GPS for the NHS

“You are on your own. And you know what you know.

And YOU are the guy who’ll decide where to go.”

                                                                               Dr Seuss (2)

 

In his introduction to “The Road to Character” David Brooks, American journalist and author, writes  of the current emphasis on building ‘résumé virtues’ which contribute to external success, at the cost of those deeper values that he terms ‘eulogy virtues’ – those spoken of at your funeral. In each chapter he sketches individuals who faced their own unique weaknesses and emerged with some measure of self-respect. He concludes, however, that the modern day emphasis on self is about talent, not character. ‘This meritocratic mentality was beautifully captured in Dr Seuss’s 1990 book ‘Oh the Places You’ll Go!’ the fifth-biggest seller in the history of the New York Times list and still a popular graduation present.’ Brook proceeds to describe the boy in the story being ‘reminded that his life is about fulfilling his own desires.’ (3)

Life philosophy forged from rhyming verses may not carry great gravitas, but in a society where attention spans are dwindling and a rise in book sales is skewed by the inclusion of adult colouring books in the statistics, it appears that our generation is far from literate. Fictional Super Heroes, however, attract great popularity – those imbued with special powers to fight giants and survive against the odds. This reflects the prevailing aspiration that all should, like their heroes, win life’s battles. William James (1842 – 1920), the father of American psychology, was one of the first to propose that the problem of mankind was low self-esteem. As is often the case with theories of human behaviour this holds elements of truth and in the social and political milieu of its day there was a significant need to redress the balance of oppressive regimes. The shadow side, however, has created a mind-set that, perhaps, overvalues ‘self’ at the cost of acknowledging either our community interactions or our own mortality.

Nelson Mandela spoke of reciting the 19th Century poem ‘Invictus’ during his time on Robben Island and has brought it to a new generation: -

‘I am the Master of my fate

I am the captain of my soul.’ (4)

The lines may be inspiring but do not acknowledge our essential humanity. Over the millennia mankind has sought to find causation for events whether from history, bloodline or the supernatural. We continue this today, striving to establish the determinants of disease development and progression. No individual has complete mastery of the situations that befall them, although they can exercise choice as to how they react to those circumstances, however straightening they may be. To be effective, medical practitioners need to acknowledge the current prevailing emphasis on the ‘self’. In the twenty first century there is a massive yearning for control. To control not only the news of hatches, matches and dispatches, but control of the actual events themselves. The era of the paternalistic, controlling doctor has faded. Quality care aspires to allow individuals to retain command of their ‘soul’ and not be swamped by a ‘doctor knows best’ attitude. They are the Captain of their particular ship. There are, however, societal constraints regarding what treatments are acceptable and there will always be opportunity costs to our decision making.

The autobiography ‘When Breath becomes Air’ (5) paints a vivid self-portrait of a young man intent on establishing himself as a world-altering neurosurgeon, suddenly transposed to the role of patient, sufferer and statistic. As he outlines his diagnosis and interactions with his oncologist and other health care professionals he experiences a different aspect of captaincy.  In the melee of his multi-morbidity he encounters the WICOS problem. This is an American hospital acronym – Who is the Captain of this Ship? As a patient he was in desperate need of assistance with decision making and keeping in touch with reality. For Paul Kalanithi this was deeply personal. For all health care workers it is a vital question to ask and to answer as we interact with those who seek our care.

There is current turmoil in the provision of Primary Care services throughout the National Health Service. The present arrangement is dysfunctional and there are many contributing strands. In 1948 Beveridge claimed the NHS was created to slay five giants – want, disease, squalor, ignorance and idleness. After nearly seven decades the social, political and scientific backdrops have changed. The giants, however, have not been slain. There are immeasurably more health-enhancing procedures that can be done, but no political will to debate the questions of what services are appropriate to be offered free at the point of need. An unforeseen downside of the development of a free-at-the-frontline service is that generations have become passive participants in their own health. Health is no longer esteemed and the assumption has developed that if something can be done it is necessary. This need becomes synonymous with disease.

