Utopia in Emergency Medicine

Tudor England was a fairly brutal place. Both the monarchy and the custodians of religion promulgated a philosophy of mercurial cruelty towards the populace, which did not begin to abate until well into the seventeenth century. Original, innovative ideas were swiftly snuffed out, and their heretical manufacturers subjected to barbaric and grisly punishment (of which death was often the least painful).

But there were some bright stars. Thomas More (1477 – 1535) was one. A polymath, politician, and humanist, he wrote a book called ‘Utopia’. This was the first coinage of the term in literature. It told the story of a society governed by reason. On the island of Utopia, citizens had no need of lawyers, or even laws, as they were able to control themselves, quite nicely, thank you very much. They all had the greater good in mind. It was a work of significant wit, and was written as a mirror to the callous ideology of the day, of life dictated by greed and self-interest.

Today, the accepted understanding of Utopia is a description of a wondrous and perfect place. Certainly as derived from the Greek eu-topos, the word can be construed as a good place. We like to imagine waterfalls, nymphs, clean shiny buildings, good, honest people – a population free from hunger, poverty, disease. But, in fact, this is thought to be a fallacious derivation. Etymologically, the word is better translated from the Greek as no place, or nowhere.

In other words, there is, and can be, no such place as utopia.

Let us drag ourselves into the present day. Into the hospitals, the Emergency Departments, the wards, our workplace. Here we would like to see ourselves as contributing to the greater good of society. Working tirelessly towards improving the lives of our fellow humans. Striving for utopia. But, in reality, mostly we feel we work in loci of conflict. We feel powerless, downtrodden, and even (and forgive the melodrama), a little oppressed. Far more dystopian than utopian.

So why is utopia so unattainable?

An interesting explanation can be seen in patient surveys. When our own health system underwent a radical overhaul several years back (a sort of celebrity makeover, with more gaudy name changes, butcher’s paper covered in fluorescent post-it notes, process mapping, ‘think-tanks’, meetings, and glitter than a late night, free to air, poorly rating satire), patients were asked what they wanted from their visits to the E.D. By far, the most pressing desire was to be seen quickly. Secondly was to have rapid, comprehensible communication about the goings-on around them. Way down the list, or not even there at all, was the odd concept of a correct working diagnosis.

Thus, the two groups who frequent the emergency department; the clinical staff, and the patients, had entirely different priorities about what the greater good actually was. It is likely that no amount of conversation across the divide could change that. The United States has it harder. Ubiquitous Press Ganey scores circle above clinicians’ heads like vultures. But the principle is the same – what is one man’s idea of a perfect institution, is antithetical to another.

The hospital accountant has a different view of hospital ideology to a clinician. A lone rural practitioner has vastly different views on perfection in health to those of us in ivory towers. There is no greater good. Utopia is a pleasant phantom.

I feel more hopeful seeing things this way. Less resentful of the bureaucratic apocalypse, more accepting of individual’s needs and desires from the health system in which I work, instead of feeling so righteous, so hard done by. There are only degrees of good, and my scale will be different than everybody else’s. Plus, I can speak of this without fear of being tied up at the stake and watching the curling flames licking at my feet.

Thomas More did not fare so well. He was decapitated (the most humane and merciful execution of the day), and had his head fixed on a spike overlooking London Bridge. It wasn’t the book that did him in, however. It was a result of his refusal to bow to Henry VIII’s salacious religion swapping for, let’s admit it, carnal purposes.

And so it’s back to dystopia for us. Long may we enjoy it.

Further Reading

…and for the full video and talk and podcast head to the Dystopia talk on the SMACC website