Tag Archives: PoMo

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:

When words are not enough

This is a simple plea for mixed teams and visual tools.

I once asked a friend if he dreamed in colour or black and white, and he said ‘neither, I dream in concepts’.   By contrast with both of us, many post-modernists  seem to believe that thought can only be verbal, but that way madness lies: The only validity of 1+1=2 is as a representation of words, and ‘one plus one equals two’ is a social construct.  Oh dear.

I challenge this doctrine that the Word is god.  When I want to work out how things relate to each other I find words are completely useless. They are are ok for communicating concepts (sometimes) but often I find them bad for uncovering concepts, and they are next to useless for working out how things relate to each other.

Years ago I learned a consultancy or counselling exercise whereby you or the client list(s) all the factors on 3x5s and the client organises them in groups on a table.  It is great for aggregating things together.

The house is a mess, the dog has fleas, the kids are in trouble for losing their home-work, and you’re broke because you’ve been buying lunch at work all month.

Write ’em on cards and put them all on the table along with everything else, and suddenly there’s the Eureka moment: the common thread is being short on time.  Deal with that and the other problems melt away.

But until you get the chance to move them around and play them off against each other, you think you’ve got dozens of impossible little problems, instead of one or two larger  ones.

There are many variations on this, and it’s used formally in a lot of project planning workshops for grouping activities into work-streams and blocking them out in time.

The pure gold in this approach is its value in working out the relationships between things.  You can do  on whiteboards, you can do it with cards, you can do it with post-its.  These days I am lazy, so I do it in PowerPoint or Visio. The point is that it’s a process, you won’t arrive at the finished diagram in five minutes, but the very activity of moving things around, like blobs in a lava lamp, will enable your thoughts to coalesce and clarify.

This isn’t just a post about tools, though. It’s saying that there are some conclusions you will never arrive at if you stick to words.  It helps to understand how your team think.  NLP divides thinkers up between the auditory, the visual and the kinesthetic.  I am increasingly doubtful about this, and find it more useful to place them within a venn diagram with circles for the numerate, the verbal and the visual.

Get one of each on your analysis team and so long as there’s no explosion, you will really be cooking with gas.  And I’ve said it before and I’ll say it again: if you get stuck on a problem, change  your tool.