Tuesday, October 30, 2007


Saturday, October 27, 2007

A layman's healthcare economics

What is the ideal median age for a country with a population greater than 10 million? What is the ideal demographic profile, long-term? What is the optimal healthcare expenditure as a percentage of GDP?


My personal shortcut for a human development index (HDI) is a combination of median age and Gini co-efficient: a high median age and low Gini equals a high HDI; a low median age and low Gini is not likely to obtain anywhere in the world and most countries with a low HDI have high Ginis with variable median ages, however larger populations tend to have lower median ages because of high fertility, high maternal and infant mortality and low life expectancy.


The ideal demographic profile does not exist – it is too complex, depending on the size of the population, extant infrastructure, literacy levels, life expectancy, savings levels….


The optimal healthcare expenditure too is complex and depends on gains to be made by spending on infrastructure, education, public health and security. Most non-healthcare expenditures tend to have higher health related benefits than direct healthcare expenditures. In all cases, I would expect the optimum healthcare expenditure to be less than education related expenditures.

Friday, October 26, 2007


Many people present to the ED because of minor injuries that happened in a public place: someone slipped on a banana peel on the sidewalk in front of the bank. If you saw it happen, you’d have a hard time not laughing and yet the first responder, usually someone within the bank, is unwilling to accept the responsibility for saying that things are probably okay.


They may say just that and suffix “but it’s probably better to go to A&E just to be sure”. And people acquiesce as if autonomy and interoception are like unicorns – one is not allowed to act according to one’s own common sense and one cannot know intrinsically that something is wrong within one’s body.


These people are correctly triaged as priority 4 and usually end up waiting an hour or two to be seen to be told what they already knew: no harm has been done. They usually apologise right off for wasting time. I used to demur, now I say nothing: they are right. Unnecessary presentations introduce friction.


The world is becoming less personal at the same time that it is shrinking faster. My solution to this problem is authentic living: to act in good faith, honestly; to say what you mean and mean what you say with due regard for the feelings that may be evoked; and to be willing to be wrong.


About some – few – things we cannot afford to be wrong, but the world is increasingly becoming a place where no-one is willing to be wrong: a bland and constricted living.

Thursday, October 25, 2007


The world is filled with extraordinary people. The top 1% = 66 million people.

Tuesday, October 23, 2007

Social Contract

I see patients. Patients come to be seen.


I see patients to deal with their perceived problems. I often ask patients, “What would you like me to do for you?” and many times they answer, “I don’t know.” Sometimes, I deal with problems that patients do not perceive, that I believe have to be dealt with. In those latter circumstances patients can usually be persuaded to let me solve the problem I see.


I am not invested in a course of action or an outcome. I am invested in the process. So, I don’t have intrapsychic difficulty with patients who won’t let me solve a problem they haven’t presented with (incidental problems).


I have a problem-solving orientation. It is perhaps a default male position: we expect to fix things. It is nevertheless a reasonable ED orientation: we find and fix problems. And that is the reason that patients present to us, but not all problems can be defined nor can all defined problems be fixed.


That adults present with problems they should know cannot be defined or fixed is something that puzzles me no end. Do they present in the hope that their assessment is wrong or do they present…?


Adults do have a highly developed sense of the impossible. They do not seem to have an equally developed sense of the possible. I am not being facetious: the one does not imply the other.


When terminal patients present because they fear dying they violate fundamentally our social contract. It is reasonable and human and expected that one fear one’s death. It is a rape to expect a stranger with an impotent fiduciary responsibility to deal with that fear. As clinicians we remain humans in our interactions with those humans who present to us as patients: our humanity leaves us open to emotional contagion. And I find such emotional contagion more tiring, more draining, than extreme physical labour.



de Bono's six hats

•         White hat (Blank sheet): Information & reports, facts and figures (objective)


•         Red hat (Fire): Intuition, opinion & emotion, feelings (subjective)


•         Yellow hat (Sun): Praise, positive aspects, why it will work (objective)


•         Black hat (Judge's robe): Criticism, judgment, negative aspects, modus tollens (objective)


•         Green hat (Plant): Alternatives, new approaches & 'everything goes', idea generation & provocations (speculative/creative)


•         Blue hat (Sky): "Big Picture," "Conductor hat," "Meta hat," "thinking about thinking", overall process (overview)



De Bono Hats - Wikipedia, the free encyclopedia



 “To give pleasure to a single heart by a single act is better than a thousand heads bowing in prayer.”





