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.

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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:

• Simon Singh’s reflections on his recent libel case
• The Skeptics, the Chiropractics and the Quacklash

Farewell to flakiness – or why I’m not entitled to my own opinion

I was raised by people of great personal and moral integrity with reasonable intelligence who had no exposure to science or scientific thinking at all. This didn’t stop them having Opinions on things so it is no surprise that they were Flakes one and all. Bless ’em.

Flaky thinking is cozy, it provides comfort blankies such as “everything happens for a reason”or “someone was looking after me that night”. It also provides explanations which appear to be simple and easy to understand: ” stimulating the body’s natural healing processes” or “bright lines of golden energy”.

I’m not going to rip into acupuncture, auric photography, biomagnetic bracelets, biorhythm charts, cranial-sacral therapy, earth energy lines, feng shui, food sensitivity analysis, homoeopathy, osteopathy, reiki or any of the other forms of flakiness which I’ve spent money on in my time. To be honest, I cannot be bothered. Either you consider me to be foolishly narrow-minded because I dismiss them or foolishly forebearing because I don’t critique them and we both have better things to do with our time than argue the point.

Let’s just say that I spent my money on all of the above, probably thousands of pounds now that I look at the list, but I don’t feel ripped off; every one of them brought me a good 40 minutes of someone’s undivided attention and a nice warm placebo effect. I was lucky; it was a life-style choice not a fearful attempt to ward off cancer. But I wouldn’t spend my money on any of them again.

So what undermined my warm fuzzy view that the word “energy” means something when used metaphorically, that there are forces which cannot be measured by science, and that there is more to life than meets the eye?

Lots of things. Feel free to skip the list and cut to the conclusions at the end of the piece.

• I check out the Asthma UK site and realise the approaches described are infinitely more cautious, detailed, rigorous and robust than the approaches of the herbalists I’d instinctively turn to.
• My father, with cancer, is dramatically better after a stay in hospital which grants him at least another year of good quality of life.
• A crystal healer describes the “lovely warm lines of yellow energy” flowing through her treatment rooms. When I ask her if she can see them she says “no, but Gordon has dowsed them and told me where they are”. The inane warmth in her voice sets my alarm bells ringing.
• I read The Selfish Gene by Richard Dawkins.
• I have to describe my symptoms to the German pharmacist rather than selecting the herbal tinctures and ointments I’d choose in the UK; I find myself thinking “These German pharmaceuticals are very effective” and then realising that they might work well simply because they are pharmaceuticals and being German has nothing to do with it.
• I work for a large petro-chemical company and find that the individuals there are responsible and serious people, and not in fact the spawn of satan who just don’t “get” it.
• I acknowledge that the scientists working on GMOs are (a) intelligent and (b) not malicious. I think that they are wrong about genetically modified organisms being good for the planet, but acknowledge that if they are wrong then it’s not because they are stupid.
• A friend sends me a link to DHMO.org and I realise just how easy it is to writes spurious science-speak which is manipulative and emotional.
• A friend of mine compulsively adds and subtracts numbers to find co-incidences and meanings without noticing that if you manipulate any date enough you can reach the number 7, or 26.
• I read something which explains that the phenomena described in all documented near-death experiences (tunnel vision, a distant light, etc) are also consistent with specific forms of neurological shut-down.
• I develop an increasing respect for the methodologies in my own field, and by extension for standards’ based methodological approaches in others. In other words, I come to prefer rigorous testing to instinct.
• I have a relationship with a statistician.
• I come across evidence that a feeling that there a ghostly presence in the room can be reliably triggered by certain localised electro-magnetic phenomenon.
• I read The Demon Haunted World by Carl Sagan.
• I regularly flick through copies of the British Medical Journal and discover that the research studies are of varying quality but explicit about their limitations and scope.
• Triptanes provide effective migraine relief.
• I read Snake Oil by John Diamond.
• I start a post-grad degree and within a few months become imensely more picky about authorities and references.

Ok. It’s not a particularly impressive list: a lot of it is based on a distaste for poor critical thinking in others which of course doesn’t demonstrate any improvement in my own, the books are pop-science even if the scientists are credible, the rest of it is un-referenced and at this distance in time I have no way of checking where I got the information about near death experiences and ghostly presences from.

But…

But I think that the real epiphany is that I am only entitled to an opinion on subjects where I have some expertise. Guess what – experts really do know better. It’s a matter of knowing my limitations. I cannot bake cakes, design power stations or diagnose illnesses. I have no choice but to delegate those tasks. Generic intelligence is not the same as experience, training or qualifications and this is hard for people, particularly those educated in the social sciences or humanities, to accept.

Not all experts are equal, of course. Gillian McKeith’s “doctorate” is a tad light-weight to say the least, though the woman is undoubtedly sincere. We cannot accept the word of experts unquestioningly. We must continue to challenge and ask the pertinent questions – how did you arrive at that conclusion – how large was your sample-size – how well conducted has your research been – where do you get your funding, and so on. But challenging does work: 20 years of hindsight bias, selective memory, anecdotal evidence and the placebo effect do not equal one double blind controlled trial. Sorry.

Some people argue that science is just as much a matter of belief as religion is. It isn’t of course. I’ve argued that you have to trust the scientists but as Reagan put it you “trust but verify”. You can by definition repeat and test a scientific experiment or demonstration. You cannot test bach flower remedies, post-modernism or god. In fact there’s even a commandment against it.

This of course means that the opinions of true experts whose conclusions are based on testable and repeatable methods vastly outweigh yours and mine. We are entitled to doubts, concerns, worries, uncertainties and even rage, anger and disgust. Those are emotions and emotions are not opinions. We must also remain entitled to challenge – that is what accountability is.

To some extent I do miss the warm fuzziness of flaky thinking, but on the other hand if you acknowledge that real life is unfair, that shit happens, it becomes much easier to deal with. Nastier, but more straight-forward. There are a few flaky things I still adhere to: meditation, NLP and yoga specifically, though I’m not going to defend them here. The only school of “alternative” thought which I have not yet found to be intellectually undermined is the Buddhist approach to re-incarnation. To be honest, I doubt it’s got any validity to it, but does have the merits of being (a) internally consistent and (b) not yet countered by harsh scientific enquiry. However you look at it, the idea that bad things happen to good people for no reason is a nasty one.

I had been going to illustrate this with one of the Cadbury’s Flake ads but I couldn’t find the girl painting a picture in a poppy field in the rain, so I decided to show you this instead which did at least make me laugh.