There’s nothing I could write today that’s even half as spot-on as yesterday’s Economist leader.

The recipe for saving the NHS requires radicalism, but of a simpler sort: turning the NHS from what it has become—a sickness service—into what its name promises—a health service. That will mean spending more money. But to spend it productively requires a shift in focus: away from hospitals to the community, from treatment to prevention, from incentivising inputs to encouraging better outcomes.

A system focused on hospitals is one designed to treat people only after they have become really sick. That is the equivalent of buying more fire extinguishers while dismantling the smoke alarms.

The whole thing is well worth five minutes of your time.

When I was 12 years old, my geography teacher sprang a test on us. Part of the test was to draw various Ordnance Survey map symbols.

I am red-green colourblind. I had learned that a youth hostel was represented by a pink triangle, but I couldn’t identify the pink colouring pencil. I tried my best, and wrote alongside something to the effect of ‘I am colourblind—this symbol is supposed to be pink, but I’m not sure whether I’ve chosen the right pencil.’

The teacher marked my answer as incorrect, noting that she ‘had’ to mark what I had drawn, and what I had drawn was a green triangle. I was annoyed. My mum’s brilliant solution, which saved any future embarrassment, was to use stickers to write the name of the colour on each pencil.

I gave up studying geography less than a year later, though I can hardly claim that colouring-pencil based trauma was the reason for that.

This article by Andy Baio on The Verge made me think about this. He talks about the colourblindness and accessibility in everyday life.

This crops up from time to time in my work, too, though less so these days than it used to. I used to struggle with spreadsheets where people RAG rated things by shading cells. These days, at least in my line of work, people are generally too indecisive to rate things as ‘red,’ ‘amber’ or ‘green.’ Things are generally classified as ‘amber/red’ or ‘green/amber’ or ‘red/amber.’ This replaces a simple three-point rating scale with an absurdly complex seven-point scale, totally negating its effectiveness in a way which would usually irritate me… except for the fact that it means the ratings appear in text, not as shading.¹

But it still happens: guidance has ‘red’ and ‘green’ pathways; our clinical record system has red and green dots to indicate especially high or low consequence diseases; our professional appraisal system colour codes my appraisal form sections as green for ’complete’ and red for ‘incomplete’; people produce wholly inaccessible charts and maps; people like to add comments to text in red and green.

I recently expressed disappointment at Caroline Creado-Perez’s Invisible Women for asserting ‘that if women are the majority practitioners of an activity, then barriers to that activity are automatically a gendered issue.’ Given that about 10% of men are colourblind and only about 0.5% of women, it occurs to me that this is a great reverse example. By Creado-Perez’s yardstick, I should criticise my (female-majority) employer for gender-based discrimination when they produce documents which don’t account for the needs of colourblind people. But that doesn’t seem like it would be a helpful approach to life.

Most of the time, I don’t really think about it, though I’m not shy about pointing out the issue when it arises (and the examples in Baio’s article feel very familiar). Wendy occasionally feels mildly sad at the thought that I’ve ‘never seen the true beauty of a rainbow,’ and is occasionally surprised at my fashion choices, but otherwise… it’s all good.

The Ishihara image at the top looks to me like it has a hazy, slightly wobbly ‘21’ in it. It probably looks like a ‘74’ to you.

1. Some morons even extend the schema by adding a ‘black’ category, to add an additional three points to the scale (‘black,’ ‘black/red,’ ‘red/black’). This is unforgivable. ↩

There are two adverts I keep hearing at the moment. I think the combination of the two might be harmful to health.

The first says:

One in two people will get cancer in their lifetime.

The second says:

One in two smokers will die of a smoking-related disease.

I wouldn’t quarrel with either of those statements. However, I think hearing both might lead people to underestimate the risks associated with smoking. I think people think “cancer = death” and that “a smoking related disease = cancer”. They may therefore—completely inaccurately—conclude that smoking doesn’t change the risk of death all that much.

Of course, not all cancers are life-shortening—indeed, many don’t even warrant treatment, and many require only a one-off minor procedure.

Of course, there are many life-shortening smoking-related illnesses which aren’t cancers.

I worry, though, that people will just compare “one in two” with—well—“one in two.” That wouldn’t be helpful.

The picture at the top of this post is an AI-generated image created by OpenAI’s DALL-E 2.

Reflections are sparked by the strangest things.

I was on my way to deliver a teaching session scheduled for a room off a service corridor in the basement of a hospital. The corridor was familiar. I was transported back to working as a foundation doctor, when building work meant traversing this endless corridor in the dead of night to get between hospital wings.

The sensation was so reminiscent that my hand automatically wandered to my back pocket to make sure I still had my ‘list,’ the indispensable scrap of paper serving as an aide memoire, with tasks and patients scribbled all over it. For a junior doctor, losing your list is akin to losing your mind, but I haven’t carried one in over a decade.

As I walked that corridor years ago, I would often be strategising about how I could fit an almost endless list of tasks into a narrow window of time. Most of my anxiety was related to doing things. These days—and I think this is common to most doctors as they become more senior, not just those in health protection—most of my anxiety is related to not doing things.

When presented with a situation, ‘doing something’ is almost always the easiest option for experienced doctors, not least because the burden of actually doing the work typically falls elsewhere: taking a specimen, giving an antibiotic, calling a meeting, putting up a sign.

But ‘doing something’ is very frequently the wrong option, partly because resources are limited, but more importantly because not everything benefits from an intervention. Specimens won’t always change management and can cause anxiety while awaiting results. Antibiotics don’t work for everything, have unpleasant side effects, and are a limited natural resource. Meetings don’t always achieve anything and sometimes just kick the can down the road, at a huge time cost. The world already has too many signs, and signs rarely solve problems.

‘Doing nothing’ is often right. Time is a diagnostic and prognostic tool. Waiting to see if a risk is realised is sometimes more rational than responding to an uncertainty.

But ‘not doing things’ is hard. As the adage goes, the coroner doesn’t criticise the doctor who gave the antibiotic that didn’t work, but finds fault with the doctor who didn’t give the antibiotic that might have helped.

‘Not doing things’ is exhausting. Going against someone’s expectations and saying ‘no’ can be emotionally taxing as well as time-consuming. It frequently takes longer to explain and justify and document why you aren’t doing something than it would to just do it. It typically sets up a confrontation that needs to be de-escalated before it begins.

‘Not doing things’ is also necessary, particularly when it might save time. My time is limited and the demands on it are—at least as far as I can tell—unlimited. Working out where my time is best spent is not easy. Saying ‘no’ to things that I’d usually enjoy is dispiriting, but often necessary.

More challenging still is when someone else decides that ‘something must be done’ and requests my participation—even when my judgement is that the better option is to ‘do nothing.’ Do I participate to try to limit the madness? Do I opt out and leave them to it, even if this might precipitate bigger risks down the line?

I still worry about how to do numerous things in a short period of time, but the anxiety of commission is far outweighed by the anxiety of omission these days.

The picture at the top of this post is an AI-generated image for the prompt ‘a world of clocks’ created by OpenAI’s DALL-E 2.

At this time of year, along with the majority of medics, my thoughts are turning a lot to the process of reflecting on clinical practice. This is something that I think most of us do most of the time, but written reflections form a mandatory part of continuing professional development for most medics. Many of us fail to keep on top of them, and end up with a glut to write towards the end of the financial year.

I’m also currently reading Haruki Murakami’s Novelist as a Vocation. I’ll tell you more about that when I’ve finished it, but I wanted to feature this passage (actually, two concatenated passages) where Murakami is giving advice to aspiring novelists on reflecting on their everyday experiences. It’s as good a description as I’ve read anywhere of the process of reflection, and so really resonated with me.

Make a habit of looking at things and events in more detail. Observe what is going on around you and the people you encounter as closely and as deeply as you can. Reflect on what you see. Remember, though, that to reflect is not to rush to determine the rights and wrongs or merits and demerits of what and whom you are observing. Try to consciously refrain from value judgements—conclusions can come later.

I strive to maintain as complete an image as possible of the scene I have observed, the person I have met, the experience I have undergone, regarding it as a singular ‘sample,’ a kind of test case, as it were. I can go back and look at it again later, when my feelings have settled down and there is less urgency, this time inspecting it from a variety of angles. Finally, if and when it seems called for, I can draw my own conclusions.

I really liked this description, but it was Murakami’s next paragraph that completely stopped me in my tracks:

Nevertheless, based on my own experience, I have found that the occasions when conclusions must be drawn are far less numerous than we tend to assume. Indeed, the times when judgements are truly necessary—whether in the short or the long run—are few and far between. That’s the way I feel, anyway. This means that when I read the paper or watch the news on TV, I have a hard time swallowing the reporters’ rush to give opinions on anything and everything. ‘Come on, guys,’ I feel like saying, ‘what’s the big hurry?’

