalmology registrar for advice — we agreed it was probably nodular episcleritis, and that it was reasonable to use steroid eye drops, having excluded a dendritic ulcer by slit lamp examination.

But as one moves from the particular to the general, cognitive dissonance becomes a trickier creature to tame. I don't think it is any secret that I am not a great fan of the Quality and Outcomes Framework (QOF). I have doubts about the clinical validity of parts of it, I believe it distracts from other, equally important aspects of the GP's role, and I am convinced that it is a serious threat to independent thought. The fact that I have to play by its rules is a potent source of cognitive dissonance, which I try to lessen by a combination of valuing the good parts of the QOF (improved diabetic care for example), refusing to comply with some of its most dubious demands (routinely using depression scoring tools), and reminding myself that the practice's financial viability, and my own income are dependent on a degree of adherence.

Similar manipulations of values, beliefs and behaviour come into play when it comes to dealing with such ball-breaking impositions as the Information Management and Technology Direct Enhanced Service. To prove how ‘paper light’ (or lite, as it is revealingly described in the endless missives from the PCT) we are, we are obliged to churn out reams of paper, with personalised Training Needs Assessments for each member of the practice, linked to Personal Development Plans, completion of Online Information Governance modules, and an 8-column table of Action Points, Objectives, Constraints, Accountabilities, Outcomes and Blah-di-blahs. This kind of exercise produces in me a pitch of cognitive dissonance that is almost unbearable. It can only be resolved by delegation, and adopting a probably delusional belief that one day sanity — or at least a sense of proportion — will return.

I could go on: Choose and Book, Practice Based Commissioning, Appraisal and Revalidation, universal prescription of statins, the idea that GPs are in a position to solve the problem of obesity, the reduction in acute beds while ill patients sit in corridors and ambulances, the Private Finance Initiative, Payment By Results, ISTCs, CATS (in fact almost anything beginning with capital letters and/or reducible to acronyms) — they all induce in me a state of dissonance that threatens to make every day a nervejangling cacophony.

I have found a temporary solution, and that is to take a 3-month sabbatical next winter. I'm planning a few weeks as a ship's doctor on a trip to St Helena, and then flying to Australia and New Zealand for a couple of months. But hang on a minute: what about global warming? I can feel that familiar sensation already …


1. Festinger L. A theory of cognitive dissonance. New York: Wiley; 1957.
2. Neighbour R. The inner apprentice. Dordrecht: Kluwer; 1992.

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners