One of the attractive features of medicine as a career is its broad reach. Dealing with the human condition requires not only technical skills but a sense of what it means to be human, of suffering, and of our relationship to each other in the midst of all this. My former professor of general practice, the late James McCormick, summed this up beautifully in 1979 in his pioneering book, Doctor, father-figure or plumber, even if we might gently rephrase the title in a more gender-sensitive era.
This need to see the bigger picture is supported in many ways and, in particular, by the openness of major medical journals to a wide array of reflection and research across the humanities and social sciences. Of particular note is a weekly feature in the Lancet called The Art of Medicine, which in recent weeks covered medical history, the (f)utility of pain, and consumerism in medicine. The Lancet also hosts reviews of arts events relevant to medicine, including the recent Abbey Theatre production of A Midsummer Night's Dream set in a nursing home.
Another major international journal, the Quarterly Journal of Medicine, which is edited by Prof Seamas Donnelly of Trinity College Dublin and Tallaght hospital, published my favourite paper of 2014, comparing doctors, managers and public representatives' views about acceptable level of risk in discharges from the emergency department.
The author, Prof Shaun O’Keeffe, is a geriatrician in Galway whose research in the areas of ethics in later life, delirium and restless legs syndrome has received international acclaim. This portfolio is complemented by some fascinating studies, emblematic of which was a paper about the richness of the linguistic content of GB Shaw and PG Wodehouse into their 10th decade, a testament to the “use it or lose it” theory.
In the paper about risk, Prof O’Keeffe teased out some of the challenges in the social contract between society, management and professionals. Using a series of vignettes of patients presenting to the emergency department, doctors, healthcare managers and politicians were asked to state the degree of risk they were willing to take in discharging patients.
Element of risk
This is an important issue; an area of public debate that has been growing since the publication of a seminal work,
The Risk Society
, by Ulrich Beck, in 1986. An element of risk is inevitable in medicine and, in particular, in high-pressure environments such as the emergency department, even with optimal processes.
The elimination of all risk may sound like a good idea, but would come at a cost of unnecessary admissions, increased length of stay, and investigations and procedures that can not only cause harm to the individual but also restrict access to other users.
It is hard to condense such a complex subject, but a comparison that captures the essence of the paper is the average risk that each group would accept for a suicide after discharging a patient with depression. For the doctors, this was 1 in 1,000, for the managers 1 in 5,000, and the politicians it was 1 in 10,000.
These hitherto unspoken disparities are at the heart of significant tensions in how society deals with the challenge of designing a health system that can never eliminate untoward events. Indeed, as Beck wrote, “someone who depicts the world as risk will ultimately become incapable of action”.
Such tensions may underlie the recent standoff between Hiqa and the HSE over the Midland Regional Hospital at Portlaoise, and indeed were deeply evocative of my own unpleasant memories of dealing with HSE management over the Leas Cross report.
With higher aversion to risk, managing a system that they know not only demands the embracing risk but may also be distorted by political manoeuvres, such as the maintenance of emergency services in centres where this is no longer prudent, non-clinician managers and politicians are likely to be significantly more averse to levels of accompanying critique that clinicians tend to take for granted.
We must all be grateful to O’Keeffe for research which we hope will open a more robust dialogue between the medical profession and managers, politicians and the public about the inevitability of risk in medicine and to ensure that the task of defining acceptable risk is one in which managers and politicians must also accept their due share.
Prof Desmond O’Neill is a consultant physician in geriatric and stroke medicine and professor of medical gerontology at Tallaght hospital and Trinity Centre for Health Sciences. Twitter: @Age_Matters