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The illusion of patient choice


“Pick a card…any card”, as the saying goes.

I remember being the recipient of this common trick when I was a medical student at a friend’s for dinner, where a magician was a fellow guest. The scientist in me wanted to know how it was done, so I prepared to follow my card studiously. I chose carefully and deliberately, feinting to pick one card from the fan offered to me before choosing – in my eyes – a less obvious card. However, after returning the card to the deck, the magician threw his arms up with a flourish, the pack hitting the ceiling with a thud, causing cards to scatter across the room. Amazingly, my chosen card was stuck to the ceiling, fixed in place by a drawing pin.

I made peace with the fact that I would always choose that card and applauded in awe.

The magician’s choice

A few years ago, during a lecture, I was introduced to the concept of the ’ magician’s choice’ by Daniel Sokol (a medical ethicist and magician). He used it as an innovative analogy to illustrate how, in obtaining consent, the presentation of the different options is nothing like the free choice it is intended to be. Rather, the possibilities are presented, much like a deck of cards, only this time the ‘trick’ is that the clinician– whether consciously or not – weights information, making a certain choice more likely.

I was reminded of this concept recently after reading about a new app due to be rolled out in the English National Health System. This new platform, it is claimed, will enable patients to see waiting times at different emergency departments, the implication being that they will choose to go to the one with the shortest wait. Unsurprisingly, this sparked a Twitter debate about whether or not this actually was a useful tool to help patient flow, with strong opinions on either side.

To my surprise, however, everyone seemed to assume that this app would offer choice. My first thought was, ‘ Choice, what choice?’

Patient choice?

For many years, the NHS has offered explicit patient choice for specialist outpatient care, offering a range of different hospitals at the point of referral. In recent years, the system has evolved to display waiting times. Sounds good so far? To an extent, I agree. A transparent system that allows patients, in conjunction with their GP, to book in to an appointment – even obtaining a date and time – is a pretty simple but effective use of technology. My objection is that the offered choice is nothing but an illusion.

The patient is given little idea of the constraints through which their choice is made. For example, many of the children I see have a long-term condition (epilepsy). Effective, joined-up care is much more than a quick hospital consultation, achieved through a combination of having a point of contact via their specialist nurse, close liaison with school, tracking of development progress, and surveillance of mental health and well-being. This is best achieved through local, networked care, a system which has been carefully developed over many years.

When I see a patient outside this framework, the care is not just difficult to deliver – in what is far from a delicious irony, it actually gets delayed. When I have to inform families that ‘I can’t access that information’, ‘they won’t accept that referral from me’, or ‘our nurse doesn’t cover that area’ (all recurring themes from my practice over the last year), I empathise with the fact that they took a decision that they thought would get quicker access to care for their child, only to discover now that delay was just shifted further down the road.

There are ways around this – not least patient record systems that speak to each other. Yet that sort of change doesn’t happen overnight, so until it does, surely patients deserve better? Until then, this resembles the ‘three cup and ball’ trick. The patient believes they have options when the system is too constrained to offer the truly free choice advertised. No matter how much you try to pick the cup with the ball under it, the pieces move, and the magician ensures you never can.


  • Amit Bali is a Consultant Paediatrician with an expertise in epilepsy, working in London, where his work around holistic epilepsy care the development of the Healthy London Partnership Paediatric Epilepsy Care Standards. Under the guise of a Clinical Leadership interest, he likes thinking about what makes people tick. He is definitely not a magician.


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