Experience

As healthcare changes, adopting increasing evidence for its interventions, there is a body of work trying to understand exactly how clinicians and their patients make individual decisions. There are five accepted influences at work. One of these is the experience of the clinician (and to a degree of the patient who may be in a position previously experienced)

Arguments for decision making less dominated by public knowledge, "evidence", talk up the value of the clinicians' experience. Is this warranted?

Feeding Babies

This is not strictly a healthcare issue but healthcare professionals do get involved. For a while the word was that "breast is best" and this got extended to the idea that small babies should be fed exclusively on breast milk. This advice was given to mothers. It seems now some work suggests that an earlier introduction of other foods may be useful and is associated with less food allergy later on. So science progresses. Is this the final word? Probably not. However this report set off a tirade from the midwifery profession. "What do these people know" "We know best and best is breast" etc. Here's the point. Midwives, and many other groups of healthcare professionals, deliver care and advice but have no developed mechanism to generate new knowledge. The midwives are not about to do the next piece of research to help get to the bottom of this yet they become vituperative when their current stance seem in need of change. They feel threatened. The core their professional status seems in question. "How could others know more about this than ourselves?" But of course they do. This situation is widespread and those groups afflicted feel the insecurity of their position and accordingly adopt unhelpful inflexible postures. Yet this will affect everyone as healthcare enters the biggest transformations in its history. We need to understand and attend to this situation.

Safety before Convenience

What we need from healthcare is complex and many of our requirements conflict. We surely want healthcare to be safe and we also would I am sure prefer it to be reasonably convenient. But if the two conflict? It is becoming clearer that complex interventions are more safely provided in centres with a significant throughput where the experience of the teams builds up and adds to the overall quality of the work. This move to fewer centres conflicts with the convenience enjoyed by many populations who had smaller centres in their midst. Because healthcare in an open public system has every decision scrutinised by the public this demand for local provision acts as a brake on improving safety. We need as individuals to be better informed of the issues to help us support rational developments.

Sociology in Healthcare

Healthcare starts with a desire to relieve human suffering. Its great triumphs have come where that suffering is caused by some abnormal bodily process - a disease. Addressing disease will frequently relieve suffering in a major and prolonged way. But not always and often not before additional suffering has been caused for example by surgery, chemotherapy or radiation. Many patients bring their suffering to healthcare in search of relief yet are disappointed when healthcare finds no disease which it can address and consequently often contributes little to the patients well being. This group of patients may be numerically the most common and there is an urgent need to understand what causes such illnesses. The supposition is that there are psychological and social factors at work. To understand such illnesses healthcare needs a working partnership with social science. Sadly this has thus far proven impossible. There are of course lots of sociologists with an interest in illness but there activities are ill co-ordinated with healthcare and they seem to pursue an isolated agenda, heavily laden with sociological theory and deficient in any serious volume of empirical data. In short they approach the problem with the superior air of a group who know the answers but in reality they contribute little to patient welfare resting content to have, to their own satisfaction, confirmed the correctness of their theories.

This will not do. Healthcare must find and work with sociologists who will approach the task with some humility and open mindedness. We need to improve the help we can give patients whose illnesses are not rooted in bodily disease. We need to work with sociologists to produce useful knowledge and ultimately rescue patients from the embrace of the multitude of deceitful charlatans who currently take their money and give nothing in return.

Why does it cost so much

Because we need healthcare that actually works, that actually helps real serious threats to our wellbeing and which is safe. That costs. This week there is great concern about the use of antipsychotic drugs in folks with dementia. Yes it happens and yes it probably happens too often. But. Could we do without these drugs here? Depends how much we want to spend. If every dementia sufferer had a nurse beside them around the clock we might be able to keep them safe and comfortable without drugs - not guaranteed but possibly so. That would require 6 or 7 nurses for each and every patient. Not affordable? You must judge If it was your parent and you were paying? If an insurer was paying and you were sharing the premiums to pay for everyone? If it was a public healthcare system and you were paying the taxes? The doctors know that these drugs can calm agitated patients without making them unconscious ( which is another option but vastly more dangerous) offering some relief to all concerned and safer than the usual practical alternative.

The Change

No improvement in healthcare will be possible unless key issues are understood.

The most important is that healthcare is in the middle of a massive once in a millenium change. This change began slowly in the 1960s or so, has gathered pace by now but still has many decades to run. Youngsters now using or working in healthcare will experience a transformation over their lifetimes.

What is this change?

For the first time in history healthcare can offer to ill persons treatments which will reliably help them.

Is that not what happened before?

No.

What happened before and for many illnesses still happens and will continue to happen for many illnesses for a while yet is that ill people were and are offered treatments which are believed to work. Many actually do but many dont.

Sounds a bit dull.

It is not.

It is the most amazing transformation imaginable and its effects reach everyone involved in ways which most of us (including me) cannot yet comprehend. Healthcare, medicine, doctoring, nursing - think of it in any way you choose - will never be the same again - but be sure it will be better than it has ever been before.

I shall explain.

In the mists of time most illnesses were a mystery. Apart from pretty obvious things like injuries no one knew why a person got ill. Assorted explanations were given, many involving what we now know to be the supernatural but few reliable effective remedies emerged.

For the past thousand years or so folks took to observing and thinking about natural events, including illnesses and began slowly at first to understand how they might arise and how they might be helped. The methods of science (science is just thinking about what we see) were being refined and the pace of improved understanding of illness speeded up.

By the middle of the 20th century much was known of the body and its ailments and a little about the mind and its sufferings. From that knowledge suggestions as to how to help ill persons were made a bit like this:"We see you are ill, we see certain abnormalities in your body , we know a bit about how that aspect of your body works and so we suggest you try this which ought to work". Note the key word - the proposed treatment ought to work based on our analysis of your predicament. The method was one of applying rationale to the situation. Seldom could a doctor or whomever put hand on heart and say " We have tried this out on many people in a similar situation to yours and we have found that doing this seems best and will do more good than harm".

Medicine had a vast array of remedies to offer both surgical and medical but none of them were, as we would now demand, "evidence based".

From the 1960s on and with accelerating pace that began to change. More and better studies were done which showed precisely the likely benefits and risks of any given test or treatment and from these studies we selected and recommended those approaches which gave the best results.

All this sounds fairly reasonable and desirable but as we will see it was to transform healthcare beyond recognition. That change began to gather pace in the 1980s, grew amazingly in the 1990s and generated the spin-off effects which we now have. The change is still not nearly complete and will continue for decades improving and transforming healthcare beyond anything we can currently imagine. Read on!

The Debate

President Obama has initiated a debate on the future of healthcare in the USA. What does he get? Posters of his face with a Hitler moustache on it!

Some debate!

More seriously, most debate about healthcare fails because the participants lack knowledge of current issues and future possibilities. We shall progressively examine and display the issues and the possibilities.