BMJ 7094 31 May 1997 contents

BMJ No 7094 Volume 314 Saturday 31 May 1997

This Week in BMJ | Editor's Choice | Press releases

Editorials

1563 Stroke prevention in atrial fibrillation
Tim Lancaster, Jonathan Mant, Daniel E Singer

1564 Medical associations: guilds or leaders?
Donald M Berwick

1566 Should trusts be allowed to fail?
C Chantler, A Maynard

1567 British doctors are not disappearing
Peter Richards, Chris McManus, Isobel Allen

1568 Tackling deficient doctors
Gabriel Scally

News

1569 Tobacco industry memo leaked
Sexism rife in biomedical science
MRC to abolish project grants
Passive smoking linked to heart disease
AMA backs abortion bill
Ban on gifts for Romanian doctors
Traditional doctors in India defended
GMC issues guidance on circumcision
Authority stops funding homoeopathy
Labour moves to cut costs

Papers

1575 Population based study of prevalence of islet cell autoantibodies in monozygotic and dizygotic Danish twin pairs with insulin dependent diabetes mellitus
Jacob S Petersen, Kirsten O Kyvik, Polly J Bingley, Edwin A M Gale, Anders Green, Thomas Dyrberg, Henning Beck-Nielsen

1580 Doctors and patients don't agree: cross sectional study of patients' and doctors' perceptions and assessments of disability in multiple sclerosis
P M Rothwell, Z McDowell, C K Wong, P J Dorman

1584 Influence of cholesterol on survival after stroke: retrospective study
Alexander G Dyker, Christopher J Weir, Kennedy R Lees

1588 Review by a local medical research ethics committee of the conduct of approved research projects, by examination of patients' case notes, consent forms, and research records and by interview
Trevor Smith, Edward J H Moore, Hugh Tunstall-Pedoe

1591 Intentions of newly qualified doctors to practise in the United Kingdom
Trevor W Lambert, Michael J Goldacre, James Parkhouse

1592 Role of medical factors in 1000 fatal aviation accidents: case note study
S A Cullen, H C Drysdale, R W Mayes

1593 Drug points: Interaction of thyroxine sodium with antimalarial drugs
Y Munera, F C Hugues, C Le Jeunne, J F Pays

1593 Drug points: Acute renal failure due to rhabdomyolysis in presence of concurrent ciprofibrate and ibuprofen treatment
S Ramachandran, P D Giles

General practice

1594 Postal survey of patients' satisfaction with a general practice out of hours cooperative
Chris Salisbury

1598 Evaluation of a general practice out of hours cooperative: a questionnaire survey of general practitioners
Chris Salisbury

Information in practice

1600 Using the technology of the world wide web to manage clinical information
Hamish S F Fraser, Isaac S Kohane, William J Long

1604 Netlines
Mark Pallen

Clinical review

1605 Science, medicine, and the future: Substance use disorders
Marc A Schuckit

1609 ABC of mental health: Common mental health problems in primary care
T K J Craig, A P Boardman

Education and debate

1613 The performance of doctors. II: Maintaining good practice, protecting patients from poor performance
Donald Irvine

1616 Health in China: The healthcare market
Therese Hesketh, Wei Xing Zhu

Letters

1619 Asian doctors are still being discriminated against
A Esmail and S Everington

1619 What happens when the private sector plans hospital services for the NHS
J J Owens and C Aitken; M D Rees; P A West; R Pollock; M Rosen; A M Pollock and others

1621 Consensus statement on criteria for the persistent vegetative state is being developed
B Jennett and others

1622 The future of Britain's high security hospitals
R F Travers; B Caton

1622 Young people, alcohol, and designer drinks
P Catterson and others; A M MacKintosh and others

1623 Legal abortions save women's lives
W Savage and others

1623 Abortion must not be advocated as preventive solution to unwanted pregnancy
S Ross

1624 Neonatal risk factors for cerebral palsy in very preterm babies
E N Allred and others; D J Murphy

1624 United States has recommended screening for colon cancer
A H Chapman and A Blakeborough; M H Stolar

1625 Oropharyngeal blood blisters are known as angina bullosa haemorrhagica
J Gibson

1625 Vasospasm of the nipple was described in 1970
E Hey

Obituaries

1626 F G Bolton, H R Chapman, D B Evans, C H Neaves, R Platt, F C Poles, H Stott, M A E Symonds, E Walker, G S Wigley, H J O White

Medicopolitical digest

1628 Fall in GP trainees * GMC's advice on recording patients * Research assessment exercise

Views & reviews

Soundings

1629 Be yourself
Liam Farrell

Personal view

1629 And the band played on...
Andrew D Weeks

Medicine and the media

1630 Media focus on failures of screening programme
Jane Johnson

1631 Anatomy of a media backlash
Douglas Carnall

Medicine and books

1632 A Decent Proposal: Ethical Review of Clinical Research D Evans, M Evans
Susan Bewley

1632 Dying Well: A Holistic Guide for the Dying and Their Carers Richard Reoch
Elizabeth Murray

1633 Regulating Medical Work Judith Alsop, Linda Mulcahy
Marilynn M Rosenthal

Minerva

1634

S2 Career Focus Classified supplement

Bringing it back to blighty
Nicholas Banatvala and Annie Macklow-Smith

Editor's choice

Medicine's need for leadership

Thoughts of leadership are more likely to embarrass than inspire a doctor. Medicine seems to have problems with leadership, often appointing or electing compromise candidates to institutions that are designed to be hard to lead. Doctors' difficulties with leadership probably stem from them being trained to work as individuals and to value highly their independence and autonomy. They think about patients rather than systems - and for most of what they do that is right. But problems with leadership may account for why worldwide there is a sense that doctors have less and less control over their own destiny. Articles in this BMJ challenge doctors to take leadership more seriously.

Don Berwick argues that medical organisations have a great opportunity to lead (p 1564). "There is," he says, "a large gap between how health care could perform and how it does perform ... error rates are too high, waste is too pervasive, technically correct clinical services are too often withheld, and technically incorrect procedures are too often used." Medical organisations should not deny this but set about leading improvement. And to improve health care we require not better professions but better systems of work. Berwick suggests five steps that medical organisations can take in order to lead in improving health care. The first is to state clearly defined and measurable aims - like, for instance, reducing error rates that currently stand at something like seven for every 100 hospital admissions.

Britain's General Medical Council, which regulates doctors, is, says Gabriel Scally, accepting the challenge of leadership (p 1569). "Instead of merely wagging the finger and telling doctors what they should not do, the council has made a determined attempt to forge an explicit view of how doctors should practice to the highest standards." Scally's editorial accompanies the second of two articles by Donald Irvine, the president of the GMC, in which he describes the council's strategy for assuring the public that doctors "remain capable and safe throughout their practising lives (p 1613)."

New procedures for responding to doctors who perform poorly will be introduced in Britain in July, but the emphasis must be less on inspecting out the bad and more on developing systems for improving overall quality. As Berwick says, "Inspection alone cannot improve quality .... Unless it is linked to strategies for improvement it produces tremendous waste and timid aspirations."

Marilynn Rosenthal supports this thinking in her review of a new book, Regulating Medical Work (p 1633). "We need," she writes, "to scrutinise the organisation of medical work to see where and how it supports doctors and where it makes work harder for doctors." We need, in other words, leadership.