Crocuses are a lovely reminder that spring is on the way. Both globally and across the UK, purple crocuses are planted to remind us of humanity’s pledge to eradicate polio.

In the years when my parents were born, there were as many as 8,000 cases of polio each year acquired in the UK, leaving many families bereaved and tens of thousands of children with lifelong disabilities. An effective vaccine was developed in the late 1950s, and as a result of the success of its rollout in the UK, there has been not a single UK-acquired case of polio in my lifetime. It’s easy to forget the astonishing and unprecedented progress we made in public health in the twentieth century.

We haven’t eradicated polio worldwide quite yet, though we’re getting close, with only tens of cases reported each year. Two of the three strains of polio have been consigned to the history books. The purple crocuses should remind us that we still need to finish the job.

I had to attend some leadership training this week, which is a cross we must all bear from time to time.

The trainer declared that IQ, as in ’intelligence quotient’, was one of only four jointly conceived attributes which make up a rounded person. The others, for what it’s worth, were cited as the ‘emotional’, ‘physical’ and ‘spiritual’ quotients.

The trainer explained that the word ‘quotient’ shared a root with ‘quadrant’ and was chosen because there were four domains.

My bullshit antennae were firing so intensely at this point that they may have been visible if it wasn’t quite so long since I last cut my hair. Yet, at least the trainer’s misplaced confidence made me spend a few minutes reading around the topic from sources more reliable than the course’s tie-in leadership paperback.

The Oxford English Dictionary says that ‘quotient’ is a direct borrowing from the Latin ‘quotiens’ meaning ‘how many times’ or ‘how often’. In the ‘intelligence quotient’ sense, it’s referring to the quantity of intelligence. There’s no historical or modern sense in which it connects to a sense of there being four parts.

The prefix ‘quadr-’, as I should have remembered from school, comes from the Latin numeral ‘quattuor’.

But what about IQ? I should have remembered this, as I recall presenting on it during a special study module I took in learning disabilities a couple of decades ago. It was created in the early 1900s by the German psychologist William Stern as a standardised figure for monitoring child development: simply divide their ‘mental age’ by their ’chronological age’ and multiply by 100.

EQ is rooted in more modern psychology, while PQ and SQ seem to be modern inventions by leadership gurus, keen to repackage and upsell ancient philosophy.

I may have been cynical about the course, but it clearly has made me learn something.

In my job, one of the trickiest things to consider in outbreak management is the secondary effects of any restrictions. They are often difficult to predict, let alone quantify, yet they can drastically alter the balance of risks.

Imagine, for example, a batch of ready meals which are suspected of being contaminated with a bacterial pathogen yet are destined to be heated and served to hospital patients. I think everyone’s first instinct would be to withdraw the meals to reduce the risk of giving patients food poisoning.

But this decision would not be as straightforward as it first appears. The risk of illness from the meals might well be mitigated—but not necessarily eliminated—by the need to heat them, which will usually kill the bacteria. If the patients are not to have the hot meals, then they will have to be served something else. If that ‘something else’ is, for example, pre-packed sandwiches, then the risk of illness for vulnerable patients from pathogens such as listeria, which are reasonably common in pre-packed sandwiches, might be higher than the risk associated with the hot meals.

In this scenario, the fact that patients must be fed and that there will, therefore, be a secondary effect is obvious and predictable. Sometimes, secondary effects are entirely unpredictable, and you can do no more than take an informed, professional guess. And then, crucially, keep an eye on the impact of interventions so they can be tweaked if necessary.

The same is true in clinical medicine: adding one extra tablet to a patient’s regimen might reduce their risk of developing a particular illness. But it might also increase their side effects, interact with another medication, or be the extra tablet that tips them over the edge into non-compliance with the whole regimen. Well-intentioned decisions can have unexpected secondary consequences.

Kelsey Piper of Vox gave a great example of the importance of considering secondary effects last week. She describes the fact that the US Federal Aviation Authority has done extensive research which has found that it is considerably safer for very young children to fly in their own secured seat, rather than travelling in someone’s lap. They give clear public advice on this, yet—despite all the evidence—choose not to mandate it.

