Perspectives
The art of medicine
Escaping the scarcity loop
We belong to a group of medical educators who share a
concern about pressures in our work that threaten our
capacity for reflection and creativity. We meet regularly
to discuss papers that might enhance our practice and
recently came across one by Arthur Frank in which he
outlines sociological influences on medical practice.
Frank argues that sociologists have a duty to uncover the
unexamined assumptions that underlie the discourses
of today’s society and to question these when needed.
We were intrigued by Frank’s use of the term “scarcity
loop” to describe an assumption that he believes
dominates health care. He describes this as “the endemic
contradiction in health care between the hopes, desires
and expectations that capitalist techno-science thrives
on generating, and the realities of what can be delivered
and who can afford what”. Frank proposes that “the
task for social science is to refuse to treat the scarcity
loop as inevitable and instead to critique the effects of
positioning scarcity as the premise of virtually all health
care decision making”.
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,
Pol de (d.c.1416)/Musee Conde, Chantilly, France/Bridgeman Images
112 www.thelancet.com Vol 394 July 13, 2019
The term scarcity loop could be taken to mean that there
can never be enough funding for health care—so that
difficult decisions always need to be made about allocating
resources—or to encompass the commodification of health
and how physicians collude with industry to conjure up
an image of health based on consuming more resources.
Following Frank’s lead, we decided it would be productive
to regard the scarcity loop as a collective state of mind in
which we are all caught up when thinking about health
care, irrespective of our individual political views. Thus,
everyone’s shared assumption nowadays is that enough or
not enough has become the measure by which everything
is judged—from the allocation of an individual doctor’s
time to government spending on medical research.
What are the costs of subscribing to this assumption?
At the level of the individual practitioner, it means that
our actions and decisions are determined, consciously or
unconsciously, by the notion of monetary equivalence. Even
when we believe that we are practising in accordance with
our values, we often still remain constrained by a system that
requires us to justify the allocation of resources, including our
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
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.

What would happen if we stopped always calculating
what was cheaper or more efficient in an arena of such
complexity and uncertainty as medicine, and advocated
instead for a system that encouraged practitioners to place
attentiveness and person-centred care as the overarching
principle for everything that we do? Many clinicians around
the world are in effect already seeking to practise medicine
in this way. They do so by applying a range of different forms
of reflective practice including mindfulness or by belonging
to peer supervision groups. Some adhere to models such as
narrative medicine and relationship-based care. What an
understanding of the scarcity loop offers is an overarching
framework or a counterview, enabling us to consciously
position ourselves as carers rather than providers and to
see these choices as explicit acts of resistance in relation to
an assumption that otherwise holds us in its thrall.
A coherent counterview to the scarcity loop would
encourage doctors to suspend our anxiety about over-
running or expending too much emotional energy with
one patient and instead allow our common humanity to
come alongside others and forge a connection with them.
By doing so, we could experience more fully what they are
experiencing, develop a shared understanding, and allow
ourselves to think about the root causes of illness rather
than its surface presentations. Allowing an abundance of
attention would alleviate the patient’s feeling of being
deprived, together with our own sense as clinicians of
frustration and disconnect, with therapeutic effects for both
parties. By moving from hasty appointments to calmer
ones, from transactional to relational encounters, and from
transient patterns of medical work (like locum contracts)
to longitudinal commitments, we might actually save
everyone time—for example, by not ordering unnecessary
and sometimes harmful investigations and treatment
with consequent medicalisation and repeat attendances.
We would spend less of our clinical time deflecting the real
issues in favour of tangible, linear interventions, seeking
answers to the wrong questions. Is it possible that we might
actually make savings, despite this no longer being our first
priority? It might in fact be the assumption of scarcity itself
that is making us profligate.
At a political level, assumption of the scarcity loop
as Frank describes it is based on an almost universal
acceptance that there is no alternative to capitalism as a
way to organise society—an acceptance that Mark Fisher has
termed “capitalist realism”. In other words, as professionals
we are so enmeshed in the prevailing ideas about how to
approach health care that we are no longer able to evaluate
critically whether the values we espouse are in fact resulting
in a healthier population or a more anxious and unequal
one. Effectively, we take for granted an economic model
rooted in notions of consumerism and individualism.
In our current mindset, economics itself is regarded as a
science of scarcity, studying the relation between desired
www.thelancet.com Vol 394 July 13, 2019 113
Perspectives
ends and finite means that could be used for different
purposes. The implication of this model is that perfect health
might be achieved if there were available an endless resource
that allowed unlimited investigations, medications, surgery,
and other interventions. Hence, we are constantly pursuing
that unattainable end, without realising it. Not surprisingly,
patterns of consumption of health in high-income countries
also seem to mirror patterns of consumption of food,
land, and other resources, which are governed by the same
pervasive assumption. This is in direct contrast to other parts
of the world where true scarcity is endemic and people lack
even basic access to health care.
We believe that doctors should now be encouraged to
raise their level of thinking beyond the parameters set by the
scarcity loop in public health as well as individually. Rather
than simply complaining about its day-to-day manifes­
tations, from inflexible guidelines to escalating technology
and organisational imperatives, we need to recognise the
invisible power it has over us and over society as a whole—
and to name, discuss, and question it. As Alex Evans suggests
in his book The Myth Gap, perhaps we need to find better
governing myths as a society, ones that help us to “think
in terms of a larger us, a longer now”. To do this, health
professionals need to consider actively how the philosophy
underpinning the scarcity loop also determines social
inequalities in health, the disproportionate influence of the
pharmaceutical and other industries, including the fast food,
soft drinks, and alcohol industries, as well as wider political
issues such as the climate crisis and militarism. A common
theme among these is the notion that every resource
should be the subject of competition, and everyone should
constantly strive to obtain more for themselves. From
medical school onwards, we should therefore encourage
clinicians to evaluate health policy and guidelines critically
and examine the influences that shape them, as well as
their unintended consequences. Following Frank’s lead, we Further reading
should aim to develop clinicians who are able to question Evans A. The myth gap: what
happens when evidence and
the scarcity loop and escape from it, thereby allowing them arguments aren’t enough?
to actively think about how we look after one another and Eden Project Books. London:
care for society as a whole. We should support practitioners Transworld Publishers, 2017
who take account of the social and political contexts of their Fisher M. Capitalist realism.
is there no alternative? London:
patients’ conditions, act as advocates in helping people Zero Books, 2009
to overcome these, are engaged in communal activism, Frank A. From sick role to
and use their professional authority to undertake acts of practices of health and illness.
political courage. Medical practice should be defined not by Med Education 2013; 47: 18–25
the imagined material equivalence of all health care but by Goldacre B. Bad pharma:
how medicine is broken and
different kinds of currency such as kindness and connection. how we can fix it. London:
Fourth Estate, 2012
*Rupal Shah, John Launer Mullainathan S, Shafir E.
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:
Times Books, 2013
rupal.shah7@nhs.net
Wilkinson R. Unhealthy societies.
We are grateful to members of the Thinking Group whose discussion prompted this the afflictions of inequality.
essay, and to Professor Arthur Frank for sharing his ideas with us. London: Routledge, 1996