Less-than-busy doctors: “The Beetle Hunter” Arthur Conan Doyle

S J Perelman wrote a series of New Yorker articles titled “Cloudland Revisited”, wherein he re-read or re-watched various books and movies of his youth. In what now seems a slightly grating way , he invariably finds them ludicrous pulp. Anyhow, in “Doctor, What Big Green Eyes You Have”, Sax Rohmer’s Fu Manchu stories come in for the treatment. In this, Perelman writes:

“Petrie, I have travelled from Burma not in the interests of the British Government merely, but in the interest of the entire white race, and I honestly believe – though I pray I may be wrong – that its survival depends largely on the success of my mission.” Can Petrie, demands Smith, spare a few days from his medical duties for “the strangest business, I can promise you, that ever was recorded in fact or fiction”? He gets the expected answer: “I agreed readily enough for, unfortunately, my professional duties were not onerous.” The alacrity with which doctors of that epoch deserted their practice has never ceased to impress me. Holmes had only to crook his finger and Watson went bowling away in a four wheeler, leaving his patients to fend for themselves. If the foregoing is at all indicative, the mortality rate of London in the nineteen-hundreds must have been appalling.

 

My understanding is that Arthur Conan Doyle had a quiet career as a private ophthalmologist before literary work overtook his medical efforts. Of course, the structure of medicine as a career was very different then. The medical student and junior doctor of popular and popular-ish fiction tends to have more free time than is the norm nowadays.

Conan Doyle’s short story The Beetle Hunter is very much in this mould. Perhaps this paragraph reflects more about Conan Doyle’s own view of the medical professional than strictly being a piece of social history, but there you go:

I had just become a medical man, but I had not started in practice, and I lived in rooms in Gower Street. The street has been renumbered since then, but it was in the only house which has a bow-window, upon the left-hand side as you go down from the Metropolitan Station. A widow named Murchison kept the house at that time, and she had three medical students and one engineer as lodgers. I occupied the top room, which was the cheapest, but cheap as it was it was more than I could afford. My small resources were dwindling away, and every week it became more necessary that I should find something to do. Yet I was very unwilling to go into general practice, for my tastes were all in the direction of science, and especially of zoology, towards which I had always a strong leaning. I had almost given the fight up and resigned myself to being a medical drudge for life, when the turning-point of my struggles came in a very extraordinary way.

A story in which a recent medical graduate now is immersed in idleness would be seen as fatally implausible. He or she would be doing pro bono work down the lab, sequencing some beetle genome or other. Of course, this striving means we are Much Better People than those of long ago. Doesn’t it?

 

 

 

 

 

 

 

#OceanOptimism, powerlessness, hope, and change.

The current BBC Wildlife Magazine has a fascinating article by Elin Kelsey, of the Ocean Optimism Project, on how media-fuelled environmental despair and nihilism ends up demoralising people to the degree that positive action seems impossible. She cites much research on the “finite pool of worry” and the paralysing effect of despair, and the power optimism to reverse this trend. The article isn’t available online, but in the post below from my other blog I highlight relevant passages from a Kelsey piece in Smithsonian Magazine on similar themes.

This article is obviously focused on ecology, but is all too true of our healthcare systems. For similar reasons to those Kelsey ascribes to environmentalists who are wary of being overly focused on good news, frontline workers in the health service naturally tend to focus on what is wrong, what is proving impossible, what needs to change. This is necessary, but can become an overwhelming counsel of nihilism, fostering cynicism and very often helping to entrench negative practices.

This is very relevant to the various themes on valuesmorale, “blame culture”, and possibility of positive change within not only the HSE but any healthcare organisation.

