Ben Hoban is a GP in Exeter.
It is hopefully uncontroversial to say that doctors want to help, to improve the health of their patients. One of the great frustrations of the job, in fact, is the realisation that this isn’t always possible, for the simple reason that those patients often have their own goals, or at least seem less committed to ours than we expected: they don’t take their tablets, miss appointments, and refuse to follow the perfectly reasonable advice that we’ve given them. As with many things in life, health-care would be easier if it didn’t depend so much on other people, or if we could at least control their behaviour. If that makes you half-smile, it’s because it’s half-true; the other half is worth looking at more closely.
We register the difference between how things ought to be and how they are, and do what is necessary to close the gap: we put on a jumper, look for food, or give our adrenal glands a ‘squeeze’.
The urge to control is intrinsic to us as mammals: we are constantly engaged in homeostasis, adjusting our internal and external environments to maintain a thousand physiological parameters within narrow ranges. We register the difference between how things ought to be and how they are, and do what is necessary to close the gap: we put on a jumper, look for food, or give our adrenal glands a ‘squeeze’. We are often unaware of this process, but sometimes notice the incongruence that drives it, a perceptual itch that we try to scratch but cannot always reach. It is the same itch which leads us to nag our patients about their habits and their medication, although we are perhaps better at controlling our physiology than other people. The causal link between our actions and any outcome may be dubious, but the relief we feel at having done something, especially when there is an improvement of some kind, is so strongly reinforcing that we tend to ignore this. Our cognitive-behavioural homeostasis therefore readily gives rise to illusions of control: what I did must have worked because things seem better now.
Strictly speaking, illusions of control refer only to this imagined or inflated sense of our ability to influence outcomes.1 We are prone to other illusions too, though, including the idea that control is possible in the first place. On a basic level, we can of course decide which shoes to put on in the morning, what class of antihypertensive to prescribe, or how to manage demand for appointments after a long weekend. Once we look beyond the immediate effects of these decisions, however, we may find that they have other consequences too: the shoes look good, but are uncomfortable and unconducive to home visits on foot; the tablets are out of stock, necessitating further communication and decision-making; prioritising the immediate availability of appointments can paradoxically worsen access in the longer term.2 While it is therefore possible to alter outcomes in principle, simple interventions rarely have a predictable effect. If it is true that the purpose of a system is whatever it does, we should consider that the current performance of the NHS is fully in keeping with its design, even if this wasn’t anyone’s intention.3
The idea that medicine as a project is universally benign is illusory in the same way: there are certainly many outcomes that we can influence, but they are sometimes at odds with what matters most to patients. Where medicine was once the friend of the sick, it has now become the enemy of disease, and the doctor has changed from ‘an artisan exercising a skill on personally known individuals into a technician applying scientific rules to classes of patients.’4 Even the substrate of medicine is no longer the same: risk and metrics rather than symptoms, and subtle patterns only discernible by computers interrogating massive data-sets. We have become part of a vast and restless mechanism whose purpose is to scratch the itch that we all feel, to exert control, and as with any itch, the more we scratch it, the more it bothers us.5
The acknowledged tension in general practice between treatment and prevention demonstrates that these represent not just two aspects of the same thing, but entirely different ways of dealing with people.6 Medicine at its most basic is about caring for individuals in a way that helps them get on with their lives, but we risk making it instead a way of “managing proactively” those same individuals, controlling their blood pressure or cholesterol level, less for their own benefit than for the sake of so-and-so-many strokes prevented per annumor life years added to the faceless aggregate of humanity. Roy Campbell wrote: “I hate ‘Humanity’ and all such abstracts: but I love people,” and it is difficult not to sympathise.7
If health is not just an abstract commodity, but the capacity to respond adaptively to illness in pursuit of something more meaningful, then we can never care for people simply by plugging them into the medical matrix.
The final illusion is that only those outcomes that we can in theory control are worthwhile, and that we help most by trying to achieve them on our patients’ behalf. There is no question that modern medicine is immensely powerful, and yet it is too easy to become seduced by its power, to hide behind its smooth and certain walls and concern ourselves not with making sense of someone’s individual needs, but with redefining those needs according to the help it is convenient for us to offer. If health is not just an abstract commodity, but the capacity to respond adaptively to illness in pursuit of something more meaningful, then we can never care for people simply by plugging them into the medical matrix.8
We should always want to help, and medicine equips us generously to do this. Ultimately, though, there is a limit to how much control we can exert over anyone’s health, and there is a danger that by trying too hard to go beyond this, we foster instead a sense of fear, dependence, and resentment in those we are trying to help. Life is by its nature uncertain, and we may do better to instil in our patients a degree of confidence and agency as they negotiate this than to offer them the illusion of certainty or control.
References
- Suzanne C Thompson, Illusions of Control in Cognitive Illusions: Intriguing phenomena in thinking, judgement and memory, Edited by Rüdiger F Pohl, Routledge, 2017
- Jennifer Voorhees, Simon Bailey, Heather Waterman and Kath Checkland, A paradox of problems in accessing general practice: a qualitative participatory case study, British Journal of General Practice 2024; 74 (739): e104-e112. doi.org/10.3399/BJGP.2023.0276
- “The purpose of a system is what it does,” sometimes abbreviated to POSIWID, aphorism attributed to Stafford Beer (1926-2002)
- Rhodri Evans, Ivan Illich’s Medical Nemesis at 50, British Journal of General Practice 2025; 75 (750): 26-27. DOI: 10.3399/bjgp25X740313
- Amartya Sen, Health: perception versus observation, BMJ 2002; 324: 860-1
- Martin SA, Johansson M, Heath I, Lehman R, Korownyk C. Sacrificing patient care for prevention: distortion of the role of general practice. BMJ. 2025 Jan 21;388:e080811. doi: 10.1136/bmj-2024-080811. PMID: 39837625.
- Roy Campbell, Light on a Dark Horse: an Autobiography, Penguin, 1971
- Joanne Reeve, Medical Generalism, Now! Reclaiming the Knowledge Work of Modern Practice, CRC Press, 2023
Featured Photo by Kenny Eliason on Unsplash
