The simple things in life

The ladies of the Luke household have a favourite old joke about the male of the species. It goes as follows: Wally Witherspoon gets down on bended knee and proposes marriage to his beautiful girlfriend. “Wally, darling,” she replies, “I love the simple things in life, but I wouldn’t want to be married to one.” Oh, how the ladies laugh. And yet, I have a great deal of sympathy for Wally, especially as I get older and, like many of my peers, try to simplify as much as I can in life, with the one resource I possess in abundance: experience (what we veterans call the lessons of many mistakes).

It means I’m particularly fond of ‘heuristics’, those mental short-cuts or rules-of-thumb that senior medics often employ when juggling the daily demands of diagnosis, disposal or distraction with the impetus to make a swift, important, and occasionally life-or-death judgement. (By the way, I know that being ‘judgy’ is one of modern life’s cardinal sins, but I always think of the pre-historic hunter-gatherer who must make an instantaneous judgement as to whether those blinking things in the foliage are the eyes of a sabre-toothed lion, or just the dappled sunlight. And I believe homo sapiens still needs to make such snap decisions during the course of each day).

The ‘3 D’s of Diagnosis’ have long been my preferred framework for the kind of speed-dating done in a packed emergency department: a triangulation of Distress, Derangement and – in Cork – ‘De story’ offers a useful drill before making a plan for any patient. An even simpler reflex check applies to hospital or office politics. In short, when a decision seems bizarre, undemocratic or unfair, Cicero’s legendary query, ‘Cui bono?’, applies. In plain English, ‘for whose benefit’ has that been made?

Even when it comes to the really big issues, like emergency department overcrowding, the delayed construction of maternity hospitals, or the maniacal gunning down of American school children, I resort to a trio of simplistic explanations. My ‘3 I’s of Misgovernance’ include Incompetence, Indifference and Ideology.

Naturally, at the outset of a career as a consultant or general practitioner, there is a tendency to blame difficulties on a ‘totally useless’ colleague, manager or civil servant, but I’ve come to believe that indifference to those affected by bad policies is often the actual issue. And the more I’ve thought about this, and the more meetings I’ve had with those responsible for dodgy decisions, the more I’ve appreciated that the indifference usually originates in simple thoughtlessness.

People making policy frequently fail to really think about the consequences of their decisions for other people. Of course, decision-makers may deliberately avoid putting themselves in other people’s shoes, because to do so is often emotionally uncomfortable.

Call me naive, but I’m inclined to forgive incompetence and indifference. After all, ‘to err’ and all that, and I remain eternally optimistic that incompetent or indifferent people – even those high up in the hierarchy – can learn to be more thoughtful or considerate, given a little humility and flexibility.

Alas, the same cannot be said about the ‘ideological’. Here, I have a real problem. Stupidity, short-sightedness or carelessness rarely lead to the sort of epic misery produced by fanatical believers in an ‘-ism’ or idea. Cleaving to the simplification with which I started, I tend to blame our chronic shortage of hospital beds (and the consequent misery for those waiting for one in EDs) on a diffuse ‘Thatcherism’ that prevailed throughout these islands for a decade and a half after Margaret Thatcher became British Prime Minister, in 1979.

This meant cuts in public spending and tax, trust in the free market, and a paradoxically centralised approach to decision-making, which marginalised unions (including doctors’, nurses’ and ancillary healthcare workers’).

One of the features of this -ism was the deployment of dubious but politically-useful economic doctrines, such as the one that allegedly supported massive reductions in Ireland’s hospital bed numbers, because ‘in the future, so much healthcare will be done in the community’.

The original driver was the financial difficulties of the 1970s, but the net result was a loss of 22 per cent of all hospital beds in the Republic between 1980 and 1998; and, for the forty years (so far) of my medical career, we have failed to reverse those losses, despite our rapidly-ageing population.

Another -ism which seems to be at the heart of much misery here is the apparent militant atheism which recently sought to delay, for yet another period of ‘re-engagement’, the relocation of the National Maternity Hospital (NMH) from the intolerably inadequate Holles Street site to the Elm Park campus of St Vincent’s University Hospital, formerly a devoutly Catholic institution (where I initially trained).

This move, and the proposed physical and cultural architecture of the new hospital, were enthusiastically supported by clinical and support staff in Holles Street, who are desperate to improve their working conditions, and those endured by the 7,000 mothers who give birth annually in the often-dilapidated NMH. And yet the move was opposed by politicians who discern a sinister Papal hand hovering over Elm Park, despite the increasing invisibility of clergy and nuns in an imminently post-Christian Ireland.

But still – ignoring the paranoid delusions of the maniac in the Kremlin – surely the worst of the ideologies that affect healthcare workers in the West is that which drives the relentless slaughter of the innocents in American schools. I heard yet another Republican politician tie himself in knots, on the radio, the morning after a ‘bullied teen-aged loner’ massacred 19 children and two adults in Uvalde, in Texas, in late May 2022.

The author and Conor Deasy in Cork.
Listen to their conversation on the IMT podcast ‘Irish Medical Lives’ – Search “Irish Medical Lives – Prof. Conor Deasy”

The interviewer asked the politician if he thought the shooter should have been able to purchase two assault rifles days after his 18th birthday and – hesitating slightly – he suggested ‘perhaps not’ if he’d a ‘criminal’ or ‘mental health’ history. The problem was, the broadcaster pointed out, it was widely known that the mass murderer was ‘deeply troubled’ and ‘violent’, but he had no criminal record or formal psychological diagnosis.

Yet even this conundrum was nothing compared with that introduced by Ken Paxton, Texas Attorney General, who reportedly ‘dismissed the notion of enacting restrictions on firearms – reasoning that shooters wouldn’t follow the law anyway’ – and said; “I’d much rather have law-abiding citizens armed and trained so that they can respond when something like this happens, because it’s not going to be the last time”.

So, once again, an American politician argues that the cure for guns is, er, guns. And teachers must become part-time soldiers in a scholastic Wild West.

What connects all of these scenarios is a disregard for the healthcare workers who’ve pleaded for years for more beds to allow them to offer the care their patients need, who’ve begged to leave the grossly inadequate buildings in which they struggle to provide basic maternal care, or who’ve argued that, while children in the USA are now more likely to die from gunshots than any other cause, and are twenty times more likely to die after being shot than their peers in Europe, Australia and Japan. Proper gun control would reduce this frightening toll.

In short, deranged people with guns have massacred people in England, Scotland and Australia in recent decades, but the subsequent restrictions in access to weapons have massively limited their use in these countries since.

And, famously, the Japanese have almost eradicated gun crime (in 2014, there were six gun deaths there, compared with 33,599 in the USA). Why? Well for a start, to get a gun in Japan you have to attend a day-long class, take a written exam, and pass a shooting-range test with a mark of at least 95 per cent. And then come the checks for extremism, drug use or crime.
Here, then, is another really simple idea.

The millions of dollars ‘donated’ to American politicians who lobby for the National Rifle Association are regularly publicised in the US media. And many years ago, the American activist, Upton Sinclair, said: “It is difficult to get a man to understand something when his salary depends on his not understanding it”.

So, for the 21st century, I’d replace ‘man’ with ‘politician’ and add ‘status’ to ‘salary’.
That sort of explains public health challenges, everywhere, doesn’t it, Wally?