General Practitioners have been cast as the ‘Gatekeepers’ of the NHS. In the 21st Century it is difficult to visualise gatekeepers. A small elite do live in gated communities, with uniformed employees operating electronic gates from a distant control room, but ‘gatekeepers’? No, the cliché is outmoded. The default image is that of a car park attendant issuing tickets to those who have already decided on where they are going to park. The vehicle owners assume admission on their terms and this does not conjure up a picture relevant to General Practice. Implied within the obsolete gatekeeper term is the understanding that only those with significant, treatable disease will be granted access to secondary care and discharge out through the gate will be facilitated, unquestioningly by that same keeper. A new model is urgently required.

The image of a gate brings to mind Kipling’s poem ‘The Way through the Woods’ (6) although it does not in fact specify a ‘gate’ but only a ‘way’. As it reflects on a 70 year span perhaps it is apt to read as an allegory of the NHS:

They shut the road through the woods

Seventy years ago

Water and rain have undone it again

And now you would never know

There was once a road through the woods

There might be benefit in seeking out that old lost road and relearning how to travel through the woods. Wrestling with the politics and provision of health care is not confined to the NHS – the developed world as a whole struggles to reconcile scientific advances with what we can and cannot expect of our mortal existence. Seamus O’Mahoney in the opening chapter of ‘The Way we Die Now’ (7) comments  ‘When death was no longer ‘tame’ when it became hidden and medicalised we found ourselves lost and disorientated without a script to follow.’ Much of our encounter with ill health and disability also lacks a script. In an age of immediate information it is easy to gloss over the fact that information is not knowledge; facts do not equate to healthcare; care is qualitatively different from the application of systems.

We have become a tick-box culture and expect our bodies, our health and our dying to fit neatly into boxes. But life does not tessellate. The natural world has many examples of neat mathematical tiling such as seen on the petals of snakes head fritillaries and the complex three-dimensional mosaics of a honeycomb, but human life and its maladies are not so neatly boxed.

The technological era has long promised algorithms for taking over medical decision making but, in fact, it remains limited as human nature has so many vagaries. If we are to treat patients as the unique individuals that they are, then a deeply personalised practice and administration of the healing arts is required. In the twelfth century Maimonides proposed ‘The physician should not treat the disease, but the patient who is suffering from it’ and the same sentiment was expressed by Osler at the turn of the twentieth. People are fickle and that is the nub of the amazing intricacy of medicine.  In striving towards mastery of such art stimulation can be found in every consultation.

Diagnoses and management plans are seldom defined with precision. In his convoluted speech about ‘unknown unknowns’ in 2012 (8), Donald Rumsfeld outlined the system of psychological analysis known as The Johari Window. There are days in medical practice when the unknowns and uncertainties are so prevalent that situations most closely resemble one of the best recognised nonsense verses in the English language:

Twas brillig and the slithy toves

Did gyre and grimble in the wabe

All mimsy were the borogroves

And the mome raths outgabe. (9)

The author, Lewis Carroll, did list many of his definitions, but when he included the rhyme in ‘Alice Through the Looking Glass’ (10)  it is Alice who comments after attempting to read the verses :

“It seems very pretty” she said when she had finished it, “but it’s rather hard to understand!” (You see she didn’t like to confess, even to herself that she couldn’t make it out at all) “Somehow it seems to fill my head with ideas – only I don’t exactly know what they are! However, somebody killed something; that’s clear at any rate.”

Out-patient correspondence and discharge summaries can also be rather hard to understand. Occasionally there is a clear conclusion, but often layers of uncertainty about what has eventuated are only thinly disguised.

Carroll gave his definition of the word ‘gyre’ as – ‘to scratch like a dog’, but the word was not his invention as it was defined in 1420 as ‘a circular or spiral motion’. It is particularly used of a huge, circular, oceanic surface current. Yeats used the word in his depiction of a maelstrom in ‘The Second Coming’ (11) and this sense was continued in Chinua Achebe’s 1958 novel ‘Things Fall Apart’:

Turning and turning in the widening gyre

The falcon cannot hear the falconer

Things fall part; the centre cannot hold

Mere anarchy is loosed upon the world.

