BMJ No 7113 Volume 315 Saturday 11 October 1997 This Week in BMJ | Editor's Choice | Press releases Editorials 893 The oesophageal Doppler monitor Tong Joo Gan, Joseph E Arrowsmith 894 Attention deficit hyperactivity disorder Florence Levy 895 France seeks to curb health costs by fining doctors Jennifer Dixon 896 An inspectorate for the health service? John Oldham 897 Every system is designed to get the results it gets Gerald T O'Connor News 899 Memory recovery techniques warned against BMA calls for changes to legal aid system US nurses paid at same rate as doctors London councils fail asylum seekers Neonatal screening test to be expanded Call for routine cystic fibrosis screening Paediatric guidelines for HIV treatment Radiotherapy reduces breast cancer mortality BMA examines options for funding the NHS Labour says NHS faces hard choices Nightclub discriminated against asthmatic Inquiry into lung transplant fiasco in Quebec Wages to double for Romanian doctors Statement: Three days needed to recover from head injuries Papers 905 New renal scarring in children who at age 3 and 4 years had had normal scans with dimercaptosuccinic acid: follow up study Sue J Vernon, Malcolm G Coulthard, Heather J Lambert, Michael J Keir, John N S Matthews 909 Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial Susan Sinclair, Sally James, Mervyn Singer 912 Effects of obesity and weight loss on left ventricular mass and relative wall thickness: survey and intervention study Kristjan Karason, Ingemar Wallentin, Bo Larsson, Lars Sjöström 917 Impact of medical school teaching on preregistration house officers' confidence in assessing and managing common psychological morbidity: three centre study Chris Williams, John Milton, Paul Strickland, Nick Ardagh-Walter, John Knapp, Simon Wilson, Peter Trigwell, Eleanor Feldman, A C P Sims 918 Occurrence of renal scars in children after their first referral for urinary tract infection Malcolm G Coulthard, Heather J Lambert, Michael J Keir 916 Correction: Bone density and risk of hip fracture in men and women: cross sectional analysis Chris E D H De Laet et al General practice 920 Can students learn clinical method in general practice? A randomised crossover trial based on objective structured clinical examinations Elizabeth Murray, Brian Jolly, Michael Modell Clinical review 924 Fortnightly review: Epilepsy in childhood B G R Neville 931 ABC of palliative care: Breathlessness, cough, and other respiratory problems Carol L Davis Education and debate 935 Why is Sweden rethinking its NHS style reforms? Margaret Whitehead, Rolf Å Gustafsson, Finn Diderichsen 939 Personal paper: Risk language and dialects Kenneth C Calman, Geoffrey H D Royston 943 An attempt to save money by using mandatory practice guidelines in France Isabelle Durand-Zaleski, Cyrille Colin, Claudine Blum-Boisgard 942 Correction: How to read a paper: Papers that report diagnostic or screening tests Trisha Greenhalgh Letters 947 Graded exercise in chronic fatigue syndrome C Shepherd and A Macintyre; A J Franklin; M Sadler; E M Goudsmit; P D White and K Y Fulcher 949 Chronic fatigue syndrome in children E G Dowsett and J Colby; G Jacobs; M Hume 949 Special hospitals J Kenney-Herbert and M Humphreys; A Bartlett 950 Summative assessment compounds workload for MRCGP examination T P Cunliffe 950 Inequality in funding for AIDS across England threatens regional services M A Bellis and others 951 New combined hepatitis A and B vaccine M Dedicoat and C J Ellis 951 Requesting necropsies T Davies; K Khunti; G Matfin and others 952 The future of healthcare systems P Bundred and I Buchan; J Shapiro; P Milner and others 953 Deaths from cervical cancer began falling before screening programmes were established A E Raffle 954 Doctors should beware of asking for too high a salary R Baker 954 BMJ apologises to cats everywhere A House and A House Obituaries 955 R M Hardisty, I A Harris, J Price, P R Wilson Medicopolitical digest 956 NHS crisis has started Casualty departments Junior doctors' leaders BMA's NHS strategy Views & reviews Soundings 957 Give a dog a bad name Liam Farrell Personal view 957 A year in management Richard Ayres It's the PITS - a worthwhile extra for doctors in training Una M MacFadyen, Annette Greenwood Medicine and multimedia 959 Current Techniques in Surgery. Open Repair of Inguinal Hernia (Adult) Ed Michael Edwards Laparoscopic Cholecystectomy. A Multi-media Step-by-step Approach to Surgical Procedures Ed Michael Edwards Gordon L Carlson, Sir Miles Irving The Cot Death Cover-Up? Jim Sprott Frederik A de Wolff Minerva 892 S2 Career Focus Classified supplement Are part time doctors better doctors? Helen Gibson Editor's choice Changing doctors' behaviour: fine them, or get them to improve their processes? This week's BMJ describes two unusual experiments and contains a strong message about improving health services that emerges from three separate editorials on totally different subjects. We are particularly pleased to publish the randomised trial by Elizabeth Murray and others showing that medical students can learn their clinical skills just as well in the community as in hospital (p 920). Educationalists worry that medical education is not taken seriously enough by doctors, and we would like to publish more research on educational initiatives. The problem we face is that too many papers describing new initiatives have inadequate evaluation - often nothing more than whether the students liked the course. A randomised controlled trial of an educational initiative is thus an exciting event. We are hoping to publish guidelines on evaluating educational initiatives and would like to hear from anybody interested in such a project. The second experiment is a policy initiative in France to contain costs by making clinical guidelines compulsory. On p 943 Isabelle Durand-Zaleski and others describe how 75 doctors have so far been fined for failing to comply. The rate of increase in spending on the areas covered by the guidelines has fallen, but enforcement is costly, and there has been no assessment of outcomes. As Jennifer Dixon points out in her accompanying editorial (p 895), targeting doctors' behaviour is just one way of containing costs; others include constraints at the system level, such as capping overall budgets, and measures aimed at reducing patient demand, such as user charges. User charges, she argues, are unfair on patients until steps have been taken to tackle the health system and doctors' behaviour. A heavy cost in healthcare systems, argues John Oldham in his editorial (p 896), is that of poor quality: "a haemorrhage of scarce resources." In discussing a possible inspection and standards body for the NHS, Oldham warns that although inspectorial systems can generate fear and distort behaviour, the move to set up an Ofsthealth reflects legitimate public and political pressure for better quality care. Doctors may well need it as a catalyst to encourage them to stop viewing their activities in isolation and to look at whole processes of care. Taking a systems view is also Gerald O'Connor's theme (p 897). He describes the way cardiac surgeons in New England improve their practice, pointing out that individual surgeons work within a complex system and just removing one with outlying results will have only a tiny effect on outcomes. Essential to this improvement activity is an atmosphere of trust. "No one must get punished as a result of seeking to improve." Home | Current contents | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline