Don’t blame it on Baltasar

As The Jacksons famously said, “don’t blame it on the sunshine, don’t blame it on the moonlight, don’t blame it on good times, blame it on the boogie“. Baltasar Gracián (1601-1658), a Spanish Jesuit and philosopher would have probably agreed with the sentiment.

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Learning objectives

1. Introduce Baltasar Gracián to those unfamiliar to his works

2. Reflect on one of his aphorisms

3. Reflect on the relationship between medicine and politics

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The son of a doctor, Gracián wrote The Pocket Oracle and Art of Prudence, a collection of aphorisms on how to thrive in Baroque society. He included the following passage:

Look for someone to help you shoulder misfortunes. You will never be alone, especially in risky undertakings; to be so would be to bear all the opprobrium. Some people think to take all the responsibility, and take all the criticism. You will have someone to free you from trouble or to help you shoulder it. Neither fortune nor the rabble are as ready to take on two people. This is why the shrewd doctor, whose cure was mistaken, is not mistaken in seeking someone who, under the guise of further consultation, can help carry the coffin. Share the burden and the sorrow, for misfortune borne alone is twice as intolerable.

I think this would be an opportune moment to reiterate the nature of my posts. As I have stated previously,  posting items onto this site does not mean that I agree with them. The aphorism above exists and should not be ignored because it may feel uncomfortable or antagonistic to the culture of modern medicine. To paraphrase Thomas Jefferson, if you can only afford to buy one newspaper, read the one you disagree with.

Returning to the aphorism by Gracián above, consider the following questions as stimuli for reflection:

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Questions

What are the dangers of clinicians working in isolation?

Do you discuss complex clinical cases in team meetings?

How did you develop your threshold for referral?

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During my training it was repeatedly alluded that that doctors became more cynical with experience. This may not relate to experiences with patients but with healthcare systems and associated political factors. Gracián can be considered an ultimate realist and pragmatist in a system of flux and uncertainty. His words may appear brutal to those entering the healthcare system as students and trainees who are unfairly oversimplified as being idealistic. Similarly, more seasoned doctors  may be perceived as having lost their idealism having to navigate through a complex and changing clinical world.

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Questions

Is cynicism part of medical identity?

If so, how does this interplay with the attribute of honesty typically associated with doctors?

Do you consider yourself a realist or an idealist?

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Wait, wait… Gracián was writing about politics not healthcare, wasn’t he?

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Questions

Are medicine and politics inexorably linked?

Are the issues of medical training, healthcare funding and patient expectation primarily  political or medical?

We learn our medicine from science, evidence and experience. Where did you learn how to be a healthcare politician?

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The term realpolitik is used to describe politics based on pragmatic rather than ideological considerations. Often associated with Machiavelli (who I hope to discuss in the future), it can be considered a negative term as it may bypass ethical considerations. In politics it can be used in situations where an individual seeks power, security or survival. Despite looking, I cannot find a similar term used in healthcare, perhaps because acting in such a manner  would be considered an antithesis to the expected behaviour of a doctor. At the risk of coining an awful protologism, in the future I will describe the action of healthcare workers who primarily act pragmatically as realmedik.

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Questions

Can doctors operate inside a bubble of pure medical ideology?

What are your thoughts on defensive medicine?

Does realmedik exist?

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Relatively more recently, Balint has described the phenomenon of collusion of anonymity, where a “the patient is passed from one specialist to another with nobody taking responsibility for the whole person”. Again, this is something I will return to again in the future, but the much older aphorism at the start of this post by Gracián describes similar circumstances. Perhaps this culture in medicine is timeless and inter-professional. Indeed, consider how professionals in other sectors respond to or manage criticism. Please consider sharing your thoughts in the comments section below.

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Summary

There may be a tendency for experienced healthcare doctors to view those new to the profession as naive whereas they themselves may appear cynical. We should reflect on this. The interplay between health and politics is complex. Doctors learn a lot about anatomy, biochemistry and physiology but there may not be a clear path to learn about political science and how politicians influence everyday clinical decisions. If the care of our patients is our primary concern, perhaps we should not shy away from taking lessons in politics.

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Further resources