“Choosing Wisely…” A parable of the NHS

Samar Razaq is GP in Burnham

Once upon a time, in a desert not so far away, a group of people set out to travel. One day they came across a wise looking man sitting in the shade of a tree. His contemplative demeanour was mesmerising and the travellers were keen to hear what he had to say. Aware of the awe that his audience had granted him, he proceeded to speak. He told them that he had come across many groups similar to theirs over the years. In his experience, the harsh sun of the desert exerted a harmful effect on those who were exposed to it during travels. It could sometimes cause a problem, commonly known as madeupitis, which in turn could lead to death.

Seeing the effect he was having on his audience, and the obvious anxiety he was generating, the wise man proceeded to offer his help.

The travellers had already been enchanted by the wise man’s meditative bearing but now were utterly spellbound by his oratory and obvious superior knowledge. Seeing the effect he was having on his audience, and the obvious anxiety he was generating, the wise man proceeded to offer his help. Although an unpleasant condition with a potential fatal outcome, if detected early enough it could be treated in most people. The group, he said, had two options. They could continue towards their destination via the route they had initially set out on. Alternatively, armed with this new information, they could take a different route which would take them past a cactus plantation. In this plantation dwelled the testse fly (a cousin of the more well-known tsetse fly). This fly survived by feeding on travellers passing near its territory. Most of the travellers, reassuringly, would not show any adverse effects to these bites. However, some would come out in a rash of varying intensity. The miraculous thing about these fly bites was that those who came out in a rash were more likely to be the ones to develop madeupitis. After the cactus plantation, they would come across a small village. In this village dwelt a sage who had much experience in dealing with this phenomenon and would offer treatment to those who had developed the tell-tale rash.

Facing the two choices it seemed sensible to follow the path of the cactus plantation. For the majority it made perfect sense that any option that offered the reduction in risk of death was a good option. Aside from the fact that they had to take a slight detour from their original journey and endure being bitten by the testse fly, what other harm could possibly be done? Others though remain unconvinced that the detour was worth their troubles. They questioned the possibility of the fly bites not resulting in a rash in those prone to the condition or the rash being caused in those who had no chance of developing it. The group was immediately divided.

The next morning a small part of the group decided to stick to their original journey. The others, with a slight sense of anxiety, headed towards the cactus plantation. Each individual was secretly perturbed about the possibility of them being the one who would come up with the rash. As they walked through the cactus plantation they were all inconvenienced by the fairly vicious bite of the testse fly. Anxiously they waited to see if they would come out in a rash. The next morning the large majority were grateful to see that they had not been stricken by any eruption of any sort. However, there were a few who had invariably come out in a rash, just as the wise man had said. Although devastated by the appearance of the rash, they were also oddly grateful to the wise man as he had helped them identify any future problems early. They all set off to the next village to meet the sage charged with treating their rash and making them well.

As they reached the hut of the sage, they found many people there with similar rashes that had travelled through the cactus plantation from all over the desert. Here they received all manner of ointments and potions. The treatments were not comfortable but the fear of developing madeupitis spurred them along to put up with the horrible side effects. After weeks of treatments the majority were healed (other than the psychological scars of the anguish and uncertainty of the preceding weeks). They were, however, glad that they hadn’t succumbed to the more devastating effects of this dreadful condition. There were a few who, unfortunately, were not cured by the sage and proceeded to develop madeupitis, some of whom died.

The village was full of apparently healthy people being treated by this sage who was determined to keep the throngs of travellers in good shape and prevent them from developing the disease. What the travellers could not see was a group of sick people waiting by the outskirts of the village. It seemed they too needed to see the sage for a host of other problems but, as he was busy dealing with the travel weary folk who had come through the cactus plantation, they had to wait their turn to be seen. Some, regrettably, grew more ill as they waited patiently at the periphery of the village.

The small group of travellers who chose to stick to their original itinerary and avoid the journey through the cactus plantation reached their destination free of anguish and worry. Indeed some of them did fall ill with madeupitis but most of them by then had reached the age at which illness is usually inevitable. A few did succumb to the illness prematurely and were left wondering if they made the wrong choice on that fateful day they met the wise man.

A few did succumb to the illness prematurely and were left wondering if they made the wrong choice on that fateful day they met the wise man.

With the passage of time more healthy people went through the cactus plantation as new insects were discovered which caused a variety of rashes which in turn identified a host of other conditions. The village expanded and more sagacious people turned up to help treat the ever increasing influx of people. The groups of sick people on the periphery of the village grew bigger and bigger and their waits longer and longer. As a result a savant was brought into the village to deal with the throngs of sick people on the periphery. Sadly, he too got swamped by the worried well and having to keep tabs on all the healthy people making their way through the village. Word got around at the periphery, as people there got sicker and sicker, that the savant was just lazy and had no interest in seeing the infirm (who actually needed to be seen) at the periphery of the village.

Eventually everyone got fed up. The travellers complained that there were too many people in the village, others complained of side effects of all the potions used, those on the periphery complained of their ever increasing wait, the sage complained that too many people were being sent his way and lack of help from the savant and the savant complained of his inability to deal with the multitude of problems everyone presented with and of being used as a dumping ground for all the problems the sage couldn’t resolve. In the end no one lived happily ever after (except the cactus plantation owners).

Featured image by Dulcey Lima on Unsplash

The BJGP is the world-leading primary care journal. At BJGP Life we add multi-media comment and opinion for the primary care community.

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