If a dog is tied to a bicycle

BMJ 2012; 345 doi: (Published 26 October 2012) Cite this as: BMJ 2012;345:e7129
  1. Sean Ninan, ST4 specialty registrar
  1. 1Mid Yorkshire Hospitals, Pinderfields General Hospital, Wakefield, UK
  1. sean9n{at}

The senior house officer was fuming: “A&E! They’ve done it again! They’ve sent round an acute coronary syndrome who has blatantly got cholangitis.” He wasn’t prepared to let it go. “You’ve got to say something. This is a waste of our time and our bed.” It was clear that the patient’s initial working diagnosis was wrong and that he needed referral to the surgeons.

But there was little point in being upset; we have to accept that a certain portion of our referrals may have alternative diagnoses. My reply, however, may have seemed cryptic: “If a dog is tied to the back of a bicycle that is being pedalled forwards, which way does the dog run? It only has one choice—run forwards. If it runs backwards, it will go nowhere or, worse still, strangle itself.”

I was reflecting on an episode of the Channel 4 television series Philosophy: A Guide to Happiness,1 in which Alain de Botton takes us through the teachings of Seneca, a Roman philosopher. In it he shows a London van driver raging daily at the inconsiderate driving habits of others. Seneca called anger “the most hideous and frenzied of all emotions.” He felt we could control it by altering our view of the world. The London van driver set off every day knowing that people would drive in the way that they did. Yet each day, he was surprised and outraged, and each day he found himself getting worked up.

As doctors, we know that diagnoses may have to be revised in the light of new information. We know that things may go wrong during our working day. Yet each day many of us act surprised by what we encounter at work and rail at the injustice of it all. In the TV programme, de Botton rides a bicycle with a dog tied to the back to illustrate Seneca’s example of accepting one’s fate. Unlike dogs, however, we can reason. We can consider what things we can change, and what things we can’t. When we can’t change things, we need to change our attitude towards them—and accept that the diagnosis on referrals may not reach 100%, that blood samples may go missing, or that there are 25 patients waiting to be seen at the start of your shift. By accepting things a little more “philosophically,” we can focus on what we can change and improve rather than dwelling on what we can’t.


Cite this as: BMJ 2012;345:e7129


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