The curse of the quick fix

I’ve been reading Simon Garfield’s wonderful book Timekeepers: How The World Became Obsessed With Time. It is a fascinating set of narratives on the modern relationship with time. Towards the end, it slightly turns into a series of lists of conceptual art pieces that sound less Deeply Meaningful than Garfield makes out (oddly reminiscent of Evgeny Morozov’s To Solve Everything Click Here in this regard) and occasionally some of his more jokey passages grate, but most of the time (ho ho) it is a book that makes one see the taken-for-granted of the modern world for what it is. There are very funny passages on time management self-help books and on the world of haut horologie, and extremely thought-provoking ones on our time-poor age (or is it a perception? One of the time management gurus is actually wisest on this…)

Anyway a passage which struck me as especially germane to medicine, health care in general, and health IT in particular was the following – which is actually Garfield citing another author, but there you go:

And can any of these books really help us in these decisions? Can even the most cogently aligned bullet point and quadrant matrix transform a hard-wired mind? The notion of saving four hours every ten minutes is challenged by The Slow Fix: Why Quick Fixes Don’t Work by Carl Honoré. The book set its tone with an epigram from Othello: ‘How poor are they who have not patience! What wound did ever heal but by degrees?’6

The quick fix has its place, Honoré argues – the Heimlich manoeuvre, the duct tape and cardboard solution from Houston that gets the astronauts home in Apollo 13 – but the temporal management of one’s life is not one of them. He reasons that too much of our world runs on unrealistic ambitions and shabby behaviour: a bikini body within a fortnight, a TED talk that will change the world, the football manager sacked after two months of bad results.

He cites examples of rushed and dismal failings from manufacturing (Toyota’s failure to deal with a problem with a proper solution that might have prevented the recall of 10 million cars) and from war and diplomacy (military involvement in Iraq). And then there is medicine and healthcare, and the mistaken belief – held too often by the media and initially the Bill and Melinda Gates foundation – that a magic bullet could cure the big diseases if only we worked faster and smarter and pumped in more cash. Honoré mentions malaria, and the vague but quaint story of a phalanx of IT wizards showing up at the Geneva headquarters of the World Health Organisation with a mission to eradicate malaria and other tropical diseases. When he visited he found the offices somewhat at odds with those of Palo Alto (ceiling fans and grey filing cabinets, no one on a Segway). ‘The tech guys arrived with their laptops and said, “Give us the data and the maps and we’ll fix this for you.”’ Honoré quotes one long-term WHO researcher, Pierre Boucher, saying. ‘And I just thought, “Will you now?” Tropical diseases are an immensely complex problem . . . Eventually they left and we never heard from them again.’”

As my own practice has developed over the years, I have come to a realisation that quick fixes tend to unfix themselves over time, and the quick fix mentality carries a huge cost over time.

Here is Honoré’s TED Talk. Garfield has a very entertaining passage in the book where he talks at a rival of TED’s, which has a 17 minute limit (TED has an 18 minute one)

Why are doctors so unhappy?

From the UK junior doctor’s strike to survey after survey , there seems to be growing evidence that a doctor’s lot is not a happy one. Or is it not so much a “doctor’s lot” as a “doctor’s nature?”

I’ve been interested in this question (quite apart from the personal relevance!) ever since working on this review for the TLS of various medical biographies. As I wrote:

In the Western world, at least, the medical profession generally enjoys high status. For sociologists, doctors incarnate various forms of power disparities. Medical science and medical technology have made spectacular progress since the Second World War; procedures such as LASIK laser eye surgery, to give just one example, that once would have seemed magical, are now near-routine.

And yet an air of discontent is evident in much of the discourse of modern medicine. Like many others, the medical profession is under question, if not attack, on a range of fronts. Complementary remedies are increasingly popular, often with practitioners as well as patients, despite the advent of evidence-based medicine and numerous books that have discredited their claims to efficacy. A succession of scandals in Britain and elsewhere has undermined public trust in doctors and nurses. Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

There was somewhat more I wrote originally, but for reasons of space, had to be cut

 

. Much was based on my reading of Myers and Gabbard’s wonderful The Physician as Patient – a book I reviewed some years ago . As I wrote then, Myers and Gabbard illustrate the power of the case vignette, a somewhat neglected form nowadays, and I also wondered about the  self flagellation possibilities of audit (linked I guess to the Imperative Voice one gets so much of in medical journals)

I didn’t write in my 2008 review of one of the points Myers and Gabbard make – based on psychoanalytic literature – about the much-vaunted grandiosity and pomposity of doctors – the “god complex.” In their reading, this (when it occurs) is a defence mechanism against the ultimate power of death against all our efforts. Personally, there are only a handful of doctors I have come across – and at this point I must have come across hundreds in various contexts – who in any way lived up to the “god complex” stereotype.

Are doctors less happy than other citizens? Surveys and so forth can no doubt be adduced to prove the point (though I must admit after the US Presidential Election having an even greater scepticism about ANY survey or poll being used as “evidence”)  and the lived experience of doctors is increasingly one of a beleaguered profession overwhelmed by competing and constant demands. Is this because of specific issues – funding, resources, de-professionalisation – of the contemporary world?  Is it because of a cultural shift from doctor-knows-best to consumerist healthcare? Or is it something deeper and perhaps near-inherent to the kind of person who is drawn to the practice of medicine? Or something deeper and perhaps near-inherent to the practice of medicine itself?

There is, on one level, more discourse about health and healthcare than ever before. On another, there is often a a euphemistic, evasive quality to much of it. So many terms – from “evidence-based” to “patient centered” – have become godterms that conceal the complexity and diversity of healthcare (both complexity and diversity are themselves “godterms”, increasingly, but I use them very deliberately here) and the contending priorities at play.

This is an area ripe for pompous theorising about Society and Culture and so on, and perhaps I have done my share of this already. One final thought: the WHO definition of health is:

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Do you, reader, really believe that? Do you really, when you think of what it is to be healthy, think of”complete social well-being”?  What is “complete physical, mental and social well-being” anyway?

The point is not to denigrate “well being” in some way – or not to recognise the value of a positive rather than negative definition of health. The point is, this  grandiose definition has consequences – underlying not just health policy and practice but how we think about what it means to be healthy, and also what doctors (and nurses, and psychologists, and OTs, and physios, and everyone else with apologies for those left out) are trying to achieve. I would argue that the WHO definition is something out of a kind of worldly messianiac pseudo-religion rather than a workable basis for a human-scale endeavour.