Friday, 7 February 2014


The very best artistic and literary works have at their heart an idea and composition.
We can all write and draw; some of us can even write and draw very well. But without a compelling idea and without a highly developed sense of composition (ie: how all the bits are fitted together to make a whole) we will not join the Vermeers or Smarts or the Rushdies of this world and achieve greatness.

                                                                                                                 The Art of Painting by Jan Vermeer

Van Gogh wrote of the Dutch masters

And there is the story of Jeffrey Smart struggling with the composition for a work he was painting only to find his struggle over when a wood shaving from refurbishments going on in his house floated down and landed on the unfinished work adhering to the wet oil paint on the canvas. He turned the wood shaving into a seagull and that was the piece needed to make the composition complete. It became one of his best known works.

The Bus Stop, Jeffery Smart
And what is the composition of medicine? Surely not what is represented in this poster.
The thing that separates writers who produce one good work from those who produce good works over and over again is that the former compose well by accident whereas the consistently good writer knows how to do it over and over again. And so it is with music.

Writing in 2005, Litaker et al (1) touch on what I consider might be something like composition in healthcare:

“Although health is influenced by an individual’s characteristics and choices, accumulating evidence suggests that contextual attributes may influence a variety of health outcomes.”

So the way in which we assemble all the bits and pieces around the patient may influence outcomes.

In art, ‘The artist determines what the center of interest of the art work will be, and composes the elements accordingly. The gaze of the viewer will then tend to linger over these points of interest, elements are arranged with consideration of several factors …… into a harmonious whole which works together to produce the desired statement – a phenomenon commonly referred to as unity.’

So too does the clinician having recognised the patient as the ‘…center of interestcompose the elements accordingly…’. She or he will take into consideration several factors and work them into a harmonious whole which will then lead to diagnosis and a treatment regime.

If we then move from the individual, the patient, to the collective of patients and think about composition in the healthcare system, the analogy still stands up. Writing in the BMJ with some foresight in 1962, former Chief Medical Officer of the UK Ministry of Health Sir John Charles said (2):

It is my submission that in the operations of our National Health Service, and those other services concerned with the public health, whether administered by the Ministry of Health itself or by other Departments of Government, we have a series of undertakings, symbiotic at least, if not so completely co-ordinated as they might be, which contribute to the social context of our health.’

He went on……..

‘(a) The treatment of the patient as the “whole man" and not merely as the carrier and example of a pathological manifestation.

(b) The recognition of him as a member of a family-and the consideration of the effects of his illness upon the family.

 (c) The evocation of the communal machinery, whether operating through the local health department or otherwise, which will assist him and the family in whatever way help or guidance may be required.

(d) The relevance of occupation to the patient's illness.

(e) The place of psychological factors -- the stresses, strains, and suffocating frustrations of modern life and modes of living-in the causation and continuance of the patient’s condition.’

Halfon et al writing in the Healthcare Quarterly in 2010 (3) also talks about the importance of considering all the bits and pieces and (more importantly) how they need to be skilfully put together when faced with healthcare challenges across populations:

“There is no simple biological reason why the risk of pregnancy-related death in Sweden is one in 17,400 while it is one in eight in Afghanistan; why the life expectancy at birth of men in the Calton region of Glasgow is 54 years, 28 years lower than that of men in Lenzie, just a few kilometres away.”
These striking disparities “reflect avoidable and unnecessary suffering,” a California-based team of healthcare researchers say. Social environments clearly matter for health. Yet these critical factors – the social determinants of health – have been “conspicuously absent” from the recent US healthcare debates.
But the question remains: if health is individual and biological, how do social determinants get “into the body”? How, exactly, does my social context affect my health?’’
The University Of Michigan Department Of Health certainly gives a nod to the importance of composition in seeking to improve healthcare quality. Its course in

Social, Cultural and Community Context of Healthcare talks about how

‘Residents will learn how to recognize the diverse factors that influence the health of individuals in the community. They will be able to identify social, cultural, familial, psychological, economic, environmental, legal, political and spiritual factors that impact health care and health care delivery. They will respond to the social context created by these factors by planning and advocating the appropriate course of action at both the individual and community level. They will develop zero tolerance for stereotypic language, racism, sexism, ageism, and aspersions to individuals or groups based on ethnic, religious and sexual preference or lifestyle choices. They will avoid identifying individuals by the name of their disease. They will understand all the reasons behind non-adherence and methods to mitigate it. They will learn the benefits of being an advocate for better health for patients in the community and understand the resources available in the community to provide ethnicity- and gender-sensitive and culturally-competent healthcare’.

So, in short, it is important to understand how best to assemble all the elements of healthcare both for the individual and for the community to achieve the most pleasing results.

‘A work of art is said to be aesthetically pleasing to the eye if the elements within the work are arranged in a balanced compositional way. However, there are artists such as Salvador Dalí whose sole aim is to disrupt traditional composition and challenge the viewer to rethink balance and design elements within art works’.(4)
Run your eye back up to the Vermeer with which I started this BLOG, then down to the Dali below and I will leave you to decide what achieves the most pleasing result.

                                                                         Still Life Moving Fast, Salvador Dali: 

Peter Carter
Chief Executive Officer
February 2014

(1)     Litaker, David MD, PhD*†; Koroukian, Siran M. PhD†; Love, Thomas E. PhD†‡
         Medical Care June 2005 – Volume 43 – Issue 6 – pp531-540
(3)     Halfon, Neal, Kandyce Larson, and Shirley Russ. 2010. “Why social determinants?”   Healthcare Quarterly 14 (Special issue, October): 9-20.
(4)     Wikipedia

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