Perspectives

The art of medicine

Escaping the scarcity loop
We belong to a group of medical educators who share a The term scarcity loop could be taken to mean that there
concern about pressures in our work that threaten our can never be enough funding for health care—so that
capacity for reflection and creativity. We meet regularly difficult decisions always need to be made about allocating
to discuss papers that might enhance our practice and resources—or to encompass the commodification of health
recently came across one by Arthur Frank in which he and how physicians collude with industry to conjure up
outlines sociological influences on medical practice. an image of health based on consuming more resources.
Frank argues that sociologists have a duty to uncover the Following Frank’s lead, we decided it would be productive
unexamined assumptions that underlie the discourses to regard the scarcity loop as a collective state of mind in
of today’s society and to question these when needed. which we are all caught up when thinking about health
We were intrigued by Frank’s use of the term “scarcity care, irrespective of our individual political views. Thus,
loop” to describe an assumption that he believes everyone’s shared assumption nowadays is that enough or
dominates health care. He describes this as “the endemic not enough has become the measure by which everything
contradiction in health care between the hopes, desires is judged—from the allocation of an individual doctor’s
and expectations that capitalist techno-science thrives time to government spending on medical research.
on generating, and the realities of what can be delivered What are the costs of subscribing to this assumption?
and who can afford what”. Frank proposes that “the At the level of the individual practitioner, it means that
task for social science is to refuse to treat the scarcity our actions and decisions are determined, consciously or
loop as inevitable and instead to critique the effects of unconsciously, by the notion of monetary equivalence. Even
positioning scarcity as the premise of virtually all health when we believe that we are practising in accordance with
care decision making”. our values, we often still remain constrained by a system that
requires us to justify the allocation of resources, including our
Ms 65/1284 f.7v July: harvesting and sheep shearing by the Limbourg brothers, from the “Tres Riches Heures du Duc de Berry” (vellum) (for facsimile copy see 65830), Limbourg,

own attentiveness, compassion, curiosity, or willingness to

give of ourselves as human beings. There is an implicit shared
belief that we should ration even our humanity.
“My feet hurt, I can’t breathe, my stomach is still playing
up…I don’t know where you want to start, doctor, but I feel
under attack”. This opening remark from a patient seen
recently is not unusual and is echoed in different forms by
many other patients. Because of a mindset dominated by
the scarcity loop, physicians instinctively focus on the list of
physical complaints rather than considering why someone
might describe themselves as feeling “under attack” and
what this means. Typically, doctors may assume that
spending too much time with one patient is potentially
wasteful and will take resources away from patients still
waiting to be seen. Accordingly, we refuse to see or address
the suffering and loss that lie just below the surface of what
the patient presents, and we justify this to ourselves and
others in the name of efficiency. Other effects of the scarcity
Pol de (d.c.1416)/Musee Conde, Chantilly, France/Bridgeman Images

loop include the way doctors have become increasingly

defensive in our practice to avoid being considered
culpable for errors: this is predicated on privileging certain
measurable outcomes and the assumptions we have made
to get there. In the same way, we focus on how to make
people live longer (something that is also measurable and
often technologically achievable) but not on how to make
lives mean more. Thus, the prevailing discourse of our time
actively discourages us from probing into what it means to
our patients to experience ill-health and into what being
well would constitute for them.

