Ben Hoban is a GP in Exeter.
I knew something was wrong as soon as I saw the look on Chrissie’s face. All our receptionists have been on the Advanced SmilingTM Course, and she was clearly making a superhuman effort to project confident professionalism, but showing too much of the white around her eyes to make it look convincing. She turned in my direction as I tripped noisily over a box of stool samples in the corridor, and mouthed, ‘Help me!’ I was meant to be in a meeting but this looked serious. I brushed biscuit crumbs off my waistcoat and opened the glass door into reception. On the other side of the desk was someone I could only describe as grey. I’m not talking about their clothes or hair, or even their skin colour, although in fact it was oddly difficult to put a finger on any of those things. What I really mean is that nothing about this person seemed fixed or settled, but rather somewhere in between, blurred and ambiguous. I blinked and tried hard to focus, resolving the blur into a young white man wearing a cheap light blue suit and trainers, but when I looked back at his face, it had aged and was clearly female and South Asian, and the suit had turned into a navy skirt topped with a cream cashmere jumper; the baseball cap certainly didn’t fit, but then it did, as everything in front of me cycled through a bewildering succession of variables, and I started to feel the floor swaying.
On the other side of the desk was someone I could only describe as grey. I’m not talking about their clothes or hair, or even their skin colour, although in fact it was oddly difficult to put a finger on any of those things.
“I’ve come to read the meter,” intoned this apparition, and for a moment I thought I was on firmer ground. “I don’t think so, it’s all online now.” They smiled and I realised that if I kept my eyes on the smile and stopped trying to resolve the blur around it, the swaying was less noticeable. “Shall we have a look?” Our reception area is split into three separate lanes: Urgent-and-Important, Urgent-but-Not-Important, and Important-but-Not-Urgent; the patients all wear lanyards with a badge corresponding to their lane. We sometimes end up with a fourth one too, and it was snaking around the desk and through a doorway to one side, from which the sound of traffic and chatter on the pavement outside could be heard. Our visitor was shifting between lanes in a way that was starting to affect the flow and I collected them as quickly as I could to go and read the meter.
Our premises are purpose-built and top-notch, you understand, so we don’t have an under-stairs cupboard, although there’s a kind of backstage area next to the staff loos where the circuit breakers, fire alarm control panel and gas and electric meters live. I lifted off the cover and was halfway through a “ta-daa” gesture when my hand froze in mid-air. Instead of the chunky LCD units I was expecting, I saw a screen displaying what looked like a high-tech chessboard, although the size and number of squares fluctuated slightly. “What you’re seeing is a high degree of black-and-white in your practice systems, with artificially suppressed entropy and a lack of granularity. You can boost your resolution by buffering more uncertainty, but it doesn’t look as tidy, just a lot of grey, I’m afraid.” The morning was starting to feel seriously weird, and I tried to make sense of what this person had just said. “You’re telling me we’re not grey enough? We work really hard to make things as clear as possible, so that everyone knows what’s what, and the patients get to see the right person for their problem. I spent ages writing the protocols and scripts! We’re delivering a third more appointments than we were a year ago, and I got some terrific feedback at the last conference for our e-consultation templates. The AI assistant goes over the patients’ history and spots any red flags, the triage team allocates an appropriate outcome, and hardly anyone even needs to see a doctor anymore. You should see our QOF scores!” My interlocutor looked up, like a pack of cards being shuffled at speed. “Yes, quite. In such an efficient system, though, I wonder why you need to deliver so many more appointments than before.”
There was a dial next to the chessboard display marked ‘Ambiguity Tolerance,’ which I could see was currently set close to zero; there weren’t any other numbers, although I recognised the symbol for infinity at the other end of the scale.
Blind spots are a funny thing, aren’t they? You look around and see what you expect to see, and it all kind of makes sense, but you never notice the bits that are missing; kind of part of the definition, I suppose. I had the strangest feeling of things falling into place, of a vague sense of unease crystallising into something more definite. We were certainly doing a lot, but I found myself wondering for the first time whether any of it was actually helping. Despite all the smiling, there was often a sense of grim determination about the surgery these days, of everyone holding on tight as the wheels turned faster and faster. In our eagerness to make things better, had we perhaps lost our sense of what that really meant?
“Would you like to adjust your settings?” As the visitor interrupted my reverie, I realised that they had changed, or perhaps I was just seeing them differently: less riffling of faces and outfits, and more of a settled someone, even if it wasn’t clear exactly who that someone was. “Yes, I suppose we could give that a try, couldn’t we?” There was a dial next to the chessboard display marked ‘Ambiguity Tolerance,’ which I could see was currently set close to zero; there weren’t any other numbers, although I recognised the symbol for infinity at the other end of the scale. I gave the dial a very gentle clockwise turn and realised that my hand was shaking. For a moment, nothing happened, and then there was a huge crashing sound from the front of the building; I felt sick as I quickly made my way back to reception. The health information screen in the waiting room had come loose from its wall mounting, crushing the blood pressure station beneath it. No one had been hurt, and in fact no one seemed to have noticed. Patients were ignoring their smart watches and fitness apps and had started talking to each other. Someone from the urgent-but-not-important queue had given up their space to help a man in the important-but-not-urgent queue with a Zimmer frame and a questionable tie to complete their symptom list. In the corridor behind me various healthcare professionals emerged cautiously from their rooms, some still tethered to work stations by their headsets, and realised that they weren’t alone. Chrissie had fallen asleep on the desk, looking exhausted but profoundly relaxed, and one of the other receptionists – I realised I didn’t even know his name – had put a stack of patient feedback questionnaires under her head.
I went back to take another look at the meter and saw that the rigid chessboard pattern had been replaced by an undulating seascape of grey; it was actually rather pretty. Our visitor seemed to have left, but as I walked around the practice, I thought I caught glimpses of them here and there. There was a background hum of conversation in the office and I noticed that a lot of people seemed to be ignoring the usual protocols and dealing with things their own way; it seemed to be working well. I had already missed my meeting and went instead to clear up the mess in the waiting room.
Featured photo by Nathan Dumlao on Unsplash
