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Br J Gen Pract. 2009 August 1; 59(565): 626.
PMCID: PMC2714799

The importance of everything else

When I was a boy I was good at hitting targets. I scored a near ‘possible’ with a .22 in the drill hall next to Abingdon Station and immediately found myself in the school shooting eight. A consequent excursion to Bisley left me unable to hear anyone else in the chapel choir for 3 days and with a high tone loss in the left ear (the one unprotected by the rifle stock) which persists to this day. I must have been so focused on aligning the sights of my 303 with the exact centre of the bull's-eye that I didn't look around to notice that I was too far forward on the butts, or maybe that the boy on my left was too far back.

Targets. Focus. Bottom lines. None so deaf but hear the resonance — the buzz, the buzz — of these terms today. Or recognise in them the distinctive cadence of our culture. The engine of our progress. Specialisation. Narrowness. Blinkers. Money.

The thing about targets is that they have to be defined. That means that they can always be measured. Success can thus be quantified. Failure can be proved. Censure can be justified. Vilification can be pursued. Bullets can be power pointed.

Contrast the baggy, diffuse approach which tries to contemplate the ‘holistic’ scene. Which attempts to take in a motley host of hypothetical, immeasurable, and tenuously-linked implications, distant in place and often, contemptibly, in time. Which worries about the future of the wood, while the focused mind forges ahead, boldly and blindly, in Top Gear, to target the trees.

If, to take one example, you are a specialist in sun-avoidance acting for a seller of highly potent sunscreen formulations, you can drive your words, rapier-like, straight to the heart of your employer's target by focusing on the proven link between sunlight exposure and ‘skin cancer’. (Especially if you include in your frightening figures a majority of tumours that are technically cancer but are nonetheless trivially-curable and/or only locally invasive.) The success of your career will thus be assured.

Benefits of sunlight exposure, if any there are, are mere folk law, popular tradition and common sense. No evidence-based connection has been established, for example, between obsessional sunlight-avoidance in childhood and reduced bone density in old age. Nor is it likely to be, certainly not until the most pallid of these children have grown old. Not your problem. Meanwhile, parents of healthy-looking children can be deftly demoralised by your finger-wagging, but evidence-based, assertion that the smallest degree of visible tanning is a response to solar damage. Let them search as they may for hard, scientific evidence of the benefits of unimpeded outdoor play; of psychological harm done to children by linking everything nice in their lives to danger; of undiscovered toxic effects of heavy, chronic exposure to highly potent skin applications. For you such woolly worries can be excluded in your marvellously focused gaze.

People like me have made a difficult journey in order to accept this new approach. But at last I can see the force of the advantages outlined above and I have to admit that my life has become a great deal easier and less worrying as a result. Now I am here in the twenty-first century in spirit as well as in calendar I can flash my sacral tattoo (having sourced a pair of genuinely sagging trousers on the internet) and embrace the Quality and Outcomes Framework as the brilliant idea the College says it is. I can at last see that the important people in government really do know best, and that their distant perspective, unencumbered by detail nor burdened by medical training, makes them the only people who can even attempt the Herculean task of reducing the complexity and human subtlety of day-to-day general practice to an array of tick boxes.

I now see the simple rule for success in the brave new world: focus your attention on targets, and close your mind to the importance of everything else.


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