Ben Hoban is a GP in Exeter.
I am not a sailor, although I sometimes find myself all at sea when talking to patients. The comfortingly familiar medical horizon has a way of receding from view that still takes my breath away, leaving me in an open boat, longing for the certainty of charts and global positioning satellites that might shrink the ocean to a more manageable size and help me find a safe harbour. It is good to recognise the landmarks of home, to be able to sail reliably between fixed points, but many consultations take us far beyond them. From before patients even enter the room, we are taught to structure what they tell us, to channel and direct it safely, and yet we regularly find ourselves swamped by real human needs which overflow any bounds we try to set them. Especially when time and resources are limited, the necessity to help a suffering individual make sense of their experience can become a body of water on which our most sophisticated navigational aids are useless. Even when conditions are less extreme, it is surprisingly easy to steer what feels like a reasonable course and make good headway, only to find ourselves approaching an unfamiliar or unwelcome shore.
One of wayfinding’s distinctive features is that it is largely intuitive, relying more on an overall sense of what is appropriate in a given situation than on explicit directions or reasoning.
We are used to thinking of modern medicine as an expression of universal scientific and technological principles and easily overlook its origins within a specific historical and cultural setting.1 While it is crass to exoticise other cultures or project onto more traditional ones a false nostalgia for our own imagined past, it would be foolish not to learn from them where we can. A case in point is the ability of Polynesian navigators to sail reliably between islands in the vastness of the Pacific Ocean by observing stars, ocean swells, prevailing winds, the appearance of clouds, and the flight paths of birds. It is an example of highly skilled seafaring, or wayfinding, which also illustrates a more general approach applicable to the challenges inherent in our consultations.2
One of wayfinding’s distinctive features is that it is largely intuitive, relying more on an overall sense of what is appropriate in a given situation than on explicit directions or reasoning. There is nothing mystical about this: intuition simply describes the rapid and unconscious application of relevant experience, typically through rules of thumb, or heuristics.3 As doctors, we have perhaps been forced too often to justify our decision-making to feel entirely comfortable with this, and the result is that we over-value simple rationality, approaching an ocean in the same way we would a pond.4 The difference is not just one of scale.5 It is possible to know a pond and sail across it based on that knowledge, but we cannot know an ocean in the same way and must use our judgement instead, applying general principles in good faith to our current context.6 Without knowing their precise position, wayfinders can still navigate effectively by maintaining a constant angle between the hulls of their catamaran and the direction of the wind and swells. Similarly, we may not know what we’re dealing with in a consultation, but can base our management on the need to maintain a level of uncertainty that feels acceptable.
While science teaches us to value objectivity, wayfinders lean into their subjectivity, engaging with their environment in such a way that how they feel accurately reflects what is happening around them. They do not consult a compass, so much as become one; they do not try to reach a distant island, but trust instead that if they align themselves properly with local conditions, the island will come to them. When people talk about making healthcare more proactive and less reactive, they overlook the fact that whatever good this achieves necessarily comes at the cost of becoming also more controlling, less responsive, and therefore less effective at a personal level. We may work hard to establish that a patient doesn’t have cancer but find that they consult our colleague about the same problem the following week because that was never their concern in the first place.
When people talk about making healthcare more proactive and less reactive, they overlook the fact that whatever good this achieves necessarily comes at the cost of becoming also more controlling, less responsive, and therefore less effective at a personal level.
We are routinely encouraged to be patient-centred, as if this were simply a matter of making some minor adjustments to an otherwise doctor-centric approach. The reality is that patients bring their own problems to the consultation, whether they map neatly onto a medical template or not, and they retain ownership of those problems when they leave. We do them a great disservice by mangling their stories to fit the requirements of online forms and consultation tools, as if the only acceptable account of their illness were one that suited our way of working. Wayfinders are experts rather than authorities; they inform their expertise with the observations and concerns of those who are in the boat with them. If we want to address someone’s problem, we must first let them tell us what it is. If we want to help someone, it can only be in terms that are meaningful to them; anything else is simply not help. While it may not be literally true that we are in the same boat as our patients, the consultation is a voyage which we can only make together, and in whose success we are both invested. In order for it to end happily, it therefore makes sense for us to sail well, think of those on board as crew rather than passengers, and see where the journey leads.
If you ever find yourself all at sea in a consultation too, then, please consider that you may already have what you need to find your way. An experienced practitioner does not need to know everything in order to act and can safely rely on their intuition; our own feelings and the incidental details in a patient’s story are not distractions to be ignored, but information to guide good judgement.7 There may be times when we can only navigate the slow way, crawling from one headland to the next. At others, it is quicker and generally more effective to embrace the open sea and let the island come to you.
References
1. Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present, Harper Collins, 1999
2. Chellie Spiller, Hoturoa Barclay-Kerr, John Panoho, Wayfinding Leadership: Ground-Breaking Wisdom for Developing Leaders, Huia Publishers, 2015
3. Gerd Gigerenzer, The Intelligence of Intuition, Cambridge University Press, 2023
4. Heath I. How medicine has exploited rationality at the expense of humanity: an essay by Iona Heath BMJ 2016; 355 :i5705 doi:10.1136/bmj.i5705
5. Greenhalgh T. Intuition and evidence–uneasy bedfellows? Br J Gen Pract. 2002 May;52(478):395-400. PMID: 12014539; PMCID: PMC1314297.
6. Olson A, Kämmer JE, Taher A, et al. The inseparability of context and clinical reasoning. J Eval Clin Pract. 2024;30:533‐538. doi:10.1111/jep.13969
7. Smith CF, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract. 2020 Aug 27;70(698):e612-e621. doi: 10.3399/bjgp20X712301. PMID: 32839162; PMCID: PMC7449376.
Featured Photo by Jordan Steranka on Unsplash
