BMJ 2001;323 ( 27 October )

Editor's choice

Learning from failures

Just how difficult managing a chronic disease can be comes across in Colin Guthrie's opening letter (p 997): "Within a year almost half my personal workload became this health promoting clinical input. In the end almost all of these patients required a continuous personal input to maintain their weight loss, regular exercise, or healthy eating." So imagine how hard it is for patients.

And patients' concerns emerge as being complex in this issueour second theme issue on chronic diseases. It's a good theme for the BMJ since it unites doctors of all disciplines and has many facetspatient partnership, evidence based medicine, informatics, quality improvement, psychology, social policyeven philately (pp 966, 969).

So, although this issue includes studies showing that chronic disease management programmes can improve outcomesfor example, in coronary heart disease (p 957) and type 2 diabetes (p 970), there's also plenty about the failuresand probably more to learn from them. Howard Wolpert and Barbara Anderson observe that even patients who have received comprehensive education in diabetes and are skilled in self management have difficulty controlling their glucose levels (p 994). They argue that doctors' emphasis on discipline and tight control sends the implicit message that good control is synonymous with the patient having to give up flexibility and choice, so the doctor's well intentioned efforts end up having the opposite effectwhat psychologists call "miscarried helping." Instead clinicians must find out what patients' real goals are and help them to achieve those.

Chris Griffiths and colleagues examine why south Asians in east London have higher rates of admission for asthma than white patients. They found that south Asians had less confidence in self management, less confidence in their general practitioners, and less familiarity with the concept of preventive medication. Eric Cheng and colleagues found that among women with multiple sclerosis those who couldn't walk were much less likely to receive preventive health services than those who could (p 958). This might be because doctors think preventive screening isn't important for such women or simply because services aren't accessible to people who can't walk.

Doctors who are themselves patients often have valuable insights, and Kay McKall offers some in her personal view (p 1011). Having had depression herself, she knows what people with depression want"Feel free to ask us if we are suicidal . . . When you give us drugs tell us about common side effects . . . See us frequently at first . . . Just sustain us and give us a focus of hope until the drugs work."

Footnotes

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