When Wendy and I are watching the news on TV, we frequently comment “It’s not though, is it?’ in response to opinions given by reporters who get caught up in their story’s importance. It irritates us when reporters give commentaries that a moment’s thought would dismiss: ‘this is the most serious crime of the decade,’ ‘this is the biggest political crisis since the second world war,’ ‘this is a make-or-break moment for the political party,’ and that kind of thing.

I’d never before made the connection between thinking reflectively and avoiding a rush to judgement. Now that it has been pointed out, it’s obvious—but reading the above passage was a definite ‘aha’ moment for me, a moment that allowed to see a connection between disparate ideas for the first time.

The picture at the top of this post is an AI-generated image for the prompt ‘a photo of a doctor looking pensive in a mirror’ created by OpenAI’s DALL-E 2. The mirror is a pun on the word ‘reflection,’ just in case that’s not immediately obvious. There’s nothing funnier than a joke that has to be explained.

This 2022 book by the noted palliative care physician from Kerala in India was highly praised by my Goodreads friend Richard Smith, and sounded like a book which would be up my street. I found it somewhat hard to get hold of a copy, but eventually tracked on down online.

I very much hope that this book becomes more widely available because Rajagopal gives some clear and important messages. His writing considers the limits of medicine, its potential to do net harm by focusing more on diseases than patients, and the fundamental importance of holistic care. While entirely different in tone, the messages reminded me a little of Ivan Illich’s Limits to Medicine.

Rajagopal was a pioneer of palliative care in India, and that aspect of this book was also fascinating. He tells us his story, from first recognising a substantial lacuna in the care of patients (a lack of proper pain management) to building a coalition of likeminded colleagues to ultimately transforming medical practice. This aspect of the book reminded me of Misbehaving by Richard Thaler, his account of how he transformed the field of economics by integrating human behaviour. In some ways, Walk with the Weary is an account of how Rajagopal transformed the field of medicine, especially in India, by integrating human compassion.

Rajagopal’s view is that palliative care ought not to be restricted to those who are dying, but that it should be there for ‘all illness-related suffering.’ I had never conceived of palliative care in that way before, but found the argument inspiring. It encapsulates something important about how medicine is best practised.

One of my regrets about the way public health is practised in the UK is the siloed nature of the work. I work in health protection and mostly deal with the acute response to cases of significant infectious diseases. Often, the people who are suffering with these diseases have myriad other needs, but there is no overall coordinating ‘sorter of problems’ to tackle that. I found Rajagopal’s account of overcoming broadly similar structural barriers in his work inspiring.

Some notable quotations I took away from this book:

Imagine a researcher, a few centuries from now, going through the history of ‘Modern Medicine.’ What would her verdict be on healthcare in the early twenty-first century? What would she feel about the healthcare system in which, despite all the accumulated medical knowledge, 80% of the world continues not to have access to basic pain relief? Would she not ask herself—how could they be so senseless to invest so much time, energy, and money in research on ‘conquering’ diseases but not focus on channelling that knowledge so as to provide relief to those in suffering?

No therapeutic scan has yet been created that can measure happiness. There is no medical intervention yet that can generate joy, but the love that I give and the love I receive may be able to do that. If I am made physically comfortable within reasonable limits, this love could well be the only thing that matters as death approaches.

The world over, pain seems to be poorly understood and taught. Diseases are given importance; pain or suffering is ignored.

Many people, including many medical and nursing professionals in India, fail to realise the depth and nature of pain. It can be beyond the average person’s imagination. If severe, it affects your personality and changes you from a sociable human being to a selfish being, caring about nothing other than one’s own pain. It fills the mind space, leaving no space for rational decision-making.

This change in behaviour is immediate when a sudden, agonising pain occurs, but generally resolves completely when the pain is relieved. Sadly, and more tragically, long-term pain, such as low back pain, often irrevocably changes a person. The person may manage to put on a normal front to the world at large, but once back in the privacy of his or her own home, the façade crumbles. The irritability surprises, others; and at some point, it wrecks relationships – between spouses, between parents and children, and eventually with colleagues too. 

There was a lot of food for thought in this book.

When I did a stint on an elderly care ward a decade or so ago, it wasn’t uncommon to send older people to a care home or similar seeing for “a period of convalescence.”

I remember discussing this with my consultant supervisor and suggesting that it seemed strange that we did this for elderly patients, but not for younger patients. I reflected on how I thought I’d benefit from a period of convalescence if I were ill, but that the hospital would want me back on the ward as soon as I was capable of maintaining an approximately vertical position.

