Hugh van’t Hoff is a GP based in Gloucestershire. He is also Director of Facts4Life.
The air is so clear now there are so few journeys, fewer flights. You can cut the air with a knife, it’s sharp and clean and the birds have found their full-throated voices. Covid-19 has put us in touch with our own mortality, our effect on the environment. The news is crammed full of data, opinions, trust and distrust. We are all thinking like armchair doctors. The tests are so frustrating, the answers so unclear. It strikes me there’s a lot that needs explaining, a lot that’s misunderstood.
I want to show you that rethinking medicine involves more than challenging the current biomedical model. It’s about understanding power. All relationships in medicine involve an exchange between those with more power and knowledge and a generally compliant receiver of care. In recent years the pace of change and the flow of information has increased with widespread access to the internet, but understanding and context lag behind.
The current Covid-19 crisis has hastened the need for analysis to flow alongside the tsunami of facts. Ministers and the government’s medical and scientific experts are trying to deal with and talk about the grey areas of medicine normally tackled by us GPs. In the main, this disease is experienced out of hospital – where the symptoms are vague and the answers more so. The role of general practice has always been to straddle the divide between the raw symptoms and signs as they present, and the sharp lens and laser treatment of hospital medicine; to arbitrate and negotiate between the ideals of the experts and the practical realities of everyday life. So, it’s not surprising that the government finds itself in difficulties trying to make grey areas black and white.
Rethinking medicine involves more than challenging the current biomedical model. It’s about understanding power.
Any rethinking of medicine needs to embrace the varied ways in which professionals interact with patients, and needs to address the exchange of information in ways which empower patients and help the professionals better share information. This role is fundamentally about education. Medical professionals need to see any interaction they have as a challenge to them to improve the way they share knowledge and insights. Doctors may know best, but they may not teach best, yet.
Our training and experience allow us to keep many different possibilities in mind, to tolerate ambiguity and to not be confused by complexity. For example, we can hold in consideration several possible diagnoses, the fact that we sometimes get things wrong and that we are experts in handling risk. In general practice, we try to remain aware of our ignorance and often – on a good day and given more than 10 minutes – we can hold these in mind while interacting with and counselling patients and their families. GPs are experts in understanding the limitations of medicine to heal, and are aware that most people, most of the time, heal themselves (whether or not any intervention is adopted). I find my patients intelligent, understanding and forgiving.
The arrogance of medicine is that we assume that people are not able to tolerate complexity. Our job is to make this complexity accessible and something which can be understood in the same way as we tackle complexities in maths, language, geography or history – we don’t stop at the times table or the present tense for example. Sometimes information needs reframing and the jargon needs stripping away. We should concentrate on communication and the social relationships involved. Medicine needs to find a way of helping people understand how we doctors process information, the way we come to a working diagnosis and how this is contingent on future information – all of which allows us to come up with a plan for now. It begins by sharing this information in schools.
In exchange for elevated status and responsibility, the ‘social contract’ between medicine and its population broadly accepts the biomedical model. It perpetuates a myth that everything can be healed quickly using drugs or surgery (or, soon, genetics) given enough time and money, and underplays the greater roles of lifestyle and inequalities. By doing this and failing to address patient knowledge and insight (health literacy) it fixes the population into expensive solutions and a compliant role. It is harder to build health literacy and knowledge once mindsets have become fixed in this way (it needs to be addressed in the early years and in primary school), and it can only do so much. Most illness is experienced by those who are disenfranchised and poor. Addressing health inequalities as well as health literacy is crucial.
The arrogance of medicine is that we assume that people are not able to tolerate complexity.
Rethinking shared decision making
Sharing knowledge (shared decision making, SDM) is more complex than just sharing information about outcomes or making it more ‘patient centred’. It is about being mindful of our social, economic and power relationship with patients and realising how important these are in our interactions. We should find new ways we can share our insights. Richard Canter wrote a powerful letter to the BMJ in 2001: “At the very least a debate that goes beyond the rather naive idea that power should be “handed over” needs to begin, for at the heart of this proposal is the very nature of medical knowledge itself.”