Séamus Sweeney

The current issue of BBC Wildlife Magazinehas a fascinating cover story by Elin Kelseyon hope and optimism versus despair in how we think about they environment. Essentially, much media discourse on the environment tends to be gloomy, doom, and generally despairing. Kelsey cites a wide range of research on how this negativity effects how we think about the environment and our beliefs about what can be done – and therefore what is done – to improve things. The full article is not available online. This article from Smithsonian Magazine is briefer, but captures her idea:

Things are far more resilient than I ever imagined. Me, green sea turtles, coral reefs blown to bits by atomic bombs. In a twist of fate that even surprised scientists, Bikini Atoll, site of one of the world’s biggest nuclear explosions, is now a scuba diver’s paradise. Bikini Atoll located in the Pacific’s…

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What practice which seems perfectly fine to us now will seem weird/unethical/laughable in fifty years?

On my other blog I posted a quote from James Jeremiah Sullivan’s essay  on the polymath Constantine Samuel Rafinesque:

That’s what’s so terrifying but also heroic in Rafinesque, to know he could see that far, function at that outer-orbital a level intellectually, yet still wind up viciously hobbled by the safe-seeming assumptions of his day. We do well to draw a lesson of humility from this. It’s the human condition to be confused. No other animal ever had an erroneous thought about nature. Who knows what our version of the six-thousand year old earth is. It’s hiding somewhere in plain sight. In five hundred years there’ll be two or three things we believed and went on about at great length, with perfect assurance that will seen hilarious to them.

One could cite many many examples of “safe seeming assumptions” in every sphere – moral, scientific, social, cultural – which as time went by became unsafe and then positively harmful, laughable or just plain weird.

There is a self-congratulatory tendency to exaggerate and outright distort how wrong people were in the past. This is a form of epochalism, the belief that we live in a time unique in human history  True in a trivial sense, but blind to the patterns of human life and what could be called the human condition. One of the recurrent themes on Stephen Pentz’s poetry blog First Known When Lost is that the modern belief that We Are Somehow Unique is an illusion. Other people, at other times, have struggled with mortality, the passing time, what is a good life, and in times in their own way as complex and baffling as our own.

Anyhow, the point of this post is really to post a question, and a question that is in principle unanswerable. What will the practices in medicine in healthcare that, in fifty years, will seem either weird or unethical or simply bad, that we take for granted today? The nature of this question that these are not things that, by and large, are objected to today, but seem a normal part of practice. One could put forward many obvious answers about eHealth or about health insurance, but of course values change over time and assuming our values now will be the normative values of fifty years is a fool’s game.

Review of “Casebook of Psychosomatic Medicine”, Bourgeois et al, IJPM 2011

The above review from the Irish Journal of Psychological Medicine follows on from my review of The Physician As Patient in the same journal. Both books were excellently written, and as time has gone by I appreciate their approach more deeply. As I say in the first paragraph, evidence based medicine and what could be called experience based medicine are often driven into a false dichotomy. Both these books possess wisdom in abundance, and wisdom based medicine is perhaps what we should all be aspiring to practice.  

Leandro Herrero: “A team is not a meeting”

 

Another wonderful reflection from Leandro Herrero, this time I am being more selective in my quoting…:

 

One of the most toxic practices in organisational life is equating ‘team’ and ‘team meeting’. You could start a true transformation by simply splitting them as far apart as you can and by switching on the team permanently. In a perfect team, ‘stuff happens’ all the time without the need to meet. Try the disruptive idea ‘Team 365’ to start a small revolution.

In our minds, the idea that teams are something to do with meetings is well embedded. And indeed, teams do meet… But ‘the meeting’ has become synonymous with ‘the team’. Think of the language we often use. If there is an issue or something that requires a decision and this is discussed amongst people who belong to a team, we often hear things such as, “let’s bring it to the team”. In fact, what people mean really is, “let’s bring it to the meeting. Put it on the agenda.” By default, we have progressively concentrated most of the ‘team time’ in ‘meeting time’. The conceptual borders of these two very different things have become blurred. We have created a culture where team equals meetings equals team. And this is disastrous.

As a consequence of the mental model and practice that reads ‘teams = meeting = teams’, the team member merely becomes an event traveller (from a few doors down or another country?). These team travellers bring packaged information, all prepared for the disclosure or discussion at ‘the event’.