I’d forgotten all about that conversation until I saw Richard Smith’s review of Recovery, a short book published last year by Edinburgh GP and writer Gavin Francis. His review inspired me to buy the book.

It’s possible that in one of those feedback loops of reading at the moment: Francis references Suzanne O’Sullivan’s It’s All in Your Head which I very recently read, and Denise Riley’s Time Lived, Without its Flow which I read relatively recently.

Francis’s argument in Recovery is that we all need time to convalesce and heal following illness.

The medicine I was trained in often assumes that once a crisis has passed, the body and mind find ways to heal themselves – there’s almost nothing more to be said on the matter. But after nearly twenty years as a GP I’ve often found that the reverse is true: guidance and encouragement through the process of recovery can be indispensable. Odd as it seems, my patients often need to be granted permission to take the time to recover that they need.

This much seems reasonably obvious, even if society pretends to have forgotten it (and certainly doesn’t practise it). Francis argues that we all need time following illness to regain as much independence as we can, and to find a balance in life.

Francis goes on to logically develop his argument, firstly making a case for convalescence even in chronic illness (we still need time to regain independence and balance), and even suggests that we would benefit from sabbaticals every seven years or so to convalescence from work. I think he is probably right.

Francis also talks about the importance of nature to recovery. I was particularly taken by his image of doctor-as-gardener:

A doctor who sets out to ‘heal’ is in truth more like a gardener who sets out to ‘grow’ – actually, nature does almost all of the work. Even when I stitch a patient’s wound the suture material itself does not knit the tissues – that thread is simply a trellis to guide the body in its own work of recovery.

This is well worth reading.

This 2021 novel by Jasper Gibson has been on my “to read” list since publication. I have been nervous to start it because I thought I would have a strong reaction to it, one way or another. And I was right: I thought it was brilliant.

The novel is a first-person account of living with schizophrenia, set in present day leafy East Sussex. Our narrator, Tom, has a first-class degree in law, and also hears the distinctive voice of the “Octopus God,” Malamock. Malamock also has the power to cause Tom to feel sensations, sometimes painful and sometimes pleasurable.

The central portion of the novel concerns Tom’s admission to a mental health ward. A doctor attempts to recruit him to a drug trial, possibly convincing or possibly coercing him to take part. There is a lot to reflect on the challenges of consenting to research, and also the complex decisions psychiatric patients must make about their treatments. Not everyone wants the voices to go away.

And what are the side effects? I don’t want any more side effects. They’re not usually on the side, are they? More in the middle. Slap bang.

There was also quite a bit in this novel about the fine line between religion and mental illness—always fertile ground—as well as reflecting the paucity of social and financial support for those with psychiatric illnesses.

Doubt is an article of faith and not its opposite.

I had expected this to be a fairly reflective novel, ruminating on mental illness—but actually, it is plot-driven with lively writing and plenty of humour. It was much the better for this.

I thoroughly enjoyed this, and Tom and Malamock will live long in my memory.

Thanks to Newcastle University Library for lending me a copy.

When thinking about risk assessment, it is often useful to separate the hazard (the bad thing that might happen) from the risk (the hazard plus the likelihood of it occurring). Things which are quite hazardous (wild tigers) can be low risk if they’re unlikely to cause harm (there aren’t any wild tigers in the UK). And things which can seem non-hazardous (coconuts) can be high risk if very likely to cause harm (perilously dangling above someone’s head on a windy day).

In a conversation recently, someone commented in passing that it wasn’t possible to meaningfully assess risk when a hazard is so large as to be unquantifiable: say the end of the earth, a world war, or a global pandemic.

I entirely disagree.

Firstly, no hazard is unquantifiable large: of the examples cited, a pandemic is less hazardous than the apocalypse.

But even ignoring that point, it’s self-evident that an activity with a low likelihood of causing the apocalypse is lower risk than one with a high likelihood of causing the apocalypse.

“Okay,” you might say, “but what I really meant is that you can’t compare with between hazards because the apocalyptic one will always win out.”

But that’s nonsense too. A threat with a negligible likelihood of causing a cataclysmic event is self-evidently lower risk than a threat with an extremely high likelihood of killing someone. Firing a gun in a crowded place is riskier than allowing visitors to tour nuclear power plants, even though there is an infinitesimally small chance of the latter being the start of a chain of events that leads to a nuclear disaster.

