Writing about how to prepare professionals for the demands of practice, Donald Alan Schön, a professor of urban studies, famously reflected:
‘In the varied topography of professional practice, there is a high, hard ground, overlooking a swamp … In the swampy lowland, messy, confusing problems defy technical solution … in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and non-rigorous inquiry?’1
CHALLENGING TERRAIN
Those who work in primary care in the UK should be forgiven for identifying with Schön’s metaphor. The professional terrain is difficult and an ‘aerial’ academic or policy view (even a sincere one) can fail to appreciate the situated realities in which we work. Those on the ground, by contrast, struggle to appreciate the larger workings of ecosystems and geography, as well as each other’s struggle. Indeed we can be frustrated by it, crushed to the point of resignation, or worse.
In this issue Nada Khan examines the increasing waiting times for ambulances, finding a system under pressure rather than fault from any professional group.2 Sharon Dixon and colleagues bring home the importance of understanding the diverse ways in which the different workers in a multi-agency safeguarding team operate.3 Failure to understand the ‘multi‘ here is at the core of failures to protect vulnerable children.
Peter Lindsay reviews Jeremy Hunt’s book: Zero: Eliminating Unnecessary Deaths in a Post Pandemic NHS. He describes the book as, ‘… a political document published, poorly written, and edited with obvious haste’. The implication here is that a failure to understand or adequately represent the realities of health care can contribute to catastrophic failures.4
KNOWLEDGE, SKILLS, AND ATTITUDES
The deployment of workers to hostile professional terrain requires a consideration of those workers’ knowledge, skills, and attitudes.
Ahmed Rashid considers a variety of patients’ unmet needs and doctors’ educational needs in our swamp including: nocturnal pain, alopecia areata, and #bodypositive.5 Terry Kemple looks at a new book on nutrition and health6 — an area that non-dieticians have little training in but which has enormous health implications.
Ben Hoban invites us to become aware of our biases.7 Two particularly relevant concepts are: exceptionalism (the rules should apply to everyone but you), and confirmation bias (when we seek out evidence and opinions in support of our view while excluding inconvenient facts or ideas).
Healthcare professionals deploying to, and practising in, conflicts and catastrophes can experience a plethora of negative emotions when their core ethical principles are threatened. In his final Ukraine report, Richard Armitage provides a powerful personal reflection on working somewhere where the resources to do good are scarce or absent.8
Sadly, many of his reflections could also be very useful in the UK.
THE NEED FOR A GEOGRAPHIC PERSPECTIVE
As a postgraduate student I was impressed by the multidisciplinarity quality of geography that encompassed and was not limited to the physical structure of the world and the nature of its many tribes, races, and other groups, their movements and needs.
If this issue’s Life & Times has a shared narrative, it is about the need to have a geographic perspective. We not only need an understanding of topography but also a shared appreciation of the terrain underfoot. We need to appreciate the context of both our clients and our co-workers. Perhaps if we can succeed at this, and share our understanding of the swampy lowlands with each other (including those on the ‘high, hard ground’), we have a chance to not only survive but also flourish as well.
- © British Journal of General Practice 2022