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 Perspectives

What would happen if we stopped always calculating ends and finite means that could be used for different
what was cheaper or more efficient in an arena of such purposes. The implication of this model is that perfect health
complexity and uncertainty as medicine, and advocated might be achieved if there were available an endless resource
instead for a system that encouraged practitioners to place that allowed unlimited investigations, medications, surgery,
attentiveness and person-centred care as the overarching and other interventions. Hence, we are constantly pursuing
principle for everything that we do? Many clinicians around that unattainable end, without realising it. Not surprisingly,
the world are in effect already seeking to practise medicine patterns of consumption of health in high-income countries
in this way. They do so by applying a range of different forms also seem to mirror patterns of consumption of food,
of reflective practice including mindfulness or by belonging land, and other resources, which are governed by the same
to peer supervision groups. Some adhere to models such as pervasive assumption. This is in direct contrast to other parts
narrative medicine and relationship-based care. What an of the world where true scarcity is endemic and people lack
understanding of the scarcity loop offers is an overarching even basic access to health care.
framework or a counterview, enabling us to consciously We believe that doctors should now be encouraged to
position ourselves as carers rather than providers and to raise their level of thinking beyond the parameters set by the
see these choices as explicit acts of resistance in relation to scarcity loop in public health as well as individually. Rather
an assumption that otherwise holds us in its thrall. than simply complaining about its day-to-day manifes­
A coherent counterview to the scarcity loop would tations, from inflexible guidelines to escalating technology
encourage doctors to suspend our anxiety about over- and organisational imperatives, we need to recognise the
running or expending too much emotional energy with invisible power it has over us and over society as a whole—
one patient and instead allow our common humanity to and to name, discuss, and question it. As Alex Evans suggests
come alongside others and forge a connection with them. in his book The Myth Gap, perhaps we need to find better
By doing so, we could experience more fully what they are governing myths as a society, ones that help us to “think
experiencing, develop a shared understanding, and allow in terms of a larger us, a longer now”. To do this, health
ourselves to think about the root causes of illness rather professionals need to consider actively how the philosophy
than its surface presentations. Allowing an abundance of underpinning the scarcity loop also determines social
attention would alleviate the patient’s feeling of being inequalities in health, the disproportionate influence of the
deprived, together with our own sense as clinicians of pharmaceutical and other industries, including the fast food,
frustration and disconnect, with therapeutic effects for both soft drinks, and alcohol industries, as well as wider political
parties. By moving from hasty appointments to calmer issues such as the climate crisis and militarism. A common
ones, from transactional to relational encounters, and from theme among these is the notion that every resource
transient patterns of medical work (like locum contracts) should be the subject of competition, and everyone should
to longitudinal commitments, we might actually save constantly strive to obtain more for themselves. From
everyone time—for example, by not ordering unnecessary medical school onwards, we should therefore encourage
and sometimes harmful investigations and treatment clinicians to evaluate health policy and guidelines critically
with consequent medicalisation and repeat attendances. and examine the influences that shape them, as well as
We would spend less of our clinical time deflecting the real their unintended consequences. Following Frank’s lead, we Further reading

issues in favour of tangible, linear interventions, seeking should aim to develop clinicians who are able to question Evans A. The myth gap: what
happens when evidence and
answers to the wrong questions. Is it possible that we might the scarcity loop and escape from it, thereby allowing them arguments aren’t enough?
actually make savings, despite this no longer being our first to actively think about how we look after one another and Eden Project Books. London:
priority? It might in fact be the assumption of scarcity itself care for society as a whole. We should support practitioners Transworld Publishers, 2017

that is making us profligate. who take account of the social and political contexts of their Fisher M. Capitalist realism.
is there no alternative? London:
At a political level, assumption of the scarcity loop patients’ conditions, act as advocates in helping people Zero Books, 2009
as Frank describes it is based on an almost universal to overcome these, are engaged in communal activism, Frank A. From sick role to
acceptance that there is no alternative to capitalism as a and use their professional authority to undertake acts of practices of health and illness.
way to organise society—an acceptance that Mark Fisher has political courage. Medical practice should be defined not by Med Education 2013; 47: 18–25
termed “capitalist realism”. In other words, as professionals the imagined material equivalence of all health care but by Goldacre B. Bad pharma:
how medicine is broken and
we are so enmeshed in the prevailing ideas about how to different kinds of currency such as kindness and connection. how we can fix it. London:
approach health care that we are no longer able to evaluate Fourth Estate, 2012
critically whether the values we espouse are in fact resulting *Rupal Shah, John Launer Mullainathan S, Shafir E.
in a healthier population or a more anxious and unequal Bridge Lane Group Practice, London SW11 3AD, UK (RS); Scarcity: why having too little
and Postgraduate Medical Journal, London, UK (JL) means so much. London:
one. Effectively, we take for granted an economic model
Times Books, 2013
rooted in notions of consumerism and individualism. [email protected]
Wilkinson R. Unhealthy societies.
In our current mindset, economics itself is regarded as a We are grateful to members of the Thinking Group whose discussion prompted this the afflictions of inequality.
science of scarcity, studying the relation between desired essay, and to Professor Arthur Frank for sharing his ideas with us. London: Routledge, 1996

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