One could spend a lifetime trying to derive where the lines lie: and, indeed, as a society, we do just that. Through time, democracy, effort and research, we try to reach a societal consensus on where the balance of risks lies. We end up taking actions that have potentially world-ending consequences (say, building nuclear weapons) because we believe it’s the least risky approach.

In reality, risk assessments are generally much more complex than this implies: the theoretical balancing of risks is often easier than understanding the likely effects of each course of action. Any given action (or inaction) has myriad effects, only a fraction of which are pertinent to the specific risk under consideration.

In medicine, giving antibiotics might reduce the risk of a bacterial infection ending someone’s life. It may also cause side effects for an individual, including death. When applied as a general rule in guidance, it will also have extensive wider societal implications: financial cost, the opportunity cost of choosing to prescribe antibiotics rather than spending time doing something else, antimicrobial resistance, and so on. Not giving antibiotics is also very likely to have a whole host of implications, which take effort to foresee. And both courses of action will almost certainly have unforeseeable consequences, too.

The process of working out the implications of each course of action can become enormously complicated, and can often be extremely uncertain. But it must be done because we must make a decision.

In medicine, at least, well-written and considered guidelines constantly try to take a reasoned, explained judgement as to which path is most likely to lead to net benefit in most circumstances. NICE, for example, is typically great at explaining its committees’ thinking on these things—and also great at changing guidance when the real world implications of implementation turn out to differ from predictions.

But sadly, not all guidelines are well-written and considered. Astonishingly, I still come across newly published guidance which reports that intervention X will reduce the risk of disease Y, with no consideration even of side effects for individual patients, let alone wider societal consequences. The guidance vacuously recommends X based on its impact on Y alone.

If Y is common but mild and self-limiting, and X is extraordinarily expensive, then prescribing X will rarely be justified.

If the risks are such that you’d need to prescribe 3,000 doses of X to prevent one case of disease Y, and X has common side effects, then prescribing X may not be justifiable.

It shames my profession that some of this faulty guidance is public health guidance—the part of the medical profession that ought to be most attuned to accounting for costs and unintended consequences.

Balancing risks can be very hard, but it is always possible and indeed always necessary, especially in medicine.

Published in 2015, this was Suzanne O’Sullivan’s first book, and it’s the first of her books that I’ve read. I was motivated to seek a copy after seeing excellent reviews of all of her books.

O’Sullivan is a neurologist, and in this book she discusses patients she has seen with psychosomatic neurological presentations, such as seizures, paralysis, and—in one particularly memorable case—blindness. Based on my experience, O’Sullivan is right to say that psychosomatic illness is not discussed in any great length during medical training. I took a lot away from this book as a result. In particular, it is always useful to be reminded that psychosomatic illnesses are no more under the patient’s control than those with organic causes.

The book is beautifully written, and I found O’Sullivan’s deep reflections on her practice and her uncertainties especially valuable.

Some quotes that I particularly liked:

Modern society likes the idea that we can think ourselves better. When we are unwell, we tell ourselves that if we adopt a positive mental attitude, we will have a better chance of recovery. I am sure that is correct. But society has not fully woken up to the frequency with which people do the opposite – unconsciously think themselves ill.

If you take one hundred healthy people and subject them to the exact same injury you will get a hundred different responses. That is why medicine is an art.

Anger has a purpose. It tells others we are not alright. It also has a lot in common with psychosomatic symptoms. It can be misleading because often it is something else in disguise – hurt or fear repackaged. It is easily misinterpreted, both by those who feel the anger and those at the receiving end. And its effect may be detrimental. It is frightening. The person at whom the anger is directed may well be compelled to flee, possibly just when they are most needed. Anger can destroy the relationship between patient and doctor. The doctor escapes or avoids or ends up treating the anger and not the patient.

There is a terribly delicate balance in the investigation of benign-sounding symptoms. One must investigate to rule out a physical cause if it seems necessary, but the line where investigations should be stopped is drawn very faintly. Primum non nocere. First, do no harm. If you investigate and find something incidental, what do you do? And when do you say no more tests?

Laughter is the ultimate psychosomatic symptom. It is such a normal part of the human experience that all its facets are universally accepted. Now all we have to do is take the few short steps to a new realisation. If we can collapse with laughter, is it not just as possible that the body can do even more extraordinary things when faced with even more extraordinary triggers?

I look forward to reading more of O’Sullivan’s books—especially her most recent one, The Sleeping Beauties, about mass hysteria events, as this crosses neatly with my professional interest in public health.

Thanks to Newcastle University Library for lending me a copy.