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.

Yesterday, I had the entirely unexpected pleasure of seeing the world’s first web server at CERN in Meyrin, Switzerland.

Over the years, I’ve read a lot about the early development of the world wide web, and I’ve also read about the storied history of Apple, including Steve Jobs’s period at NeXT computers.

Yet somehow, it had spectacularly failed to lodge in my mind that the first web server was a NeXTCube. Before I peered into the display case, my assumption was that I’d see a beige tower, probably with an IBM badge on it. It’s strange to contemplate how assumptions like that take hold, even though I must have read many times over the years that it wasn’t the case.

I also loved the sticker for its real-world mundanity. Not shown in the picture above is the handwritten comment on the top of Berners-Lee’s paper describing his system: “vague but exciting…”

It’s also fascinating to ponder the problem he was trying to solve—managing information about complex, evolving systems—and how we really haven’t applied it in healthcare more than three decades on. Even at the very simplest level, we really haven’t embraced the idea of hypertext, and of live-updating bits of guidance as new evidence emerges—or even just as new policies emerge. Most healthcare guidance remains static, with whole documents being refreshed in cycles.

For example, even the boilerplate description of many organisations at the front of documents is baked in, and only refreshed when the document is updated. If only we had learned from Berners-Lee, that could be a ‘do-once’ update that would be linked into all relevant documents.

Or, more relevantly, look at COVID guidance: each time the isolation period changed, hundreds of pages of guidance documents, including even all of those hosted on gov.uk, needed manual revision. If they’d been more thoughtfully constructed, that too could have been a ‘do-once’ update.

The counter argument, of course, is that changing ‘bits’ can substantially change the meaning of the whole, and a standing document needs approval and sign-off at regular intervals. But really, nothing in medical guidance is more complex than particle physics, for goodness’ sake, and there’s no reason that approvals to updates couldn’t be sought with an eye to where they propogate.

Perhaps we’ll get there one day.

Richard Smith recently proposed banning the word ‘prevention’ in healthcare:

A few years ago, my friend Pritt, one of life’s instinctive radicals and iconoclasts, talked to me about “the deficit model of health.” At first, I didn’t grasp his point, but slowly I came to understand. What is being prevented? Sickness, of course. Prevention leads to health, which is the “absence of sickness.” Health is defined as a deficit, the absence of sickness. And who determines if you are sick? Doctors. If we stick with “prevention” then doctors will determine who is sick and who is “healthy” because they are not sick.

Like most radical ideas, this one took me on a journey. My instinctive response was to agree: I smiled broadly as I read, ‘Dying is healthy; living forever would be unhealthy.’

Of course, ‘we need a bolder and broader definition of health—something to do with resilience, adaptability, coping, interdependence, and relationships with others, our community, the planet, and nature.’

But then, I paused. I work in health protection. Most of my job is about ‘preventing’ illness. If someone is a close contact of a patient with a particular disease, then they may need antibiotics to prevent them from becoming unwell themselves. If there’s a high likelihood that a foodstuff in someone’s fridge was manufactured in a way which has introduced contamination, that food might be better off binned to prevent food poisoning. If a cloud of chlorine gas is rolling towards a housing estate, then the people must be evacuated to prevent them from choking to death.

And then I saw the point. To see my job as ‘prevention’ is precisely the sort of simplification that I myself often rail against. My job isn’t really to prevent people from becoming unwell: they can take as many risks and be as unwell as they damn well please. My job is really to inform them of the risk they face, help them to decide whether they want to act in light of that new information, and to support them to act if they wish to do so.

This is significantly different because—as I frequently find myself emphatically explaining to others—it can be perfectly rational not to act in response to a risk. This is especially true given that most actions generate side effects, which each of us will value differently. We don’t—and shouldn’t and mustn’t—compel people to act based on our assessment of the risk to their physical health, because there might well be other things that they value more greatly.

Banning the word ‘prevention’, even from an area of medicine that might seem to be entirely focused on it, would be enormously helpful in reframing what we do.

The Times front page had a headline yesterday morning proclaiming that “most people die while on NHS waiting list”. The opening paragraph:

More than half of all people who died in England last year were on an NHS waiting list, research indicates.

