Yeh but! The importance of the Devil’s advocate in healthcare departments

I’ll get back to the tech stuff soon going to do a piece on the Pilot X at some point, but I was reading a fascinating article on my way into London about the 10th man which got me thinking, in a time when healthcare departments are often over stretched and under pressure (pushing down on me), is there room for a voice of decent and people playing the Devil’s advocate?

The Spanish/American philosopher George Santayana said, “Those who cannot learn from history are doomed to repeat it”. Which is similar to the quote “People will not look forward to posterity, who never look backward to their ancestors” by British philosopher Edmund Burke. The importance of these statements cannot be overlooked in healthcare, if we do not scrutinise and question our past (failures and successes) we are doomed to repeat the same mistakes and our improvements will stagnate. In the of learning from history, I propose a foray into the past to see what lessons we can learn and how the Devil’s advocate can help with that process of scrutinisation and learning.

Come with me then weary time traveller as we cast our minds back to October 6th 1973 the start of the Yom Kippur war, where the state of Israel was attacked by a coalition of Arab states. This surprise attack was unforeseen by Israeli intelligence services despite warning signs, Israel had this idea that because the Arab states had been defeated in wars several times that they wouldn’t attack Israel, this idea was ingrained at the highest level of office and there was no mechanism in place to challenge it. The world’s political stage would change completely, and lessons would be learnt by the Israelis. The Israelis would implement the 10th man position and the option of writing “different opinion” memos in the aftermath of the Agranat Commission. The 10th man position is a fairly simple but contentious one, there are differing opinions about how effective this position is. The idea behind the post is that if 9 out of 10 men in a room agree on an idea, it is the duty of the 10th man to argue from the opposing view point or to play the Devil’s advocate to enable the scrutinisation of ideas.

So why is the Devil’s advocate important in healthcare? Why do we need dissidence? Well in my opinion and this is probably a fairly isolated one, the importance of the Devil’s advocate is to challenge the status quo, to test the boundaries of not only patient treatment on a departmental scale but to influence policy and processes Trust, regional and nation wide. This is where I think trainees in particular can be effective because of what they can bring to the table. They can come into a department with fresh eyes (they haven’t been institutionalised yet!) and while learning the ropes can question everything the policies and processes in place why we are doing things and wether its a historic reason or whether it’s based on research, what other treatment options are in place and what departments cross over with theirs, the list of questions is endless. They are able to question the research with impunity and ask what research is influencing intervention choices and offer alternative solutions because they are learning, and people want to facilitate their learning. I also think this is where Clinical Scientists really come into their own, with a combination of clinical and technical expertise Clinical Scientists can pick apart research and interventions looking at not just individual interventions but system wide changes. In my opinion it is critically important not to create an echo chamber in the healthcare environment this has inevitably life or death implications, this comes in part from Heinrich’s pyramid which while outdated (it links the blame of for the incidents with the people and not the system) has at its core an important point that there is a link between near misses, minor incidents and major incidents, and that a reduction in near misses has an effect on the number of minor and major incidents. The more we report near misses and more importantly learn from them, the less minor and major incidents we have to deal with. This is where I think we need to build a culture across healthcare that facilitates the Devil’s advocate because questioning one’s belief does one of two things, it either challenges your beliefs based on new or opposing evidence, or it solidifies your belief based on evidence. It can also have the added effect that it helps us evaluate our bias maybe we are really engrained in using a particular intervention and haven’t considered other options, or maybe we have been doing the same process for the last couple of years and think it’s amazing, the Devil’s advocate gives us a chance to pause, review and consider our bias towards these and question whether there are improvements or alternatives to consider.

There are a couple of books that I would highly recommend reading that have influenced my point of view on this, the first The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life: Mark Manson. The second Why Dissent Matters: Because Some People See Things the Rest of Us Miss: William Kaplan.

I’ll leave you with this final thought, in the history of the NHS there have been great changes the Caldicott enquiry, duty of Candour and the Mid Staffordshire Trust enquiry are just a few examples. Without the Devil’s advocate, without people both part of the system and using the system questioning the system, do you think there would have been any changes, and what would the consequences have been?