Alan Cribb is Professor of Bioethics and Education at King’s College London and co-director of the Centre for Public Policy Research.
The consensus that ‘something needs to change’ among the Rethinking Medicine Working Group (and indeed among the constituencies with which it has engaged) has been remarkable – see ‘Why we are rethinking medicine‘.
Nonetheless, the emerging Rethinking Medicine ‘movement’ has a lot still to do to clarify and communicate the change message and to tackle the ‘how’ of change. This includes understanding sceptical reactions, avoiding getting drawn into simple ‘x=good, y=bad’ dichotomies, and acknowledging the complexities of change while clearly signposting a direction.
We must be able to counter legitimate and serious concerns from sceptics. Concerns, for example, that ‘rethinking’ is about rejecting or dismissing biomedicine; or that we are calling for the ‘old’ tried and tested practices of doctors to be replaced with some fashionable ‘new’ thing; or that ‘rethinking’ relies on the assumption that most doctors are oblivious to the limitations of biomedical thinking. In each case the opposite is much closer to the truth.
Biomedical thinking is, by definition and rightly, at the centre of medicine. In calling for a ‘better balance’ in healthcare we are repeating a refrain that has a long tradition both from outside and within the medical profession. And the primary ‘target’ of the rethinking message is not what is in individual doctor’s heads but rather the cultures and structures that make up and surround medicine.
Rebalancing is needed as a response to social change and is already substantially under way (Cribb, 2017). The relevant changes are both major and diverse – for example, the rise in long-term conditions, the trend towards less hierarchical professional relationships, new models of provision and care, evolving ethical norms, lessons from research into the social context of health experiences, behaviours and inequalities and so on.
Healthcare has to respond both to diseases and to people, and to combine careful attention to both.
The core issue is, in fact, a very familiar one – that healthcare has to respond both to diseases and to people, and to combine careful attention to both. This entails breadth and balance. And it is clearly just as much a problem to neglect biomedical agendas as to neglect personal agendas. In many respects, then, the core issue is uncontroversial. But it also needs to be acknowledged that – if taken seriously – achieving the right breadth and balance is a complex and demanding task because (1) there are different kinds of breadth to work towards, and (2) breadth sometimes generates tensions that are not easily resolved.
(1) Being more responsive to ‘persons’ in specific services or practices can entail the following shifts of emphasis:
Reviewing purposes – are clinical knowledge and skills consistently being used to help people live lives that they value, or do they sometimes get in the way of that?
Being sensitive to social context – is sufficient consideration being given to the possible social causes and solutions of health problems, or are these relatively neglected?
Attention to the quality of relationships between professionals and patients – are practices respectful and sensitive towards people and designed to harness their agency and knowledge, is there room for genuine partnership and mutuality where appropriate, or are relationships narrower and less facilitative than they need to be?
Redistributing influence – are opportunities to shift the locus of agency and responsibility towards patients and the public being taken, or are traditional assumptions about hierarchy being reproduced with too little reflection?
(2) Often being responsive to both diseases and people is simply ‘both/and’, i.e. a question of achieving breadth. But sometimes there can be tensions between these emphases that need navigating. The more we pay attention to breadth and balance the more we become aware of these tensions and balancing acts.
Again, no single element of this is new. Experienced doctors are very aware of these balancing acts and the associated challenges. In our recent research on support for self-management, for example, doctors described the related challenges and dilemmas well – they and others were actively combining support to help people “manage their conditions well” and support to help them “live well with their conditions”. Doing both of these things at the same time is often not easy (Entwistle et al, 2018).
What is arguably new is the growing level of awareness of:
- the range and complexity of the balancing acts entailed by practising good medicine under changed social circumstances
- the many ways that institutional habits, incentives and pressures can produce imbalance. There is not one single act of re-balancing to be done but rather there are multiple risks of imbalance to be tackled on a continuous basis.
At the level of the individual doctor a key part of the answer here is already well understood. It is to recognise that breadth and balance demands compound forms of expertise – medicine should always draw upon biomedical expertise but must ultimately rest upon practical wisdom. However, developing, organising and using such compound expertise is not something that it is fair to leave to the heroic mental and physical exertions of individual doctors.
The task of ‘rethinking’ is to ask how can health systems and institutions be reformed or reconfigured to achieve balanced healthcare and to actively support the practical wisdom needed to underpin it.
Entwistle, V.A., Cribb, A., Watt, I.S., Skea, Z.C., Owens, J., Morgan, H., & Christmas, S. (2018) “The more you know, the more you realise it is really challenging to do”: Tensions and uncertainties in person-centred support for people with long-term conditions, Patient Education and Counseling, vol. 101, 1460-1467.