When faced with something new, it is within all of us to come to an instant opinion, to make an impetuous decision. We do it all the time. Sometimes subsequent events show that opinion or decision to be correct, but on other occasions we change our mind once we have more information, the information we really needed to make the decision in the first place.
In the practice of medicine the traditional diagnostic model involves the gathering of relevant information from the patient, constructing an initial opinion or hypothesis, and then testing and perhaps changing it in the light of further information gathered from investigations or the opinions of others. To short-circuit that process risks mistakes.
Examples of reactivity are legion in every day life. How many of us reared up at the new idea of the compulsory wearing of car seat belts? GPs, of all people, even sought an exemption to the law because they had to get in and out of their cars frequently to visit patients at home! You couldn’t make it up.
And what about the introduction of self-service petrol stations? A distant memory, but at the time many objected, some considered it an outrage, and most saw it as a cost-cutting exercise by the garages. They were right, but things move on and there was more to it than that. This morning I drove into my local garage, helped myself to petrol, paid by card at the pump, and was quickly gone without having to interact with any member of staff at all. The machine even credited me with my loyalty points. Does this matter? Yes it does – life is in fact better for something that initially I thought a bad idea.
And, if we are honest with ourselves, how many adults at the end of the last century considered vegetarians a slightly odd, mild nuisance, yet have now moved their own eating habits at least some way from processed meat towards fruit, fibre and vegetables? I know I did, and have.
We are wary of the new or unfamiliar, yet only relevant information, and the familiarity that comes with the passage of time, can allow us to assess it properly. Wind turbines attract vehement condemnation by many people who have long come to accept the electricity pylons and cables that criss-cross the countryside.
In general practice, in the 1950s and 1960s patients objected to the advent of appointment systems; in the early 1970s many GPs didn’t like the idea of community midwives and health visitors being attached to the practice, and a few years later were slow to appreciate the value of employing practice nurses to share the clinical load, or of using computerised medical records. By nature we are suspicious of anything new and react against it. It is a deep, survival instinct.
Against such examples, some past things were seen as silly from the outset and time confirmed that initial, emotive impression. The Sincair C5 comes to mind, though in some ways that was just decades ahead of its time. That GPs should ape hospitals and use A4 records was seen rightly as daft for a number of sound reasons. And I remember the Department of Health once came up with the contractual wheeze that GPs should record the height of all adult patients every year. Happily the idea was quietly dropped. In both of those last two, the recipients of such ideas had more relevant information than those making the proposal or policy.
Again, in the early 1990s the fundholding scheme based upon individual general practices was a hasty, ill-informed policy spawned out of political dogma. It flatly contradicted some of the fundamental principles of the service, principles that the public still care a great deal about. For example, it not only ignored the efforts of the NHS to treat patients according to relative need but at a hospital level drove a coach and horses of legal contracts over that endeavour.
And it was driven forward by a zealous fervour from government and the Department of Health that not only ignored reasoned, alternative arguments by experienced people on the ground, but sought to undermine such dissenting voices, even those offering what would prove to be more equitable and economically sustainable ideas. Indeed, from those dissenting voices emerged the DNA of today’s Clinical Commissioning Groups (CCGs).
We see examples of the same sort of inadequately informed, dogma-driven ideas and policies today. The Brexit referendum is the most obvious. It really is not my intention here to be partisan - in differing ways I despair of both sides - but rather to comment on the thoroughly unsatisfactory process. The government ducked this crucial decision, opting to pass it to the electorate. Whether or not that was the right thing to do is not my point. It is what followed; that the public charged with making the government’s decision was then deprived of the impartial, expert information required to make a coherent, considered judgement.
Imagine the following: a jury is sworn in to decide the merits of an important criminal case. At the beginning of the trial the judge makes it very clear that the decision will be the jurors' to make, and that a majority decision will be acceptable to decide the outcome of the case.
But no witnesses will be called; the impartial experts waiting outside will not be allowed to address or brief the jurors. Rather, they must make up their minds, and come to their verdict, without any evidence at all other than their preconceived ideas and thoughts on the case. Accordingly, its members discuss the matter amongst themselves, argue fiercely and emotionally, eventually coming to a narrow, split decision. The judge accepts and acts upon their verdict.
That is unimaginable, yet seems a fair parallel to the referendum process.
What can we do? We cannot eliminate instinctive, emotive reactivity from human nature. But it may be worthwhile recognising it more readily, and before forming an opinion about something new trying to take a deep breath, and gather the necessary information. And where that information is lacking, to refuse to make a decision until it is available.