Their rationale is that requiring the purchase of a seat for very young children would make flying unaffordable for many families, and a proportion of those families would choose to drive to their destination instead. Driving is considerably more dangerous than flying, to the point where the FAA calculates that for every life saved by a ‘separate seat’ mandate, sixty lives would be lost on the road.

Sometimes, we can all get drawn into looking only at our piece of any given puzzle, but it’s essential to keep a broad view: you never know when a secondary effect might undermine your action.

The image at the top of this post was generated by DALL·E 3.

Last week, The Times’s leading article asked:

Why should doctors, trained at great expense by the state, not be obliged to serve a minimum number of years in the NHS?

Politicians occasionally suggest that doctors who have been trained in the UK—and who have accumulated an average of £71,000 in debt in the process—should have a period of indentured service to the NHS or else pay a still higher contribution to the cost of their training to be freed from this requirement.

I always wonder why the equivalent suggestion isn’t made regarding politicians themselves. Elections are costly, and when MPs resign mid-term, before the end of the period of service for which they were elected, there is a cost to the public purse of running an election to replace them. Why not require MPs to serve their term or repay the by-election costs if they don’t?

The answer is obvious: it’s in no one’s interest to have a de-motivated, disruptive, non-attending Nadine Dorries of an MP, trapped in a job they want to leave because of a perceived ‘fine’ if they quit—a ‘fine’ that they may not be able to afford. And it strikes me that the same applies to doctors.

The image at the top of this post was generated by DALL·E 3.

I’ve watched enough Aircrash Investigation to know that in an emergency, pilots focus on aviation, navigation, and communication—in that order. It seems like the ‘airway, breathing, circulation’ of the aviation world.

Listening to bits of the COVID-19 inquiry over recent weeks, Wendy observed that often, decision-makers were put off from making a decision due to fear of what might come next. This week’s most-discussed example has been lockdowns: there was much discussion about them being intentionally deployed as late as possible because of the future risk of behavioural fatigue.

I can understand why this happened. I obviously had no part in the decision-making, but before the lockdown was announced in the UK, I remember being sceptical that compliance would be high and thinking that it would tail off quickly. Even as lockdown was announced, I’m reasonably sure I said something like, ‘I bet loads of people go to work tomorrow regardless’. I was entirely wrong.

In retrospect, this feels similar to forgetting to aviate due to focusing on navigation: it’s ignoring what’s in front of the windscreen right now for fear of what might emerge later. In certain extreme situations, that might be advisable. Yet, generally, it’s more sensible to prevent the plane from crashing into the thing in front of the windscreen right now. One can consider whether the manoeuvre has knocked the aircraft off course once the evasive action has been taken.

Perhaps the lesson of the COVID-19 inquiry is the same. Take action to avert the crisis before you, and add nuance and course correction later when the impact is known. Don’t delay essential action because of uncertainty about what might happen later.

The image at the top of this post was generated by DALL·E 3.

They say that history doesn’t repeat itself, but it rhymes.

This morning, I’ve been reading two articles where it strikes me that there is a particular resonance in the themes.

The first is Florence Sutcliffe-Braithwaite’s remarkable account in The London Review of Books of the NHS infected blood scandal: ’We’ve messed up, boys’. This is the first thing I’ve read about these events that allowed me to grasp the totality of the tragedy. It’s a remarkable piece of writing, even by the exceptional standards of the LRB.

The second is Devi Sridhar’s editorial in The Guardian Weekly about the way politicians used scientists in the response to the COVID-19 pandemic. This isn’t quite such a must-read, and I don’t entirely agree with Sridhar’s views but fully support her conclusion that we ought to reexamine the power and independence of Government advisors. This discussion has been bubbling away in public health circles since the creation of Public Health England, which many saw as reducing the independence of scientific advisors.

Doctors and politicians both have essential parts to play in the management of public health crises. Crises require both technical expertise and democratic oversight. Doctors sometimes tend to dismiss the role of politicians by thinking that only technical decisions have weight. Politicians sometimes ignore expertise, preferring their own views or feelings about the right path. The balance isn’t easy to get right, and both doctors and politicians are eminently capable of getting things wrong.

