John A Lee
Consultant Histopathologist, Rotherham General Hospital and Honorary Senior Lecturer in Pathology at the University of Sheffield

https://doi.org/10.36866/pn.51.22

As every parent knows, what we say and what we do are not always the same thing. In professional life, judging from the many ‘Guideline’ and ‘Best Practice’ documents that I get to read, they are usually not the same thing. The documents tend to be written for a fantasy world where activities are discrete and the only thing in your diary for half a day is to give your full and undivided attention to the specific task which the writer was asked to address. In actual fact, of course, everything is quite a lot messier. What we tend to do, as responsible professionals working in the real world, is try to find a way through the day which gets our jobs done as well as they reasonably can be, while not necessarily dotting every ‘i’ or crossing every ‘t’ as we go. The same obviously applies to the difference between the way we do science and the way we write it down in scientific publications. Shock, horror. Did I write that? But actually it is important to be explicitly aware of this gap between theory and practice, between the world we actually work in and the one which inevitably seems to be conjured up (even by otherwise sensible, practical people) when we try to write it down.

One reason why it is so important, is that this theory/practice gap can fundamentally interfere with the way we represent what we do to the wider world. The trouble is that professionals in all walks of life have fallen into the habit of pretending to themselves and their colleagues that the idealised version is the way things ‘really’ are and, what is worse, they tend to represent only this version to the general public. Of course, there are any number of ways of justifying this stance and most of the time the gap is indeed small and fairly insignificant. But the problem is that there is great potential here for drift. What started years ago as a relatively informal grant-reviewing process for a fairly small number of scientists turns into a huge mega-industry processing vast sums of money, in which great pressures are generated to inflate the significance of results, as well as the likely outcomes of the next project application. What started as a well-meaning attempt to see whether a disease can be detected early turns into a vast politically­driven screening programme, where dubious benefits and significant downsides are swept away by
‘standard’ working practices, impenetrable statistics and affirmatory language.

This is probably inevitable. Those of us who understand that almost every activity carries with it a ‘Mind the gap’ sign shrug our shoulders and carry on, doing our best and playing the game to a greater or lesser extent depending on our personal agendas. Those who are less aware of the invisible signs can be seen scurrying around with worried frowns as they try to locate and deal with all those ‘i’s and ‘t’s, or, alternatively, if they are a more dominant individual, can be seen banging tables and fulminating over why this or that hasn’t been attended to by someone else. Most of the time we only have to deal with colleagues who have been similarly professionalised and this system allows us to earn our daily bread (the most important point) and even works after a fashion. But what about when we have to tell the wider world what we’re doing?

This is when the gaps can really start to widen. Generally-speaking, most professionals espouse the idea that wider public understanding of whatever it is they are doing would be a Good Idea. But there is a large caveat. The professional usually presents their topic without ‘Mind the gap’ signs. There are the obvious justifications for this – ‘Present a clear story’, ‘Don’t confuse people with details’ and so on. But in fact a hidden, powerful and somewhat less creditable reason is that ‘greater public understanding’ is usually coupled, in the professional’s mind, with a silent ‘And therefore more positive attitude to what I do.’ So there are strong incentives to paint a rosy picture, even when the benefits of a particular activity are fairly obvious.

But what about when a professional activity is perceived as controversial? What if there’s a risk that even when the wider public are better informed about it, they like it even less, perhaps even want to stop or greatly curtail it? In this situation most professionals are no different from other people – they react to preserve their way of life. They are even more likely to present an over-optimistic picture, even less likely to acknowledge possible problems. They stretch the gap as far as they dare, hoping that the debate will go away, leaving them once again in peace and misunderstood isolation.

Yet this is not really the right way to go about constructive debate. What if your over-rosy picture is found out? Then you risk being labelled as a propagandist and suffering a backlash against even a reasonable position. Even if you get the debate to go away or rumble on more quietly, you are likely to be in a more difficult situation than before – more entrenched, less likely to engage in further discussion, feeling abused and demoralised, and being perceived by the wider world as disengaged and secretive.