Leandro Herrero: “An enlightened top leadership is sometimes a fantastic alibi for a non-enlightened management to do whatever they want”

From Leandro Herrero’s  website, a “Daily Thought” which I am going to take the liberty of quoting in full:

Nothing is more rewarding than having a CEO who says world-changing things in the news, and who produces bold, enlightened and progressive quotes for all admirers to be. That organization is lucky to have one of these. The logic says that all those enlightened statements about trust, empowerment, humanity and purpose, will be percolated down the system, and will inform and shape behaviours in the milfeulle of management layers below.

I take a view, observed many times, that this is wishful thinking. In fact, quite the opposite, I have seen more than once how management below devolves all greatness to the top, happily, whilst ignoring it and playing games in very opposite directions. Having the very good and clever and enlightened people at the top is a relief for them. They don’t have to pretend that they are as well, so they can exercise their ‘practical power’ with more freedom. That enlightened department is covered in the system, and the corporate showcase guaranteed.

The distance between the top and the next layer down may not be great in organizational chart terms, yet the top may not have a clue that there is a behavioural fabric mismatch just a few centimeters down in the organization chat.

I used to think years ago, when I was older, that a front page top notch leader stressing human values provided a safe shelter against inhuman values for his/her organization below. I am not so sure today. In fact, my alarm bell system goes mad when I see too much charismatic, purpose driven, top leadership talk. I simply smell lots of alibis below. And I often find them. After all, there is usually no much room for many Good Cops

Yet, I very much welcome the headline grabbing by powerful business people who stress human values, and purpose, and a quest for a decent world. The alternative would be sad. I don’t want them to stop that. But let’s not fool ourselves about how much of that truly represents their organizations. In many cases it represents them.

I guess it all goes back, again, to the grossly overrated Role Model Power attributed to the leadership of organizations, a relic of traditional thinking, well linked to the Big Man Theory of history. Years of Edelman’s Trust Barometer, never attributing the CEO more than 30% of the trust stock in the organization, have not convinced people that the ‘looking up’ is just a small part of the story. What happens in organizations has a far more powerful ‘looking sideways’ traction: manager to manager, employee to employee. Lots of ritualistic dis-empowering management practices can site very nicely under the umbrella of a high empowerment narrative at the top, and nobody would care much. The top floor music and the music coming from the floor below, and below, are parallel universes.

Traditional management and MBA thinking has told us that if this is the case, the dysfunctionality of the system will force it to break down. My view is the opposite. The system survives nicely under those contradictions. In fact it needs them.

 

I found this reflection, especially the final three paragraphs, particularly striking. Health care organisations are getting better and better at talking the talk at the highest levels about empowerment and respect and [insert Good Thing here] – but how much that really has an impact on the daily management practices that are the day to day reality of working within that organisation?

I also like the scepticism about Role Model Power of the Big Man (or Woman) on top. Dr Herrero, described on his Twitter as an “organisational architect”, clearly has a healthy view of the reality that underlies much rhetoric. I look forward to the HSE’s Values in Action project which is very much following the lines of his work.

Hickam’s Dictum

While researching the medical saying “When you hear hoofbeats, think of horses not zebras”, I came across Hickam’s dictum – “patients can have as many illnesses as they damn well please.”

It is described as a counter-saying to Occam’s Razor, which has always struck as a a heuristic saying which has been misused many times to suggest that the “simplest” explanation MUST be true. Occam’s Razor can be a valuable tool for cognitive discipline, but it is NOT a normative statement about The Way The World Is

Hickam’s Dictum was a new one on me, but has a reasonable presence in the medical literature. And it is very far from an abstract notion.

There is a whole world of medical sayings and proverbs (a lot of which are new ones on me) out there. On the one hand, they represent a sort of hidden curriculum of heuristic tools. On the other hand, how influential are they really? As I said, I have never come across Hickam’s dictum before – but I think I will end up quoting it quite a bit.