The white coat’s burden – healthcare colonialism

red arrowColonialism is a mindset.  It governs how you see and behave unequally towards others. Few espouse the “white man’s burden” literally nowadays – and Kipling meant it ironically anyway, not as justifying a “noble enterprise”. But there is still a “colonial mentality” behind the inherently unequal relationships in lots of UK healthcare.  Why is that?

Tripping over the problem

You don’t have to go far to trip over  the problem.  Just dip into patient leader Michael Seres’ latest blog about the travails of being a patient when you are “the only patient in the room”.  On the basis of this bizarre experience, you will have to agree with him that “patients are from Mars and helathcare professionals are from Venus”.

A couple of weeks ago I had my first taste on the phrase that I had believed was consigned to the dark ages –  “what do patients really know.” I was invited to attend a clinical commissioning group strategy meeting in my area. It was a room of around 150 GPs and primary care practitioners. Amazingly I was the only patient in the room. In one of the breakout sessions we got on to discussing how doctors need to invest more in educating patients. It was simply a round table conversation and I spoke about peer to peer interaction and how doctors can actually learn from listening to patients, reading patient blogs and interacting on social media. The moderator and then the GPs around the table looked at me, told me that what I knew was only as a patient and then proceeded to tell me that I must be one of those nutty bloggers like mumsnet.  Whilst being compared to the highly successful website mumsnet is undoubtedly a compliment (not that it was meant that way), to say I was flabbergasted was an understatement. For once in my life I was silent. I didn’t know whether to rant, to respond or whether that response even deserved a reaction.

Theory good; practice often lacking

Why do these things keep happening?  It isn’t supposed to be like that.  Even the RCGP’s Commission on Generalism acknowledges that essential tenets of primary care practice embrace a specific ethos for :

empathy – intelligent use of insight into the whole setting of the patient’s plight

engagement – a commitment to active involvement in every aspect of the patient’s care

an appreciation of limits – understanding and acknowledging the specialist aspects of care

professionalism – in clinical communication, interactions and behaviour.

That should create lots of space for patients to have an independent role and for their experiences to have equal value.  But the theory gets left behind as the predominant colonial culture – “how we do things around here” –  takes over out there in practice.  Too many health care professionals – not all of them clinicians by any means –  have got a bad dose of the “white coat’s burden”.  They have to make patients better (in their own image).

They are the enlightened elite whose power needs no justification and whose whose beneficent duty (their burden) is to bring civilisation to us poor patients (the proxy natives) by persuading us to do as we are told (eg compliance with treatment) and use their NHS appropriately.  This is futile, of course, and just reinforces their colonial mindset that we the patients have to be educated.   But it’s the other way around: we have to educate doctors and other HCPs to stop saying ‘we have to educate patients/public” to do things better (our way).

Maybe it’s about who owns “truth” 

The estimable Dr John Launer has an insight on this entrenched colonial-cum-paternal mentality and it comes down to “who owns the truth” – doctor or patient?  What’s at the root of the inequality?

Partly this has been because of the social relations that have existed between doctors and most of their patients. Partly it is because of the specific technical expertise that doctors hold. While there has been a move in recent years—and for longer in private medicine—towards a form of consumerism centred around the rhetoric of “choice”, this has often been a veneer covering an entrenched paternalism in the way that doctors actually interact with patients. What has been largely missing so far … is an idea that patients’ views of their medical encounters—including or even especially when these encounters go wrong—should be accorded equal status with our own.

The patient’s truth  –  how he/she sees the world, their life, their illness, the future, possibility of death, returning to work, having sex etc – is of equal value to the doctor’s view, but the prevailing healthcare culture does not admit that patients are experts about themselves.  It’s that which has to change if healthcare is to emerge from its colonialism mentality.  And patient leaders are the hope for the future.

Emergency services a case in point

The flap over how we use emergency services illustrates how deep this “white coat colonialism” runs.  In many years working up close with the NHS in different lay roles I’ve seen clinicians, managers, policy wonks and pundits  decry our collective “failure” as patients to use emergency services “appropriately” and witnessed campaign upon campaign to try to get us to change our nativist behaviour.  But what can they expect when their exhortations use ambiguous, subjective and value-saturated language?  “Urgent” or “non-emergency” are some of the most subjective words – like fairness –  I’ve ever encountered.   Differences in understanding influenced by culture, gender, age, geographical implications are all forgotten; no wonder campaigns fail.

What is going on is that “they” the white-coated professionals feel they have a duty to civilise “us” the natives to their ways of rational decision making and appropriate use of services. “Appropriate” is a a particularly annoying word in the mouths of the po-faced and powerful. But I wonder how coolly rational and informed HCP behaviour is in the middle of the night with a screaming, feverish toddler under your arm?  Do they calmly consult NHS symptom checker online or bust a gut heading for the nearest A&E?  Are they rationale role models of appropriate behaviour or (as I suspect) do they revert to type just like the rest of us and “go native” to the nearest A&E?

Just follow the big flashing red arrow

In fact, going native may be how to “fix” the A&E problem.    GP Des Spence articulated a big part of the obvious solution and, surprise, it doesn’t start with trying to “fix the patients” for a change.

Keep it simple. Locate emergency departments in primary care centres, and make out of hours primary care available on a walk in basis.  Keep some morning slots open so that out of hours demand can be deferred. Monitor this. Finally, insist that emergency staff rotate through general practice, because over investigation in emergency care adds huge pressure on resources.

That’s good as far as it goes.  The rest of the fix is simple too: follow what the users do already.  Make the service happen where they want to go to get it.  And don’t berate them for going to the “wrong” place. Wherever they go, then its “right” for them.

To emphasise that, there needs to be a big flashing red arrow over every A&E with the words “come in here and we will sort you out”.  It would be a bit like the Tardis on the inside with something for everyone – even the drunks.

It can work because it’s what the public wants to do anyway.  So why not make it the natural solution instead of repeatedly struggling to make people behave differently?  Everybody wins and no one gets blamed for acting “inappropriately” and clogging up A&E because it’s where they are supposed to be.  Most importantly, the white coats’ burden is lifted and they can get on with being partners in care and not “care colonialists” –  cheers all round.

The Millar Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  Feel free to contact us to discuss the opportunities.  Follow MAC on Twitter @publicinvolve



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