The redundancy of clinical know-how and the ghost in the machine
Older staff working in mental health in the public sector will have picked it up. It’s something like the faintest smell of ozone on a summer breeze which warns of the rains which will wash away the pleasures and memories of a long, settled spell. Mostly, they will doggedly tap away at the computer keyboard and maybe break up the monotony with a rushed visit to a patient they haven’t seen for a while. But every now and then, perhaps while they are pleasantly punctuating another anxiously resentful stint of electronic form-filling with a trip to the staff kitchen, a painful insight breaks briefly through.
It will be about the growing irrelevance of longevity in the business, of knowledge and experience built up over maybe two or three decades, of know-how and intuition, and of judgement and a prized ability to cut to the chase, to distil and synthesise the mess and mass of information and opinion about a patient in order to get things safely and productively sorted.
The surgeon has been ordered to hand over the operation to the clerk under the supervision of the business manager. The consultant psychiatrist breaks away from typing to apply NICE guidelines to a couple of patients before they are discharged just short of the deadline imposed by funders uncorrupted by any form of low-status clinical experience.
Paranoia, control and hierarchy are the triumvirate of cultural and political forces which turn the individual into a functionary and passive conduit for the centrally determined message, an aversion to trust being the common thread which binds them together.
The paranoid institutional mind necessarily, and neurotically, fears individuality, imagination, inventiveness, initiative, intuition, instinctiveness, autonomy, creativity, contingency, divergent thinking – in fact, thinking at all – reciprocity in relationships (because this could lead to alliances) and, most dangerous of all, risk-taking.
It prizes conformity, convergence, obedience and submission. Its currency is transaction rather than interaction; and its language the hard logic of the mantra of evidence-based practice. It assumes the folly of leaving treatment to the whims, prejudices and inconsistencies of individual professionals, whom it bamboozles with the faux wisdom of ever-changing jargon and subjugates with indoctrination into the special language of the project. It levers in rating scales, assessment tools and tortuous algorithms so that low-level clinicians are trained to think other people’s thoughts in preparation for machine-thinking.
The culture of compliance, with the professional as a passive intermediary for the centrally determined message, is underwritten and mandated by the State. Doing with must become doing to. Intervention must be the product of interrogation rather than interaction and invention. Once the embargo on thinking is firmly established and the central clinical task is changed in this way, the professional becomes a dispensable middleman and his, or her, renegade capriciousness a thing of the pre-digital past. Off-message, off-beat clinical co-exploration is anathema to the programme, a quaint, clunky spanner in the digitised works of the machine.
Where manual and technical skills were once replaced by information technology, now it is the turn of cognitive-clinical skills. Just as software for the commonest cancers will soon guide GPs, so the therapeutic relationship in mental health practice is being colonised by the computer. Where the primary container of information and, more important, understanding about a patient used to be the individual professional, now mere data is held in a centralised electronic repository. This gives rise to the fantasy that, because the machine knows so much, individual staff members are interchangeable.
This is both anti-therapeutic and risk-generating. Within, say, a couple of years of contact with mental health services, including an admission or two, the average patient will have seen well over a hundred professionals. In practice and reality, clinical accuracy and effectiveness is maximised when the professional knows the patient both when ill and - more important, because particular mental illnesses are essentially much the same – when well.
The digitisation of knowledge about patients is mirrored and compounded by the fashion of dividing up aspects of patients into categories for intervention and distributing them among different clinical staff. As a result, a patient may be seeing perhaps six professionals in the same phase of his or her illness which militates against him or her being and feeling understood, which anyway is highly protective against risk, and against risk itself being understood – as a whole instead of frame by frame.
The long, slow, unpleasant path to existential and actual redundancy lies ahead for the mental health professional who prizes agency, appropriate and measured autonomy, creative but tailored co-working, the painful acquisition of subtle skills through experience and error, and the productive uniqueness of the therapeutic relationship. Difference is now seen as subversion, the relationship as a romantic relic of a quaint clinical past. The possibility that the new non-thinking may actually increase risk is of little consequence now that being the same has silently become so much more important than being safe.
Those who observe, think, create and apply will become the ghost in the machine, an irrelevant vestige of a lost clinical world.