Embracing change

doi:10.1136/bmjusa.01070001

BMJ 2003;327:E47 (4 October), doi:10.1136/bmjusa.01070001 (published 5 September 2002)

BMJ USA: Editor's choice

Embracing change

This article originally appeared in BMJ USA

In Roughing It (1872), Mark Twain wrote that "Change is thehandmaiden Nature requires to do her miracles with." There'sa lot about change in this issue of BMJ USA.

Once upon a time, physicians made house calls and treated mostpatients in their homes. Gradually, much of health care movedinto hospitals. Now, with the high cost of hospital care, weare moving treatment from hospitals to outpatient venues andback into the home. In a study of 117 consecutive patientsdiagnosed with deep vein thrombosis at a hospital in Germany,Schwarz et al were able to provide home treatment to 80% (BMJUSA p 375). In an editorial, Eikelboom and Baker note thathome treatment of DVT simplifies the initial management of the condition (because low-molecular-weight heparin can be given subcutaneously without laboratory monitoring), increases theefficiency of health care, and improves the quality of lifefor patients (BMJ USA p 364).

Systems of care need to be changed if we are to improve qualityand access. Jane Smith reviews the teachings of the Boston-basedInstitute for Health Improvement, which recommends a radicalredesign of health care (BMJ USA p 369). The old rule of appointmentslots filled weeks ahead, for example, is replaced by the newrule that most slots are open at the start of each day.

We must change the culture of medicine to ensure safety in healthcare. In its report To Err Is Human (2000), the Institute of Medicine recommended that health care organizations adopt aculture of safety instead of a culture of blame. In this issueof BMJ USA, we publish an anonymous account of a serious medical error—and its cover-up—along with three commentaries(BMJ USA p 403). Singer writes that "we should learn to lovemistakes because they carry in them the kernel of their ownelimination" (BMJ USA p 404).

This issue features a debate about change in language. In aneditorial, Barry Pless and I announce a new BMJ policy banning inappropriate use of the word "accident" in the journal (BMJUSA p 370). Safety officials and public health authoritiesabandoned the "A" word many years ago because an accident isoften understood to be unpredictable, and thus unavoidable.A spirited debate about the new policy, from bmj.com, appearson BMJ USA pp 372-374.

As a more mundane example of change, I just replaced my car'slicense plate for the first time in 10 years. BMJ USA is onthe move!