Black-belt medicine

When I was younger I spent a few years as a Karateka.

That is, an exponent of the martial art of the open-hand (Japanese; kara = open, te = hand, ka = practitioner).

Between the ages of 12 and 16 I was entranced, caught-up in the mystique, the thrills and spills.

I should write a blog about this one day as it was a memorable time, with my first Sensei Michael Aleko, who later became a Hollywood graphic artist and my last, Douglas Paul who knew the art of Shukokai ‘body blocking’ and had previously spent time working as a mercenary in Southern Africa.

The thing with Karate, and I am not sure if this is the case with other youthful activities, the repetition of the actions, the time spend inside your head imagining all the blocks and punches generates thoughts that remain with you long after you have moved-on, grown stiff and out of condition.

What I mean by this is, even when I was 32, a lifetime after I had stopped wearing the gi, I would still conduct imaginary battles in my mind’s eye. Fantastic jumps and spins, defying gravity and common-sense.

These were never translated into actions, the dreams were of a 16 year old with a 16 year old’s abilities inside a 30 or 40 year old body.

Too many hours watching Enter and The Way of the Dragon.

Too much reading Bruce Lee.

I was talking about martial arts yesterday.

It was a Saturday morning medical student lecture, run online and arranged by students from King’s College and Cambridge.

Very prestigious.

They seemed to find me via an article I had written for the Journal of the British Geriatric Society about the speed of doctors on ward rounds.

I talked all about my experiences as a doctor who a few years ago fled the confines of the hospital ward and the strictures of in and outpatient sessions, to the freedom of the open road.

Jack Kerouac would have been proud.

In the talk I presented my ideas relating to white and black belt medicine.

I have covered something along these lines before in discussing the management concept of wicked and tame problems.

If you want to read that you can go here.

For me, the difference between the two belts and their equivalents in medicine can be described as transactional and transformational care.

The first, the former, is the white belt.

It is the doing the do, following the recipe-book, Googling your condition and following the instructions.

The instructions can be straightforward self-care ‘rest, apply ice and elevate’ in the event of a sprain, through to the most sophisticated robot or laser-guided surgery, extracting clots from the brain’s posterior-circulation (yes, they do that nowadays).

In the tame/wicked world, the issue of how you remove the clot from the basilar artery had a clear beginning and end, the start is the patient with sudden onset of symptoms, maybe dizziness and the end is the clot gone and the patient recovered.

None of this is underestimating the in-between, complex public health messaging (that gets the patient to hospital in time), the skill of the diagnostician, the logistics of the hospital or care system and the operator who removes the clot, supported by nurses, therapists, technicians.

It is likely, barring nuclear or environmental disaster that humans will continue progressing medicine in this direction, undertaking the miraculous.

That’s white belt.

Seems black belt to me, you might think.

Well, I am not trying to diminish the skill of the scientists or operators, the professors and academics who underpin all of this, it is just, that ultimately, I might be able to sit in front of a computer, press a button and receive a diagnosis, then call a number and the treatment happens.

It is finite. Doable. Within the limitations of physics and technology.

And what of black belt?

Well, that on the spectrum is wicked.

It is the thorny side of medicine.

Medicine that has dirty nooks and crannies where human error, personal preference, economics and individual variation lurks.

It is the patient who does not follow the rules, who smokes and drinks too much even after their life-saving bypass, it is the old woman who prefers to cling to her furniture rather than mess around with the shiny new Zimmer Frame bought for her by the family, it is the man with diabetes who loves a big-mac and hides his Metformin under the cupboard thinking the GP notice. (HbA1c doesn’t lie).

It is the prettiness and ugliness of getting more for less, or rationing health resources and providing sustainable care, it is convincing those people who administer the medicine or the apply the dressing that they should continue to care, day after day.

Black belt medicine is realising that the evidence-based guidelines for the management of hypertension or vascular disease or cancer reflect the opinions of academics, the statistical determinations of thousands, not the whim of the individual.

It is the caring and kindness, the compassion (yes, you can suffer with your patient), the love and support, the creativity and imagination to think around difficult problems. It is the skill of communication, being able to sense the subtleties of eye contact, tone of voice and rate of breathing that indicate worry or surprise or fear.

It is the infinite possibilities of what is means to be healthy or sick, happy or sad, angry at the state of your health, with mis-directed frustration that can be perceived as rudeness or antagonism which is in reality fear.

The best doctors, nurses, therapists, carers and support workers get this.

They see the whole of the person.

The enormity of the situation.

It isn’t necessarily something that can be taught or learned or bought, it requires focus, time and commitment. It is tapping-in to the humanity of the process of care.

In the world of martial arts, the supposed cycle is that of the student starting with the white belt and through struggles, practice and time, the white darkens to become black. It isn’t the stepwise progression sometimes bought from the shop.

In the spirit of holism, the beginning is the end.

The master once he or she arrives discovers the simplicity, they revert to white.

We contain multitudes.

There are innumerable cliches that work to describe this journey.

I’ll end with an anecdote then a poem.

One night, maybe ten years ago I was on call.

A young doctor on the ward phoned me with the story of their patient, a 48 year old man, admitted with chest pain then vomiting. He was bringing-up blood. We call this haematemesis. The most common cause an ulcer. The doctor was worried by the amount of blood and the patient’s condition.

At this time when was working in Doncaster, there were not enough gastroenterologists to run an out of hours service, the system was to call Sheffield.

‘Can I speak to the gastroenterologist on call.’ I asked the operator.

‘Putting you through, it is Dr X tonight.’

‘Hi, is that Dr X? My name is…’

‘It’s Professor X. You woke me up.’

He gave me a hard time, he wouldn’t accept the patient (transfer from Doncaster to Sheffield) – in his opinion it could wait until the morning.

The patient survived.

This was a guy pretending to be togged-out in black but wearing white.

The patient’s anxieties were not addressed – he continued to vomit, neither were my fears or those of the doctor on call on the ward.

The patient was a number, a statistic, a hazy three in the morning representation of instability.

This is from one of Bruce Lee’s books, I can’t remember which – I think he took it from (I believe) an ancient Chinese source;*

‘He who knows not and knows he knows not, he is a fool, shun him,

He who knows not and knows he knows not, he is simple, teach him,

He who knows and knows he knows, he is asleep, awaken him,

He who knows and knows he knows, he is wise, follow him’**

*There is a suggestion that this is nothing to do with Bruce Lee, regardless, it carried me through my early teens.

**Don’t over-analyse, please get on with your day.

Be well.

Rod