On the contrary, my view is that the best way to engage in constructive debate, especially on controversial topics is to try to narrow the gap. To let the public see what you are doing. To present the realistic possibilities and the difficulties as honestly as possible. To try to answer questions without hyperbole. To try and avoid the paternalistic ‘of course I know best, I’ve spent my whole life working on this thing’ attitude and trust to the fact that clearly explained issues tell their own story. To accept that, in your enthusiasm, you may have previously over-egged your case and be willing to step back if necessary. To understand that consensus may have moved away from where you thought it was when you started your activity and be willing to consider changing tack. This can be particularly hard to do in basic science or medicine, where years and decades of work can be driven purely by their perceived potential, where that ‘might’ in the conclusions of endless papers can accidentally harden into the nature of a faith. Obviously, it is precisely to try and avoid this situation (and the moral quagmire into which it can lead) that the professional has a duty to be explicitly aware of and honest about the gap between reality and theory. After all, history is pretty clear on the fact that the vast majority of our brilliant ideas lead nowhere and have no practical applications, now or ever.

I had recent personal experience of a situation which generated widespread public interest and controversy, but which helped to confirm the views I have expressed above. As a histopathologist, I regularly perform autopsies, and I do believe that this procedure continues to have an important role in medical practice. An autopsy is not rocket science, but it does provide explanations for the bereaved, important feedback to medical practitioners (we all know what can happen to open loop systems), and statistics of varying utility concerning causes of death. In November 2002, Gunther von Hagens, originator of the (in my opinion) excellent Body Worlds exhibition which attracted 700,000 visitors in London, announced that he would be performing a public autopsy – the first for 172 years – on an embalmed body. I was invited to be present and to commentate.

Whether or not to agree to participate was a tricky decision for me. On the one hand, I fundamentally believe that people do have a right to see for themselves how things are done and to make up their own minds. On the other hand, there was a tremendous establishment, professional and media furore against the event. Some of this centred on whether or not such a demonstration would actually be legal. Suffice it to say here that I had the advantage of seeing the legal correspondence, from which it was pretty clear that this event was not proscribed by current English law. But most of the antipathy to this autopsy seemed to be a straight-forward taboo reaction. The authorities seemed to feel that they might somehow get into trouble for allowing it to proceed, medical commentators – in spite of rhetorically approving public education on this issue – felt it was insensitive, was not the right way to go about it, etc etc, and basically wanted it to go away, while the media (with a few notable and thoughtful exceptions) were generally appalling, prejudged the event and wrote mainly nonsense.

After a lot of thought, I decided to participate, because I felt that allowing people to see for themselves would uphold an important principle and would also lead to a more realistic appreciation of what an autopsy actually involves (narrowing the gap). I should say that I had also satisfied myself that the full consent of the subject of this autopsy had been obtained. This was obviously, in various ways, a risky event to take part in. But in spite of the apocalyptic predictions made by some people beforehand, the feedback I have received concerning the event has been overwhelmingly positive. Although a few people clearly found seeing the procedure shocking, most were genuinely interested and valued the opportunity to ask their own questions and draw their own conclusions. The open and honest demonstration which von Hagens organised has helped replace fear with knowledge, allowing many people to be able to visualise the nature of an autopsy, whereas before they could not.

More importantly, I believe that the public autopsy was an event which marks something of a watershed in treating the general public like adults. As far as I can tell, it has done little harm, but has paved the way for more open debate on controversial topics – I can think of hardly anything else that has been as hidden away for so long as autopsies. Whether or not the eventual outcome is for the numbers of autopsies to go up, down or stay the same – in other words irrespective of any specific professional consequences – there is now at least the possibility that what happens will be for reasons that people have had an opportunity to think about more realistically.

I think that narrowing the gap is important in all areas of medicine and science, however controversial. It may feel risky. It may even lead to changes we don’t necessarily agree with. But in the long run it must surely provide a more stable foundation on which to build. Also, I think a bit more straightforwardness would help to support better quality science and medicine, by removing some of the polluting layer of doublethink from the professional mind. In spite of the trends of the last decade or two, quality does not depend on the wrapping, but on what’s inside. Practitioners of paternalistic realpolitik will doubtless find my stance on this issue naïve and foolish. But I think that the ever freer flow of information in our wired world is against them.