Uncertainty – and the NHS reforms

This is a blog I originally posted in June on The Network, but I thought that it was still relevant, so I would post it here too…

What are the three most significant words a doctor can use? When it comes to three word phrases, there are a few which stand out. Classics include “I love you” “I am Spartacus!” and “Run, Forrest, Run!”

There are seldom reasonable times or places in medicine to utilise these particular phrases, but there is another which is possibly under-utlised at all levels of the medical profession. “I don’t know”

When we enter medical school, we enter a new world and a new way of thinking. Over time we are moulded to a greater or lesser extent into a recognisable form of doctor. In the first few years this is the classical junior doctor – pale chinos, blue shirt, looking tired, bleep going off constantly, always slightly harassed. We move on, and acquire the trappings of authority – suit, real leather shoes, Mont-Blanc pen, more letters after the name. But one thing remains constant. We are expected to hold the answers. When seeing a patient for the first time as an FY1, we are often asked on the post-take round – “…and what’s the diagnosis?” As a registrar in clinic – “so what is it Doc?” As the consultant in the Grand Round / M+M meeting – “So, Dr/Mr …. What would you have done?” The whole of medical science it sometimes seems is about obtaining that final, all encompassing diagnosis of which Occam himself would have been proud.

However, as we know for ourselves, and have seen on the larger scale recently – we do not always know the answer. What then, are we supposed to do?

I would argue that we should not collude with the questioner, we should not give false reassurances, or misleading hope, but instead admit our uncertainty, and then set out a vision of how we are going to go about tackling the problem at hand, keeping to a guiding set of principles.
This is what we are facing at the moment in the NHS – a period of unequalled change, and challenge at a time when the economy is fragile, and there are perceived threats to the very fabric of the NHS.

In this context, it is only right to admit that we don’t hold all of the answers, but we are going to work very hard to understand where we are, and adhering to some fundamental principles, work our way towards a solution. Thinking about this, I am reminded of Shackleton, and his words after he lost ‘Endurance’:

“But although we have been compelled to abandon the ship,… we are alive and well and we have stores and equipment for the task ahead of us. The task is to reach land with all the members of the Expedition.”

As we navigate the health reforms, and continue to provide services to patients, we need to be aware that sometimes the most useful answer is “I don’t know… but” and that ‘but’ must include the principles of patient-centred, fair, effective and safe care. For if we keep those principles in mind, at every level of this fantastic organisation, we are more likely to succeed than if shaky answers are given, and false hopes raised.


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