I didn’t get a chance to read beyond that point, but as I walked to work, it played on my mind. I thought a lot about how it was a sad inditement of modern medicine. How depressing, I thought, that so many people are dying in limbo, expecting some kind of treatment for something, rather than being supported to achieve a good death. People who are at the end of their life should not be worrying about clinic appointments and waiting lists.

On the other hand, I thought that perhaps this news was perversely positive: it was good, I thought, to see realistic medicine enter the national conversation as never before.

And then I read the full article. And The Guardian’s coverage.

And ho-hum, I’d got it very wrong. It turns out that I was supposed to be thinking:

Record numbers of people are spending their final months in agony, waiting for treatment that never arrives. The basic promise of the NHS — that it will be there for us when we need it — has been broken.

And that the statistics represent a:

terrible indictment of this government’s mismanagement of our health services.

And:

These figures are a stark reminder about the potential repercussions of long waits for care. They are heartbreaking for the families who will have lost loved ones and are deeply dismaying for NHS leaders who continue to do all they can in extremely difficult circumstances.

I suppose my reaction differed from that of the various spokespeople because they assumed that most patients were dying while on waiting lists for treatment for the thing that killed them.

That seems so unlikely that it simply never occurred to me, and there’s nothing in the cited data to challenge my view. It’s not uncommon for someone to languish on a waiting list because they are being treated for something else: people don’t get hip replacements while they’re going through chemotherapy, for example. Certainly, some people are referred for treatment for a condition, deteriorate unexpectedly quickly, and die while waiting, but those events strike me as quite exceptional, quite far from the norm, not least because lists are generally arranged by clinical urgency.

But really, this statistic is intriguing for being an interesting combination of meaningless and significant. It’s meaningless because it is extrapolated from a small data set, we have no evidence of any causal link, and it’s not immediately obvious that improving it would improve patient care. Yet, it is significant because it helps to give some emotional context to bland waiting list statistics and reminds us that people’s lives continue while they wait.

The image at the top of this post was generated by Midjourney.

Richard Smith recently shared this editorial he wrote more than thirty years ago, on the subject of preventing whistleblowing. It seems entirely relevant to the present day.

I was particularly struck by this passage:

Most organisations eventually have to take tough decisions. Difficult choices, particularly over allocating resources, have long been part of working in the NHS. The choices will become tougher, and there may be more losers than winners. The fear that the losers will tell all to the media is what leads managers to reach for their gags. They make a mistake. Instead, they need to create organisations-be they hospitals or health authorities -where employees feel enough part of the decision making process not to need to blow their whistles.

You begin by letting everybody know what is going on. If the rhetoric is glossy brochures full of the word “quality” and the reality is elderly patients with pressure sores in back wards with peeling paint, then staff will become cynical and demotivated. They need to be convinced that the available resources are used fairly, efficiently, and effectively. The surest way to convince them is to involve them in decision making. The decisions that are made must be clearly and honestly communicated. Staff must have a chance to come back on poor decisions, and managers should not be afraid to reverse decisions that are wrong.

If staff understand the true circumstances of the organisation and feel that their views have been given serious attention then they will accept tough decisions. But if seemingly arbitrary decisions appear from nowhere then staff will be unhappy and one or two will contact the press. Managers who try to create a climate of fear will neither stop whistle blowing nor run an effective health service.

That second paragraph is remarkable: it is common sense, it has been clearly articulated for more than thirty years, yet it is seldom followed.

The difficulty so often seems to come at the point of involving people in decision-making. Frequently, efforts to do this appear as cynical attempts to justify decisions that have already been taken. This isn’t solely a problem in the health service: we can see similar cynicism, for example, towards the ongoing consultation about closing railway ticket offices.

If we choose to be as uncynical as possible, then it strikes me that this often boils down to poor communication. Smith talks about ‘glossy brochures full of the word “quality”’—and I think he’s right. Starting a conversation about funding cuts with rhetoric around ‘quality’ and ‘efficiency’ drives cynicism more than collaborative decision-making. Too frequently, managers fear being honest, and too often, managers choose not to be plain-spoken. You cannot have shared decisions if the people sharing in the decision have no idea what you’re talking about.