There’s much to ponder in Sutcliffe-Braithwaite’s piece, of which this is only a very minor part. Yet, when reading the two essays in sequence, the spectre of the problematic relationship haunts both crises.

I’ve been the proud owner of a nose for over thirty-eight years and went through more than thirteen continuous years of medical training. Yet, somehow, news of the nasal cycle had utterly passed me by until I read this article by Sarah Zhang in The Atlantic.

Since I learned about it, I’ve been borderline obsessed with it. I already knew that humans effectively have two noses, like we have two eyes and two ears. Each nostril connects to an independent nasal cavity, a complex construction with multiple functions. These include filtering, warming and humidifying air, as well as containing the olfactory epithelium which allows us to smell (and, to a large extent, taste) things. The nose also plays a vital role in speech.

It was news to me that each of the cavities contains erectile tissue similar to that found in the sex organs. Each side alternatives throughout the day in swelling, leading to slight congestion. This ensures that one cavity always has high airflow and the other low. This is important for the olfactory epithelium because different chemicals take different amounts of time to bind, meaning that we need high and low-flow surfaces simultaneously to have the full spectrum of scent. The cilia, tiny hairs which clear mucus, also suspend their usual pattern of beating on the congested side, allowing it to be more moist and hence help humidify the air we breathe.

Even more astoundingly, when one lies on one’s side, it appears that signals from the compressed armpit can induce the nasal passages on the opposite side to open.

Now that I’ve learned this, it’s obvious: I’ve become obsessed with noting which nostril is congested throughout the day. Wendy and I even sometimes ask each other out of mild amazement that we’ve never noticed.

I trust that you, too, will be amazed by this and will spend the next few days noticing with fascination what your nose is up to.

This Every article by Dan Shipper, in which he talks about admitting to himself that he is a writer, struck a chord.

When I first decided to specialise in public health a decade ago, I remember having a deeply reflective discussion with a colleague who was an academic. She had chosen to become a researcher immediately after finishing medical school, having never entered clinical practice. After many years, she finally reconciled herself with the view that she wasn’t a ‘proper’ doctor, as she didn’t treat patients.

I don’t treat patients either: my job is to protect the population’s health from infectious, biological and chemical threats. This does involve individuals sometimes, but rarely actively unwell people: I mainly advise people who are ‘well’ but who are at a high risk of becoming unwell unless they take some specific action.

Despite this, I still very much consider myself to be a ‘proper’ doctor. Living through the singular challenge of the COVID pandemic underlined this for me. The most important core skill in my job—risk assessment—is precisely the same as in clinical practice, even if clinicians don’t always realise it. Moreover, the guiding principles of my profession are my ‘North Star’, helping me navigate through situations that can become enormously complicated and political.

Before COVID, I might have been more reserved about discussing my background, perhaps feeling that mentioning it could exclude others. However, given the colossal challenges of dealing with competing ethical, practical, and organisational issues at an intense pace, having a clear and familiar identity and set of principles was invaluable. In other words, my perception of my professional identity was beneficial in practical ways.

Others might reasonably perceive my identity differently. Some individuals in roles equivalent to mine have different professional backgrounds, leading them to associate with varied identities. I’m secure enough in my stance not to feel challenged or offended by differing views but to keep drawing strength and guidance from my identity.

The image at the top of this post was generated by DALL·E 3.

Yesterday, as a result of the end of British Summer Time, I manually changed the time on five clocks:

• a wall clock
• a decorative clock
• an oven clock
• an alarm clock
• a car clock
  

This may only have taken a few minutes, but I was slightly surprised to notice the number of clocks involved. None of these clocks is new. I must have changed every one of them multiple times over the years, yet if you’d asked me how many clocks I change each autumn, I’d probably have said, ‘Maybe two?’

This is a wholly insignificant example of an interesting phenomenon: I underestimate the effort I put into things when viewing them retrospectively. I think many people are the same, almost dismissive of their own efforts.

