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President’s Bulletin: I know what you mean Mr Rumsfeld

Updated on: 21 Sep 2020   First published on 17 Sep 2020

Author:  Dr Alastair McKinlay 

Donald Rumsfeld, the former Secretary for Defense under President George Bush famously talked about what is known and unknown. His description of “known unknowns” and “unknown unknowns” caused some rather superior, wry, smiles at the time. It seemed impenetrably complex, but actually, as people rather grudgingly admitted afterwards, Rumsfeld was correct. Compared to the social media offerings of some later White House incumbents, Rumsfeld’s comments appear close to genius.

At the moment we face some “known unknowns”. We don’t know what COVID-19 is going to do in the next six months. Unfortunately, cases are rising, so a second wave seems very likely, possibly inevitable. The “unknown” is what consequences will follow. At the moment, hospitalisations and deaths are mercifully low, probably because the infection is more prevalent amongst younger people, but to assume that this will continue would seem complacent. The other unknown is whether there will be a vaccine in time and how effective it will be.

In February, when we were faced with a decision about the annual conference, the Executive concluded, as it turned out correctly, that the chance of a successful meeting in June 2020 was low. Looking back February seems a world away. I think we hoped that it would all be over by Christmas. Ironically the prediction that hostilities would be over by Christmas, was widely expressed at the start of both the First and Second World Wars. In both cases, it was false hope and the same seems likely for COVID-19.

It feels a bit like war too. At no time in my career of 38 years can I remember such a feeling of being “mobilised” for war; of being called, quite literally, to the frontline. Nor any time in my career have I ever been so acutely aware that I could actually die in the line of duty. For many colleagues, it has been much worse, particularly for those who had to shield and for those who are at heightened risk because of their ethnicity.

The first time around, the public recognised the dedication of staff and showed their appreciation by clapping every Thursday evening, week after week. The next time around the reaction of the public may not be so warm. In particular, I think they will not accept a total shutdown of diagnostics and surgery. Our patients will expect us to have learned from our previous experience with COVID-19.

The BSG has published advice on pausing services at the height of the first wave. We published guidance on restarting services as the peak passed. The process of restarting services has taken longer than we anticipated. Recalling troops from the front line it turns out, is often a more protracted process than sending them there in the first place. We have published advice on modernising outpatient services and more recently, Ian Penman and colleagues in the endoscopy section have completed a major revision of our advice on endoscopy. Ultimately what happens next time will depend on how the men and women who manage the NHS respond, to a developing crisis. This is not a criticism of managers, simply a recognition that decisions about the prioritisation of services and care will be very difficult.

As gastroenterologists and hepatologists, our requests to management are simple.

Firstly; recognise that gastroenterology and hepatology services are teams. Redeploying specialist IBD, liver and endoscopy nurses to the wards may plug a few gaps, but it decimates the service. It cripples specialist helplines and incapacitates endoscopy and other diagnostic services. If endoscopy is to be preserved, delay the redeployment of our specialist nurse colleagues to as late as possible.

Secondly; recognise that there are only 24 hours in a day and consultants can only do one thing properly at a time. In particular, lists and clinics, whether face-to-face, telephone or video, need to be assigned enough time to complete safely. During pandemics and winter surges, ward rounds become extended. The need to don and doff PPE delays everything. If outpatients and diagnostics are to be preserved consultants have to have enough undisturbed time to do the job properly, otherwise, patients will be sent for tests they do not require, or will be recalled unnecessarily to clinics. Botched consultations, like the proverbial chickens, always come home to roost.

Thirdly: during the next wave, preserve training. Do not treat all trainees as if they are generic foot soldiers who can be sent anywhere. Halting training delays the progression of the next generation of specialists and they will be badly needed after the pandemic. One of the consequences of COVID-19 is that doctors are re-examining their careers, and some will want to work more flexibly, whilst for others, covid may be the final straw that precipitates early retirement. Without new consultants, services will suffer in the future. The BSG supports innovative training, new ways of working and immersive training, but not suspended training.

Every cloud has a potential silver lining. Recently we reluctantly decided to delay the annual conference again, to May 2021. The venue is now Glasgow. We believe that there is a good chance that we will be able to have a face-to-face meeting, but it remains a “known unknown” and the executive group will continue to monitor the situation closely. The safety of our members, the staff of the BSG and our sponsors, will always remain the highest priority.

We are left, however, with a potential gap of two years without a meeting.  In January 2021 we will launch “BSG Campus”, an intensive series of webinars and virtual events to provide CPD and allow some oral presentations and posters to go ahead. Ideally, we hope members will take some study leave, if possible, to join the webinars live, but they will also be available on demand to those who register for the event. There may even be an opportunity to watch some content as units or teams. BSG Campus is not a substitute for the conference, but it does help us to become a little more covid-resilient and if it is successful, it could become an annual event.

So we have some “known knowns” and some “known unknowns”. As Mr Rumsfeld pointed out however, the “unknown unknowns” by their nature are the most dangerous, but also by definition, the most difficult to manage. As a professional society, we need to stay vigilant, be adaptable and responsive to whatever comes along. We may have to accept that COVID could continue to be a factor for a much longer period than we thought, and it might still disrupt our plans. Were this to occur, we would be able to say truthfully to the next generation, that we covered every “known unknown” that we could, and we did our best to prepare for the “unknown unknowns”. Ultimately nobody can ask more than that.

Alastair McKinlay

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