Sunday, October 21, 2007


“… what the eye sees better the heart feels more deeply.”


Robert Kegan


Our department pairs one middle grade and one consultant as mentors to two junior doctors. We have been doing this for at least 2 years now. It is an entirely unstructured process and unmonitored.


I have no idea what purpose it serves or was intended to serve. Nor do I know how the pairings are decided. I do not even know what mentees think of it. All of which means that it is not important.


It is important to me.


However, like all relationships, nothing exists without both parties being engaged. Mentees do not seem to recognise a need for mentors: the relationship is foisted with no apparent utility.


I have several times found myself more engaged with junior doctors not assigned to me because they chose to relate.


What advantages are to be expected from being mentored?


  • Technical and emotional support
  • An overview of the nuances within the department
  • A sounding board
  • Continuity


That relationships are sustained by reciprocity seems clear and undeniable to me and yet my experience has been that most people are not aware of this.

Wednesday, October 17, 2007

7 Billion

I just realised that we are seven years away from a world population of 7,000,000,000 people.

Sunday, October 14, 2007

Ambrose Bierce: Logic

LOGIC, n.  The art of thinking and reasoning in strict accordance with the limitations and incapacities of the human misunderstanding.  The basic of logic is the syllogism, consisting of a major and a minor premise and a conclusion -- thus:


  _Major Premise_:  Sixty men can do a piece of work sixty times as quickly as one man.


  _Minor Premise_:  One man can dig a posthole in sixty seconds;


therefore --


  _Conclusion_:  Sixty men can dig a posthole in one second.


  This may be called the syllogism arithmetical, in which, by combining logic and mathematics, we obtain a double certainty and are twice blessed.

BBC: NHS Errors

Wednesday, October 10, 2007

On 4-hour targets

4-Hour targets are valuable and useful: they provide information on capacity and workload. They do not determine or indicate the quality of care, nor do they determine or indicate clinical outcomes.


4-Hour targets are of no use on a day-to-day basis. They help plan future investments in staff numbers and training and in facilities and support processes. Clinicians do not have control over process times and for clinicians to act to effect mandated targets skews and compromises clinical care. To see a non-urgent case at 3 hours in preference to an urgent case at 35 minutes in order to meet a 4-hour target is nothing less than obtuse.


4-Hour targets represent a management metric, not a clinical one.

St. Emlyns Virtual Hospital

Friday, October 05, 2007

Blog posts: A review

Blog posts have been about:


  • Patients
  • Colleagues
  • Pathologies
  • Processes
  • Judgement and Decision Making
  • Heuristics
  • Learning and Metacognition
  • Knowing
  • Poetry


I think that I have been groping towards the most recent addition to my Life-Map: BUILD WISDOM.


Wisdom is about seeking the right and doing right --- naturally, consistently and completely.



Thursday, October 04, 2007

Hickam's Dictum

Patient Expectations

Patients always arrive with expectations: mostly tacit and nebulous.


Sometimes they arrive with chronic problems that their GPs have been unable to diagnose or successfully treat with the expectation that the ED doctor seeing them for the first and only time under significant time pressure in a busy and very noisy environment will be able diagnose and cure the problem.


Who said that patients should be reasonable?


Sometimes they arrive expecting an x-ray or CT scan convinced that this investigation will somehow, magically, cure the disease or injury. And sometimes it does seem to: those who could not walk are x-rayed and miraculously walk immediately after. Faith does not work as often.


Sometimes patients arrive with bags packed with the expectation that they will be admitted because they feel unwell or they fear they may become unwell or they are depressed or the rest of the family is off on holiday or….


Who said that patients should be reasonable?


Wednesday, October 03, 2007


How best to use a general AI:


  • automate the mundane
  • answer all questions
  • anticipate needs: biopsychosocial
  • manage finances
  • manage health
  • build wisdom
  • time dilation
  • enhance experience
  • prune tasks