Ours is, at its heart, a profession of service predicated on mutual trust. All too often policies aimed at resolving a particular problem in health care are inadequate not because they fail at what they were intended to do, but rather because of the unintended consequences, both direct and indirect, that are inevitable in complex systems where competing interests preclude unity of purpose. Ultimately, these policy “layers” distance us from our foundational principles and the disjointed complexity that ensues alienates the patient, disheartens and disillusions the physician, and further undermines the relationship that is so crucial to proper health care delivery. Importantly, we must realise that legislative complexity simply cannot make up for an absence of trust and instead work to foster such trust by reflecting our profession’s tradition of service to the public through a blatant, highly visible pursuit of patient welfare.
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- medical narrative
- patient centred medicine
- health care policy
- removing that which was once thought good
Imagine that you are suddenly transported to a room with walls and ceiling beyond vision, causing all that is around you to appear white. All, that is, except for the floor, which is a melange of umbrage, being dark brown to black with only the occasional whisper of colour. As you explore the surrounding area you become less and less sure that the room you occupy is even a room at all, such is its immeasurability.
You continue to wander and eventually happen upon large numbers of people clustered in groups. Some of these are on their knees painting, each in the colour that suits them best: azure, crimson, navy, oaken, violet—the colours being used are as endless as the horizon which stretches out before them. Others within the groups are standing around the painters debating the appropriateness of the various colours, and still others have no particular preference, they simply demand that it be finished.1 But why? What can it mean, in this context, to be “finished”?
You approach one of the painters and ask what all the commotion is about. The painter replies that it was decided long ago that the entire floor should be covered by paint. “But why?” you ask. “Well,” he says, “in the beginning all was white. Some considered, and rightfully so, that the floor could possibly be enhanced a bit. This being the case, we began to apply bits of varnish here and there, light modifications really. At the same time, there were those who worked to make the paint better with the creation of new colours, textures, properties, et cetera. The floor began to look absolutely stunning. Time moved on, bringing us deaths and births and all that is natural to the ebb and flow of life. As things progressed, though, the fruits of our effort revealed themselves to be quite inequitable.2 Through this, we began to see the presence of inconsistencies in what we were doing and how we were doing it, though it was generally agreed that this was mostly due to a lack of foresight, which could be avoided in the future by more detailed planning.3 In these moments we would go back and add a new colour of paint or refashion the texture. Ironically, the more we tried to find the solution to our problems in the newest and best paints and methodologies, the more problematic things became.3 This being the case, many among us have become even more convinced of the necessity for a thoroughly and thoughtfully formulated plan for how the entire floor should be painted, any subsequent problems being fixed as they arise.”
You astutely observe that the walls appear unreachable. He agrees, but claims dogmatically that it is no matter. You then raise the point that there are exceedingly few areas in which the residents appear satisfied, while there are a huge number from which complaints are continuously heard.4 He answers you by saying that, “sadly, little can be done. This is the order of things: we develop, we debate, then we paint. It remains a foregone conclusion, however, that the floor must be painted.”5
“This is interminable!” you exclaim. “I’m sure it must seem so, but the newest idea is right around the corner and it will surely save us…”.6
This is the state of health care policy development in the world today. In an effort to provide everyone with adequate health care, we seem to have become entrenched in a paradigm of “painting as policy”. The perception that vast ideological differences exist and thereby separate us from a truly equitable and sustainable health care delivery mechanism has led us to embrace the compromises of incremental policies. Unfortunately, it is upon these that further incremental policies must be ever applied as fixative such that, despite the vast amounts of effort and resources invested, we face a perpetually unsolvable crisis.5 Moreover, as the “paint” becomes three dimensional we cease to stand on the hard floor of care, instead finding ourselves increasingly trapped in a morass of policy.7 Thus we have come to find ourselves kneeling over a darkened, sticky floor.
Radically, it does not have to be this way. The clean, white floor upon which the medical tradition began is highly preferable to the chemically toxic one we now occupy. The current floor, which is increasingly characterised by self serving attitudes and public distrust,7–9 obscures the beneficence of the physician as well as the dignity of the patient, thus denigrating the qualities so profoundly necessary to the success of the physician/patient relationship.10,11 What we need is fewer arguments, fewer compromises, fewer colours. What we really need, we already had.12 After all, our chief aim in health is to provide care, not policy. The solution, therefore, is in the solvent…
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