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The big picture
  1. John Launer
  1. Correspondence to Dr John Launer, Department of Postgraduate Medical Education, London Deanery, Stewart House, 32 Russell Square, London WC1B 5DN, UK; jlauner{at}

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If I could wave a magic wand and endow all doctors with one attribute, I would choose the ability to see the big picture in everything we do. By this I mean the capacity to ask the crucial questions in every encounter. What does this patient really want from me? Who else is close to the patient and what do they want? What is my own role as a doctor in this case? How does it fit in with the roles of all the other doctors, and all the other professionals? Are we all just doing little unconnected bits of things to the patient, or are we working together to provide the single thing this patient most wants or needs?

I could give innumerable examples from everyday practice of where these questions haven't been asked, and so the big picture has been lost, or was never even noticed in the first place. Here is a typical one. A 60-year-old man with lots of past heart surgery comes into outpatients wanting a simple answer to a simple question: ‘Is there any significant chance that further tests or operations will help me, or should I just put up with my current level of angina?’ Instead of a straightforward answer, or even a frank admission of uncertainty, he gets sucked back immediately into the machine—both literally and metaphorically. He has more tests, and yet more tests, and ends up with further surgery based on what the angiogram looks like rather than a serious and prolonged conversation with him.

Another example: an 80-year-old woman is whisked into hospital with a broken hip and taken straight into the operating theatre where her hip is expertly repaired. However, no-one has been able to take a proper medication history because she is confused, and no-one has bothered to phone her children or the general practitioner to ask which pills she is taking. Because of this, she goes into heart failure after the operation. These cases are based on real examples. Ask your non-medical friends or members of your family, and you will hear dozens more stories like this. Sadly, you will probably hear even worse ones as well. Yet the remedies for these kinds of problems are not complex, nor are they expensive. They depend on something called systemic awareness, or systemic literacy.

Systemic literacy

Systemic literacy is akin to emotional literacy, except that it concerns sensitivity not just to the person in front of you but to everyone else who might be involved as well. Some people describe this as ‘taking the helicopter view’. Others describe it as seeing yourself as part of an enormous dance. One analogy I like to use is that of the Krebs cycle. If you can think of human beings like interactive molecules, constantly undergoing mutual transformation, but in three dimensions and over extended periods of time, you get a sense of the complexity of any system that exists around you every time you encounter a patient.

Paradoxically, systemic literacy can give you a sense of simplicity as well, because it helps you realise that you don't have to fix everything yourself, or here and now. All you may need to do is to make one small humble move that contributes towards taking everything in the direction the patient requires. To apply this idea to the examples above: the registrar who saw the man in cardiology outpatients could have gone into the next room to ask her consultant's honest view of the matter before she filled in a form for more tests; and the foundation year doctor who efficiently organised an urgent hip replacement for the old woman could have picked up the phone to the GP. In either case, they would have been doing more than the humdrum, automatic tasks that they thought were needed of them. They would have been working with the big picture instead.

Teaching and learning

Systemic literacy can be formally taught and learned—and personally I have over a decade's experience of doing so. Once you acquire it, you find you can apply it not just to consultations with patients but to supervision and training, to management, and to just about any other context you can name. People regularly report that ‘being systemic’ works in social and family situations as well: their friends and family begin to notice that they seem less wedded to offering advice or instant solutions to everyone's problems, and more inclined to ask intelligent questions about what everyone really wants, or about the other people who are inhabiting their lives.

Doctors in particular begin to notice how addicted they and their colleagues are to ‘sorting everything out’ in a technical way, even when no-one is actually asking for this, least of all the patient. They become aware of how often patients aren't asking for action but mainly for inaction, perhaps with a little bit extra like information, an explanation, reassurance, or simply a listening ear.

There are obvious overlaps between systemic literacy and areas such as patient centred medicine, reflective practice, communication skills, dealing with complexity, and so on. But I think there are good reasons why medical educators working with everyone from undergraduates to established doctors should name systemic literacy as something essential for good medicine, and teach it more explicitly. Firstly, medicine is getting ever more complicated, and ever more fragmented. It will be increasingly important for every doctor, however specialised they may be, to be able to step back from their own bit of widget fixing and see if it really fits with what the patient asked for in the first place, and with what everyone else is doing.

New pathways

In addition, the barriers between primary and secondary care are rapidly dissolving, so that specialists will find themselves working more in the community, and many GPs will take on more challenging case management than they have in the past. As new care pathways develop, doctors will no longer be able to rely on the traditional system of writing referral letters (or letters back to the original referrer) and then forgetting about the patient. Instead, they will need more frequent and more sophisticated conversations—in person, over the phone, or by email—to check that patients aren't falling through unexpected holes in the network.

The most important reason for teaching and learning systemic literacy is that patients are becoming healthily vociferous and are unlikely to put up with doctors who single-mindedly plough their own furrows simply because that is what they have always done, or because that is all they are interested in. If we don't learn to say it to ourselves, our patients will certainly say it to us: “please can you stand back and look at the big picture”.


  • Competing interests None.

  • Provenance and peer review Commissioned; not externally peer reviewed.