Monday, 7 May 2018

I don’t know ... but it seems to me that times are changing

Joan Escarrabill

Health care’s future is an issue that is debated multiple times. The most academic visions or those that start from the observation of reality have common elements. Increasing the number of professionals (more doctors and nurses are needed, is strongly agreed), to the extent that the weight of the hospital will be reduced and interventions in the community will gain prominence, health education of the population is very important or in what way are we going to create sustainability in a system that has contributed significant improvements during the last years, can be just a few examples of these common places of all the debates.

We all make predictions about the future and when we do, we tend to expose a couple of weak points: on the one hand we often start with "prejudices" (according to the dictionary: Action and effect of prejudging/previous and tenacious opinion generally unfavourably about something that is poorly known) and on the other we rely too much on the "assumptions" (assume that everything must evolve and that there will be no disruptions and, very importantly, that without asking, you already know the point of view of the patient/citizen). Talking about the future is a bit risky. Ultimately, in many of these debates, more unwanted solutions are proposed. Marina Garcés suggests that, sometimes, it's worth saying "I don’t know". A "I don’t know" doesn’t necessarily mean ignorance. A "I don’t know" means taking a step back to analyze the problems with a critical look (M. Garcés' conference "un-finishing the world", at the CCCB, February 2016), this critical spirit oozes in all the chapters of her magnificent book "Fora de classe" (Out of class).

Maybe, before defining the solutions, we should say "I don’t know" and think about what the frameworks of the debate should be. I would dare to propose five elements to define the framework of the debate (all of them closely related):
  1. Avoid the adanism. The temptation to think that there has been no intelligent life before us is a serious mistake. Kuhn already showed us that the past is only abandoned when there is a better solution (not before) and specifying a better option (change of paradigm) is not like turning on or off a switch, it’s a process. Advances can make us think more about solutions than about the main purpose of medicine: to avoid suffering (The nature of suffering, Eric Cassell NEJM 1982).
  2. Moral arrogance (feeling superior by definition) is a bad way to approach the future. Arrogance doesn’t help to figure out where the main vector of the future is when we have to deal with very complicated problems (wicked problems). Arrogance prevents us seeing the perspective of the other. And in the case of health care, arrogance often fails to consider the patient's perspective.
  3. Sectarianism (there is only one way), closely related to moral arrogance, although it is even more paralyzing. There must be many roads to guarantee enough variability to survive (Darwin). A good antidote for sectarianism may be to calmly feel the Goldberg variations of JS Bach (1.685-1.750).
  4. Job-to-be-done: Clayton Christensen clearly explains that we have a tendency to define functions before defining needs. Needs may require different professionals, different locations and activities different from what we do now. Innovation is not about improving, it’s about doing things in a different way to respond to unmet needs. An example: in the US, urgent care for the elderly at home is delivered by the "community paramedics". The "paramedics" are health professionals trained to work in the out-of-hospital environment, especially in relation to emergency medical transport with ambulances. These professionals have the ability to perform quality triage and decide if the patient should go to hospital. The professions that will have to face the health problems aren’t limited to "doctors and nurses".
  5. The syndrome of the magic wand: the adanism in our beliefs prevents us from looking critically at the past. This arrogance makes us think that the solutions are very easy and sectarian - that all the solutions are in a single place. That is why the temptation of the "magic wand" is commonly found in the healthcare world. Nothing is simple and everything is much intertwined. Sometimes, untangling the wool requires more actions than simply pulling on a single thread.
I wouldn’t dare to make too many strong affirmations. It must be very hard to carry the torch of purity in a perpetual race without breaks. Right now, I would only dare to say that the future of health care will be digital. And nothing more. Digital applied to health services will mean that they should be personalized, or as personalized as possible (the "one size fits all" is not digital), they should be smart (this means that we’ll have to use all the available information to anticipate people’s needs) and they must be immediate anywhere. These characteristics will change the health professions and the care organization. And all these changes generate ethical tensions between the "me" and the "we": personalization and community health. Following Marina Garcés, I would like to think that these changes can only be made (or should only be done) in a "common world", a "common world that can not be reduced to only one world". 

I’ll end now; I didn’t discover anything new. The Nobel Prize winner for Literature, Bob Dylan, already said it in 1964: ‘times they are a changing’. 

Come writers and crítics
Who prophesize with your pen
And keep your eyes wide
The chance won't come again
And don't speak too soon
For the wheel's still in spin
And there's no telling who
That it's naming
For the loser now
Will be later to win

For the times they are a-changing

NOTE: in another post we can discuss if the talent of Bob Dylan is comparable to that of Gabriel García Márquez (in relation to the Nobel) or to that of Jorge Luis Borges (in relation to literature)... but this is food for thought in another post.

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