Dealing with life’s gyre is the essence of health care. What can be gleaned, therefore, from a study of the instruments that have been developed to navigate gyre? The basic engineering idea was developed from children’s spinning tops which have been identified in cultures from Classical times to the Maori and Asian people groups. An early piece of apparatus used in maritime navigation was the ‘Whirling Speculum’ invented by Captain John Serson in 1743. It was used as a level to locate the horizon in foggy or misty conditions. The original was created using a spinning top and a mirror and subsequent gyroscopes were developed from this. The rotating wheel is described as having angular momentum, tending to keep its orientation and resist change. Modern day gyroscopes provide stability and navigational information and are an integral part of aircraft, spaceships and robots.

It would be awkward to ask today’s General Practitioner to take on the mantle of ‘Whirling Speculum’ although the original apparatus used the sense of speculum as a mirror rather than an instrument for dilating a body cavity. Moving from the outdated ‘Gatekeeper’ concept, the title of ‘Gyroscope’ presents a modern image more accurately reflecting the role of today’s GP. Managing the convoluted currents of diagnosis, prognosis, management and care requires skilled assistance.

No captain makes safe passage without contributions from their team, especially those assessing information and advice in areas where he or she is not an expert. There are numerous healthcare workers trained to follow systems and guidelines, but in the complexities of the medical world accessing a specialist in the generality of health care is invaluable. Two centuries ago Philippe Pinel commented:

“It is an art of no little importance to administer medicines properly; but it is an art of much greater and more difficult acquisition to know when to suspend or altogether omit them.”

And returning to William James we hear one of the greatest challenges of General Practice today:

“The art of being wise is the art of knowing what to overlook.”     

The future of General Practice as the NHS reaches its seventieth milestone is to be that gyroscope, offering navigational aid and being a stabilising factor amidst the swirling currents. A GP cannot be an expert in all fields and requires wisdom in choosing what to overlook. Among all those promoting advances in scientific and evidence based medicine our communities need someone with an eye on the horizon and a steady hand. When a patient’s battles are in unknown territory, there is uncertainty over the significance of symptoms or test results and talk of cure appears remote, that steadying hand is a vital part of care:

If I could tell you I would let you know

The winds must come from somewhere when they blow

There must be reasons why the leaves decay;

Time will say nothing but I told you so (12)

There is a tendency to shy away from acknowledging that death is as integral a part of life as birth. Some may, like Philip Larkin, have recurrent nightmares about their own dying - ‘Most things never happen: this one will’. (13) And Dylan Thomas’ audible pain as he screams to his father not to accept death must surely urge the family physician to sit with the patient and offer that, at an appropriate point, it is possible to accept our mortality. It is not always essential to rage against the dying of the light. (14)

A new symbol is required for General Practice. A stylised gyroscope as a screensaver on all General Practice software might give daily inspiration for practitioners to be that essential apparatus, enabling all to captain their particular ship.

A futuristic college of gyroscopic practitioners would, however, be likely to concur with Hippocrates when he reflected on the practice of medicine:

‘The art is long, life is short, opportunity fleeting, experiment dangerous, judgement difficult.’

                               

 

  1.           GPS may refer to Global Positioning System or General Practitioner Service

  2.           Dr Seuss, Oh, the Places You’ll Go (1990)

  3.           David Brookes, The Road to Character (2015)

  4.           William Ernest Henley (1849 – 1903), Invictus

  5.           Paul Kalanithi, When Breath Becomes Air (2016)

  6.           Rudyard Kipling (1865 – 1936), The Way through the Woods

  7.           Seamus O’Mahoney, The Way We Die Now (2016)

  8.           Donald Rumsfeld, US Department of Defence news briefing, 12/02/02

  9.           Lewis Carroll (1832 – 1898),  Jabberwocky

  10.           Lewis Carroll, Through the Looking Glass (1871)

  11.           William Butler Yeats (1865 – 1939), The Second Coming

  12.           W.H.Auden (1907 – 1973), If I Could Tell You

  13.           Philip Larkin (1922 – 1985), Aubade

  14.           Dylan Thomas (1914 – 1953), Do Not Go Gentle Into That Good Night