Earlier in his letter, Canter sums up the unacknowledged problems of medical power: “Lukes has proposed a threefold description of power that might be relevant here: first dimensional power, in which A forces B to do something; second dimensional power, in which A controls the agenda in any interaction with B; and third dimensional power, in which A controls the world as B sees it” (Lukes S., Power: a radical view. London: Macmillan; 1974.) In our present COVID-19 world the government is operating in the first dimension, rethinking medicine is located in the second and we are ignorant of the wider context – and as a result we are, at best, stuck in the third dimension.
As medics, we fail to see that we set the agenda in over-diagnosis, rethinking medicine and SDM. In trying to give patients some autonomy, we fall back on the easy, accepted, tried but untested idea that we should remain in charge while simultaneously asking patients what they want. We fail to wonder whether we could share our knowledge. Perhaps we don’t want to relinquish power, have vested interests or assume the information is too difficult to understand.
Whatever the case, we doctors fail to acknowledge many of our own insights: that most people will get better spontaneously (the clinical iceberg – the government tried to exploit this with its failed proposal to sit out Covid-19 whilst herd immunity was established); or normal and skewed distribution; or the idea our immune system learns from others and has a memory; or that “common things occur commonly”. All these ideas are easily taught to primary school children, successfully building confidence and changing attitudes in managing health. Most people know some of them intuitively. A large part of the power we have is invested in the assumptions we make about patients – how we piece together the bits of information we have about a patient – not the raw data, anatomy, interactions of drugs etc. That’s why continuing professional development and the sharing of medical power is as much about how we think as what we know.
It strikes me that the approach to the public by those ministers and their advisers is exactly the sort of paternalistic approach that we have been striving to move away from in medicine ever since I entered the profession, with its reluctance to tolerate complexity and share information. Contrast this with the approach of Nicola Sturgeon or Jacinda Ardern who accept that a free and open discussion is not to cede control and will not immediately cause everyone to break the rules, nor is it going to upset anyone (as much as being told partial truths). The daily update sounds to me like a 1980s consultant talking in code to a gaggle of juniors and students at the end of the bed on a ward round about cancer or end of life issues not understanding how excluded the patient feels.
In trying to give patients some autonomy, we fall back on the… tried but untested idea that we should remain in charge while simultaneously asking patients what they want.
So, if we’re going to rethink medicine, and especially now, we’ll have to work out how we can share both our thinking and the process of sorting information. Then patients will be free to come to their own conclusions and act on them. The current pandemic is forcing medicine to think and work more flexibly. We are also witnessing a rapid change in the way others think about health, where responsibility lies and the quantity, quality and delivery of the information shared. Now is the time to think more widely about how we bring education about health and illness into mainstream teaching – and not just for the next pandemic.
About Hugh and Facts4Life
Facts4Life is funded by Gloucestershire Clinical Commissioning Group to develop a health literacy curriculum to pre-schools, primaries and secondaries across the county. Hugh’s work with Facts4Life stems from his experiences as a GP trainee in inner city Bristol, and the gulf between his understanding of medicine and that of his patients. He realised that he and his profession were poles apart from their patients in terms of their thinking. Struggling to get his ideas heard he wrote to Tony Benn who advised that he conduct a trial in schools.
Facts4Life helps children understand that they ‘own’ their health; exploring health and illness is a safe and healthy thing to do; we could all embrace a wider sense of normal which includes illness but doesn’t promote it. Illness is part of all our lives; and largely avoiding it or recovering from it is our responsibility. Facts4Life aims to help children understand that this responsibility is not onerous, painful or difficult. Learning is led by students’ interests and there are no areas which cannot be safely investigated.
The ideas within the project have developed and grown over time, supported by Hugh’s continuing commitment to his work in general practice and modified by the educational team at Facts4Life. The ability to bring together the professions of teaching and medicine continue to generate multiple mutual benefits, and Hugh has seen the nurturing approach of teachers profoundly alter his attitudes to the practice of medicine. This dynamic two-way process is now thriving, driven by Hugh’s commitment to enable the Facts4Life team to embed its ongoing learning in the worlds of both teaching and general practice to the benefit of all.