The Caveman

Dr Richard Genever (Geriatrician/Physician) at Chesterfield Royal Hospital NHS Foundation Trust discusses how one of our primal instincts, fear, can positively and negatively influence decision making in the world of health and social care. ECIST would like to thank Dr Genever for allowing us to share this blog which first appeared on the PEAKFLOW1 blog. Follow Richard on twitter @DrGenever

Rabbits are prey animals. Every rabbit is aware that the end could come at any time and from any direction.  For that reason they are constantly checking for danger, living from minute to minute. Very few rabbits play the futures markets.

Most humans (with a number of notable exceptions) do not live in a state of constant peril; but it wasn’t always so. Early man lived a very tough existence. Death potentially lurked behind every rock and bush. It paid to be on your toes.

Over the millennia life changed. Hunting and gathering were replaced by online shopping but The Caveman lives on inside us. He doesn’t wait for times of extreme danger to show himself though. He appears every time we have to make a decision.  The Caveman makes us exaggerate immediate and short term risks over intermediate and longer term risks.

The worlds of health and social care are not immune to The Caveman’s influence.  Perhaps the area where this is seen most frequently is when we plan to discharge a patient from hospital.  Every discharge is meant to be a calculated balance of risks.  The risk of under treatment vs over treatment. The hazards that might be faced by a patient returning home vs the apparent safety of the hospital.  The Caveman can very easily shape our decisions, making us perceive the risks of discharge as much greater than staying in hospital, even if that is not actually the case.  The trouble is that The Caveman doesn’t know about problems such as healthcare associated infections, falls, delirium, loss of independence and other complications that can develop when people stay in hospital unnecessarily because these problems exist in a space that is alien to him – the future.

Anybody that doubts the presence of The Caveman in healthcare need only to look at the way that almost all hospitals are institutionally addicted to making patients ‘Nil by Mouth’. This instruction (that no food or drink should be given orally) is common practice before surgery but is also made in other patients in response to a wide variety of respiratory and swallowing problems.  The theory is that a patient who is ‘Nil by Mouth’ is at lower risk of aspiration (inhaling food or drink), which is a potentially life threatening situation. Unfortunately the same instruction places those patients at immediate risk of dehydration and malnutrition as alternative ways of administering food and fluids are not always feasible or desirable. The Caveman only sees the immediate risk. He also shouts very loudly and carries a club.

It is important to remember that The Caveman is sometimes right. Sometimes eating and drinking places a patient in mortal danger and alternative ways of giving food and fluid need to be sought.  Sometimes it isn’t right to discharge a patient.  The important thing is to listen to your Caveman but not to be bullied by him.  Get to know your Caveman and have a conversation with him and you find that he can become a trusted ally.