THE SUM OF THE PARTS………….
“The epic poet
collaborates with the spirit of his time in the composition of his work. That
is, if he is successful; the time may refuse to work with him, but he may not
refuse to work with his time.”
Lascelles Abercrombie
Lascelles Abercrombie
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.
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 interest…compose 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
ISQua
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
(2) Sir John Charles: BRITISH MEDICAL JOURNAL, LONDON SATURDAY
DECEMBER 22 1962
(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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