Editor's choice

Who's in control?

This article originally appeared in BMJ USA

Deciding who should be in control is a delicate matter in politics, business, and other walks of life. An infamous assertion of control occurred in the moments after President Ronald Reagan was shot by John Hinckley in 1981. Secretary of State (and retired general) Alexander Haig appeared before a platoon of reporters and television cameras and announced, "I am in control here," overlooking the constitutional chain of command that had put the Speaker of the House next in line to assume power, since the Vice President was out of town. Haig was later fired by Reagan after only 18 months on the job.

Control in medicine and public health is no less contentious. Perusing back issues of BMJ, one finds many articles about control. A British court removes a mother's right to control the treatment of her handicapped son (1999;319:278). Romanian general practitioners (GPs) want to take control of their practices (1999;319:594). A Dutch study finds that people of lower socioeconomic status perceive that they have little control over their lives, which may, in part, explain why they have higher mortality rates (1999;319:1469-1470).

Control is a theme that runs through many items in this inaugural issue of BMJ USA. Alan Jones and colleagues explored the views of GPs, nurses, and patients about the role of self-management plans in asthma care (BMJ USA p 18). Their study, and the views expressed in the accompanying editorial (BMJ USA p 12) and "rapid responses" (BMJ USA p 22), address the balance between patients' control over the treatment of their disease and the clinicians' interest in assuring compliance with recommended therapy.

Anne-Mei The and others studied the factors that result in "false optimism about recovery" among patients with small cell lung cancer (BMJ USA p 42). They found that doctors contribute to that false optimismfor example, by occupying patients with all kinds of treatment activities (eg, chemotherapy) and planning (eg, arrangement of tests and check-ups). This "medical activism," argue the authors, "might be related to a strong need for control in the Western world."

Susan Bewley describes a lesson she learned during her training in obstetrics and gynecologygive the speculum to patients and ask them to "put that inside, please" (BMJ USA p 31). As her instructor explained, "women know best where their vaginas arethey put tampons, fingers, and penises in." When Bewley asked why she had never heard or read about self-insertion before, she was told that "male gynecologists find it very hard to give up control."

Finally, Ian Morrison and Richard Smith, in their editorial on "hamster health care," write about how doctors are ceding control over patient care to government, insurers, and managed care organizations (BMJ USA p 14). Running faster and faster on the treadmill will not help doctors regain control, they maintain. Instead, "the answer must be to redesign health care."

Self management plans for asthma:

Paper (BMJ USA p 18) http://bmj.com/cgi/content/full/321/7275/1507

Editorial (BMJ USA p 12) http://bmj.com/cgi/content/full/321/7275/1482

Rapid responses to paper (Jones et al) (BMJ USA p 22) http://bmj.com/cgi/doi/10.1136/bmjusa.01020003

False optimism and lung cancer (BMJ USA p 42) http://bmj.com/cgi/content/full/321/7273/1376

Giving up control to women (BMJ USA p 31) http://bmj.com/cgi/content/full/321/7274/1454/c

Hamster health care (BMJ USA p 14) http://bmj.com/cgi/content/full/321/7276/1541