Is the NHS modernist or post-modernist?

Someone came here the other day using the following search term: is the nhs modernist or post-modernist. I’ve not blogged on the subject but it’s a peach of a question, so I’ll bite.

One of my dirty little secrets is that I don’t really know what modernism and postmodernism are.  I don’t feel bad about this because the definitions are so slippery: Wikipedia (yes, I know…) says this about them:

Modernism: … affirms the power of human beings to create, improve, and reshape their environment, with the aid of practical experimentation, scientific knowledge or technology. (My emphasis).

Post-modernism: is a tendency in contemporary culture characterized by the rejection of objective truth … It emphasizes the role of language, power relations, and motivations; the term “post-modernism” comes from its rejection of the “modern” scientific mentality developed during the Enlightenment. (My emphasis).

So I’ll take ‘modernism’ to mean ‘empirical science’ in this context, and plough on with the question.

The brief answer, of course, is that the NHS should be both. The scientific method is the best way to find out the truth about the physical universe (how drugs interact with the body); but hard science can’t cast much light on how people interact with each other individually or within organisations. So Western medical practice, which is delivered by complex organisations including the NHS, is a battle-ground for these two philosophies. In fact the history of the NHS over the past 20 years has been a matter of eroding the power of the clinicians and handing it over to the administrators. Whether this has gone too far or not far enough depends on who you listen to.

Empiricism lacks the nuances you need to explain how people and organisations behave, but post-modernism’s not the answer either: it  can and frequently does go feral. Post-modernism holds that all ideas are made up; indeed extreme relativists claim to believe that there is no underlying and testable truth in the physical universe and that scientific laws like the law of gravity are “social constructs”.  From this you get the kind of post-modernism which is mad, bad and dangerous to know, for example the idea that using the scientific method to uncover truths about the physical world is an act of oppression “because other methods are equally valid”.  Um. No they’re not.

You’d think this was ludicrous but Ben Goldacre and David Colquhoun have both commented at length on an article which has the following in its abstract:

[Our objective is] …  showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm … [and] showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.

Goldacre and Colquhoun rightly say that this would be laughable if it weren’t dangerous: medical practice strives to be evidence-based, and so it damn well should be. I want my treatments tried, tested and effective, and only a “scientific research paradigm” will do that.

However, the paper’s authors have a point, badly put though it may be: advocates of the scientific method are indeed snotty about other forms of knowledge.

Let me tell you about my friend Sarah.

Sarah’s widowed mother was dying and the doctors looking after her concluded that any attempt to resuscitate her would be needlessly cruel. The Registrar had just raised the topic of the DNR order with Sarah and her much younger sister when he was bleeped away to another part of the hospital. So the women took the heart-breaking decision themselves.

When I told a Senior House Officer about this he said “but they didn’t take that decision – the Med Reg took it”.

Viewed through rational, modernist glasses, my SHO pal is right: the choice was not theirs to make and therefore they made no choice. But even so, they experienced making it as surely as if the casting vote had truly been theirs. We need the NHS to bridge both perspectives. It seems that patients’ families will complain more about badly delivered care which produces good results than about a team who are kind but made mistakes.

The clinical aspects of the NHS should deliver empirical pills sweetened with subjectivist sugar. If they don’t, medical care seems hurried, emotionally brutal and harsh, and the patient can feel like an item on a conveyor belt, a statistic or an inconvenience. Many of these patients then seek and obtain kindlier treatment among the alternative practitioners. You see, practices like homoeopathy and acupuncture are what happens when therapies operate in a world where anyone’s ideas about what constitute medicine,  evidence and even illness and good-health are as good as everyone else’s.  There is no valid evidence-base, and treatments are chosen intuitively or anecdotally. However, the practitioners provide a service which is not available on the NHS: they sit and listen sympathetically for 40 minutes to the emotional needs of their patients. The emotional landscape is seen as the very fabric of the condition and is the starting point for holistic treatments. They are, quite literally, post-modernism in Practice.

However, those managing the trusts, hospitals and practices that comprise the NHS, should take the opposite approach. We need them to respect the needs and experiences of the different groups they deal with, but they should stiffen this touchy-feely stuff with policies and decision-making based on as much statistical evidence as they can get hold of.  And heaven knows, the NHS can provide huge data-sets.  In fairness I should say that I’m thoroughly impressed by the pragmatic intelligence of the NHS managers I have met, and rather them than me.

Is the NHS modernist or post-modernist? It’s too big an organisation for a single answer.

Which probably makes it post-modernist.

Damn.


If you’ve the time during your coffee break, then read more Ben Goldacre and David Colquhoun.

Alan Sokal is spectacularly good on just how sloppy post-modernist thinking can be.

And here are a couple of other good links while we are on the subject of alternative therapies and the scientific method:

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10 responses to “Is the NHS modernist or post-modernist?

  1. I agree entirely that medicine needs a human side. I transferred myself from UCLH to the Marsden for nephrectomy not because I had any reason to think the surgeons were better, but simply because they were nicer to me at a rather worrying time.

    But I don’t think that being nice to patients is anything whatsoever to postmodernism, which I still consider to be a fad adopted by lazy people who try to impress with complicated words.

    • Thank you for coming by and taking the time to read and comment.