It wasn’t until yesterday morning that I made the obvious connection between this behaviour and imposter syndrome. I suffer from imposter syndrome from time to time, which is unsurprising given its reported frequency among medics.¹ I’ve always associated it with feelings of inadequacy related to the current situation: ‘I’m not qualified to chair this meeting,’ or ‘Most of what I have to contribute here is common sense,’ for example. These are both phrases I occasionally find myself uttering. Intellectually, I know that feeling as though ‘I’ve not earned my place here’ is part of the syndrome. However, I’ve never made the connection between that facet and mentally discounting the effort put into prior achievements.

This is a significant insight. Strategies like systematic, structured reflection could help to increase my recognition of my prior efforts. This could improve my medical practice by giving me greater confidence in my abilities and effectively addressing imposter syndrome.

I would never have guessed that the moment of changing the clocks would provide a moment of insight like this. They pop out of the strangest places sometimes.

1. I have a particular bugbear about imposter syndrome being something that’s typically discussed as affecting women more than men despite clear evidence that the issue affects both sexes equally. But that’s for another day. ↩

The image at the top of this post was generated by DALL·E 3.

James O’Malley recently wrote about status in a way that reminded me of Will Storr’s brilliant book The Status Game.¹ It made me reflect on some disparate thoughts I’ve been having recently about the role of ‘status’ in the medical profession, and especially within public health.

A little while ago, I talked with a colleague who had moved to a new role. Their former role had been equivalent to mine: actively managing local outbreaks and situations involving risks to a geographically defined population. The formal ‘status’ of the new position was no different—the pay was the same and so forth—but the day-to-day was different. The role was part of a national team broadly concerned with developing guidelines rather than having direct input into managing ongoing situations.

I knew that, like me, this person enjoyed the messily complex, ethically challenging, adrenaline-pumping world of managing ‘live’ situations, so this seemed a slightly surprising career move for them. Luckily, I knew them well enough to ask what had possessed them to take on such a different role.

My colleague told me—not quite in these terms—that they felt that the new role had a higher ‘status’: that, in their opinion, developing policy and guidance was a more ‘senior’ responsibility than managing incidents.

I know I sound desperately naive in saying this, but that floored me. I’ve been involved in developing more than my fair share of national guidance and have always seen it as a bolt-on to my ‘core’ job. I felt able to contribute to the development of this sort of thing because of my ongoing practice and experience; it wasn’t a ‘higher status’ bit of my job than, for example, chairing multiagency outbreak control teams.

I suppose I saw writing guidance as a little comparable to teaching. It is an important and worthwhile activity, but pivoting to doing it full-time seems like a career ‘jump’ into a different field, not a ‘status upgrade’ deal.

The idea that some colleagues saw this differently was quite a revelation. I think this is perhaps unique to the public health speciality: I struggle to think of anyone I know in clinical practice who has seen the leap to a job in guideline development rather than clinical practice as a ‘status increase’ in quite this way.

Status can be a funny thing: for it to hold any meaning, there has to be a socially agreed ‘ranking’ of sorts. James talks about the boost he feels when a journalist he respects engages with his work, but part of that ‘respect’ no doubt comes from a social consensus that the journalist is ‘high status’. We might be friends, but I don’t think he’d feel quite the same status boost from me blogging about his post. At the same time, as James points out, different groups have different consensuses: I strongly suspect James wouldn’t be as excited to see a complimentary post on his work from Suella Braverman as from Barack Obama, but they’re similarly statuesque figures to their particular crowds.

Even in a small field like mine, people can see status in different places. I suspect that within individuals, people recognise different things as holding status at different times in their lives and careers. At this point in my career, I would actively decline a ‘promotion’ to a management position, for example, because I value my clinical work too highly. Perhaps later in my career, I’ll value the broader influence that management positions can have.

I guess my reflection is that our own conceptions of status are even slipperier than I’d considered. I think James and Will are right to suggest that status is underestimated as a driver of behaviour, but applying that insight to understand individuals’ behaviour is more complicated than it might initially seem.

1. He also said that Succession is better than The West Wing, and without even having seen a single episode of Succession, I’m pretty sure I disagree. ↩

The image at the top of this post was generated by DALL·E 3.