      I whole-heartedly agree that postmodernism is a fad adopted by lazy people who try to impress with complicated words. It seems to me that many postmodernists are either breath-takingly stupid or wilfully dishonest.

      However, I also think that positivism cannot cover all the bases because people and organisations are just too nuanced: whether that’s a post-modern idea or just one the post-modernists have stolen is another matter.

      But you are right, being nice to patients was humane long before the first post-modernist was spawned.

      Thanks again for reading and commenting.

      Ben

  2. “the patient can feel like an item on a conveyor belt, a statistic or an inconvenience. Many of these patients then seek and obtain kindlier treatment among the alternative practitioners. ”

    Call me emotionally brutal or harsh if you like, but that’s Darwinism in action, right there. Anyone who wants to remove themselves from the NHS by going elsewhere for kindlier treatment *that doesn’t work* is very welcome to. That goes double if they were in a queue in front of me. On the other hand, if they’re receiving any kind of taxpayer funded benefits, those benefits should cease immediately if they reject NHS treatment in favour of woo-woo magic beans.

    The NHS is one of the greatest privileges of living in this country. To reject its benefits in favour of quacks is, to my mind, at least as reprehensible as not voting.

    • Well, it’s only Darwinian if it cuts them down before they have children, or if it kills the children, of course. Which in the case of a few unfortunate MMR-avoiders it has.

      Not everyone has the education or ability to work out what’s a lie and what’s not, especially since so many of the purveyors of woo adopt sciency trappings or, worse, get BScs from apparently legitimate universities.

      All credit to David Colquhoun here for making it harder and harder for that to happen by getting those sorts of courses closed down.

      Ben

  3. Bearing in mind I am a rationalist who has NO time for woo woo magic beans, I *still* took my baby to a cranial osteopath when he screamed and puked non-stop for three months and all the conventional wisdom of the NHS could offer me was “Is this your first baby? Didn’t you know that babies cry?” until I completely fell apart on the GP and begged and sobbed for someone to help me help him.

    I am slightly ashamed that in my desperation to help my son (in a fug of post-birth pain and sleeplessness) I gave one of these quacks some of my hard-earned cash but I completely understand why people do. She spent almost an hour listening to me describe the problem and never once intimated that I was stupid, naive or making it up – with hindsight, she must get a lot of practise at this with people who don’t have a genuine medical problem, unlike my son.

    In the end my meltdown at the doctors led to a paeds referral and a consultant who prescribed the right stuff which was like flicking a switch in my son – he suddenly smiled and played with his toys for the first time. At my last, post-medication, visit to the osteopath she said his energy felt different but he might now have some difficulties with his digestion at which point I gathered him up and left. It has been my mission since to help new mums in my postion to get the right help from their doctors and not be driven in to the arms of nutjobs.

    And don’t get me started on the anti-vax movement…

  4. I think it’s such a shame that seeing a GP didn’t lead to the right sort of help.

    If you hadn’t seen a crainial osteopath would you have gone back to your GP sooner?

    One of the big reasons why people go to ‘woo’ is that woo healers are nicer than convential medics. They have to be – no one would go to them if they didn’t listen!

  5. I’m just as guilty – my lowest vertebral disc is half the thickness it should be, thanks to a combination of Territorial Army training and snowboarding mishaps.

    I’ve seen physiotherapists, an osteopath and McTimoney chiroquacktors. And, touch wood, my back is now fine. And I’m entirely convinced it had precisely nothing to do with anything any of them did, and everything to do with getting a proper mattress and pillow and giving up hitting tabletop ramps at forty mph.

    The osteopath in particular was seriously useless, recommending herbal homeopathic remedies and merely touching my back without apparently doing anything at all. I only paid her one visit, since even to my untrained eye she was clearly a nutjob.

    What annoys me a bit, in retrospect, is that when I asked my GP to refer me to a chiropractor, all he said was “we can’t refer you to one” and suggested a physiotherapist. He didn’t say “we might as well refer you to a frickin’ witch doctor as one of those quacks”, or anything similar. He gave no indication whatever that chiropractic was no more a medical intervention than homeopathy. I wish he had, it would have saved me several hundred pounds and a fair bit of time off work.

  6. Would I have gone to the GP again sooner? I was seeing him pretty regularly anyhow (he kept saying this was ‘normal’) but I would probably have hit crisis point sooner and got the appropriate help. So seeing somebody whose snake oil made me feel like I was doing something positive prolonged the time that elapsed until The Boy saw a consultant. Her placebo worked for me temporarily but sadly not for him, who obviously couldn’t tell me that what she was doing wasn’t helping.

    It never fails to anger me that as a person who had previously taken pride in my mental fortitude I had to get to the point where I fell apart in order to be taken seriously.

    Incidentally, that GP’s wife has since had a baby, and he is *far* better now at understanding parental concerns than he was before – or maybe he has come to realise that I’m not a hysterical over-reactor. Either way he is the one I actively choose for the boys now.

    • >> that GP’s wife has since had a baby, and he is *far* better now at understanding parental concerns than he was before – or maybe he has come to realise that I’m not a hysterical over-reactor

      Hah!

      Thanks all for taking the time to read and comment.

      Ben

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