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Preparing for partnership, based on moral and ethical bases.
- Sergio Stagnaro (13 June 2003)
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A PICTURE TELLS A THOUSAND WORDS - IRONICALLY!
- Rosetta Manaszewicz (13 June 2003)
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Required reading
- William A Parsonage (13 June 2003)
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Working not just with patients, but also with patient groups
- Gray Southon (13 June 2003)
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we all need each other
- susanne stevens, n/a (13 June 2003)
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Failing to adopt a patient centred approach: A multi-professional problem.
- Paul R. Elliott. (14 June 2003)
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Regrettable waste of paper
- Michael L Jenkinson (14 June 2003)
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World Medicine is Back!
- Bill Tucker (14 June 2003)
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Gone soft
- Paul A Duff (14 June 2003)
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Target audience of the BMJ
- Jay LT Ritzema (15 June 2003)
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Failure to serve the market
- Andrew D. Beggs (15 June 2003)
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A common misconception
- Jane Smith (15 June 2003)
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A degraded journal, a tabloid
- JK Anand (15 June 2003)
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On P.I.G.s and Patients
- David Elpern, Ben Barankin: benbarankin@yahoo.com (15 June 2003)
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new look
- lynsey corless (16 June 2003)
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Does the Editor have his own parking spot?
- Robert J Grimshaw (16 June 2003)
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Why does the media want to lead doctors?
- David A de Berker, Bristol BS2 8HW (16 June 2003)
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Where are you going?
- Roger A Johnson (16 June 2003)
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spread the word to widen the debate
- susanne stevens, n/a (16 June 2003)
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A breath of fresh air
- Frank O Wells (16 June 2003)
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The Big Issue
- John Hopkins (17 June 2003)
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Re: Failure to serve the market
- Carol A Teasdale (17 June 2003)
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Partnership in medicine is 2500 years old
- THHG KOH (17 June 2003)
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Patients should publish their experience
- David O Gebhardt (17 June 2003)
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What do you mean by "patient"
- Yoav Tzabar (17 June 2003)
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A little self-critique never did harm
- Patricia M. Wilson (17 June 2003)
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Supermarket car park
- Harold A. Weizel (17 June 2003)
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Doctors are not patient centered--- is that the problem??
- Syed Viqar Ahmed (18 June 2003)
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journals today, textbooks tomorrow?
- mahalakshmi gopalkrishnamoorthy (18 June 2003)
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Disappointment
- Remy McConvey (19 June 2003)
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More thoughts on car parks
- Adam Jacobs (19 June 2003)
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Arrogance of doctors
- Andrew D Beggs (19 June 2003)
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They just don't get it.........
- Declan P Fox (20 June 2003)
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Sunburn and art
- Jonathan C Bowling (20 June 2003)
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Copies of the patients' issue distributed to patients did not contain drug advertisements
- Richard Smith (21 June 2003)
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Re: Copies of the patients' issue distributed to patients did not contain drug advertisements
- Sheena Meredith (22 June 2003)
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Murder of the BMJ
- Stephen Due (24 June 2003)
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RELATIONSHIPS ARE KEY
- Chris Dabbs (29 June 2003)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy.
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Sir, As an old doctor with 46 years of clinical experience, I am “patient centred”, in the sense that I put patients first, according to Richard Smith (1), who rightly states “that being patient centred involves much more than being dedicated and caring”. Accordingly, it's a different way of thinking and behaving, where doctors and patients work together as true partners. However, in my opinion, illustrated in the HONCode site N° 233736, http://digilander.libero.it/semeioticabiofisica, a “real”, useful, and efficacious patient-doctor partnership includes more than avoiding hospital car park problems as well as A writing a letter to B, supposedly on patient’s behalf, that the patient can’t understand. In a true partnership, the doctor must obviously explain in a proper way to his or her patient the letter content and a lot of other things, of course. In a few words, exclusively if both doctor and patient, cease to consider each other as YOU, becoming WE, it is possible to reach the much desired partnerhip, based – so I think – on moral and ethical bases. Under this condition, even most medical journals can publish any material whatsoever from patients. Certainly, as always, changing is possible and desirable, but it's not easy under particular situations, like the present one, where, for a large number of reasons, primarily financial in origin, the stethoscope has been replaced by the phone and Personal Computer. 1) Smith R. Preparing for partnership BMJ 2003;326 (14 June). Competing interests: None declared |
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Rosetta Manaszewicz, Steering Committee Member, Breast Cancer Action Group (Vic.) PO.BOX 381 Fairfield, Vic. Australia
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Dear Editor, It’s become a ritual. First thing every Friday morning I log onto the BMJ – anticipating some interesting feature, latest research news, and generally to keep myself informed. This morning however was a disaster! Richard Smith talks of ‘patient partnership’ – but what I saw smacks of paternalism and/or tokenism. I am not necessarily refering to the content. The layout, design, visuals are enough to confirm my point. Why oh why does a ‘patients’ issue’ have to be adorned with huge headers, glossy pics, and a delicate swirl of colour here and there? Is the assumption that patients’ attention span is possibly less than that of a health professional, or that their eyesight is generally poorer, or that their intellectual interest will only be attracted via the visual? It is ironic that an issue claiming to spur on this collaborative and/or 'equal' relationship between doctor and patient should so blatantly reinforce the stereotypical and assumed ‘differences’. Competing interests: None declared |
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William A Parsonage, Cardiologist Brisbane, Australia
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Excellent issue. Should be required reading for all. One thing intrigues me though. Why no obituaries in this issue? Competing interests: None declared |
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Gray Southon, Retired 56 Robins Rd., Tauranga NZ
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I suggest that a much more relevant way to work with patients is to work with the groups that represent patients, mostly in the many condition specific groups (e.g. mental health, altzheimers, diabetes etc etc). Relevant groups could to be consulted to comment on particular articles. This, I suggest, would provide a much more substantive input than just individual patients. It is analogous to consulting unions about workers interests, or the BMA about doctors interests. Yours Gray Southon Competing interests: None declared |
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susanne stevens, retired cardiff cf24 3pf, n/a
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For the first time in medical history the BMJ has opened up a meaningful way of having a dialogue with those who consult doctors. More people, but not enough of those who have been most exploited and silenced in the past, have access to the net in order to share their experience so that their authentic voice can be heard. For a long time the existence of specialist journals and newsletters, produced by both practitioners and activist/support groups,meant that specialist groups talked mainly to themselves and about 'them',the practitioners or the 'those' who consult 'them.' It has led to poor relationships and skewed research impacting on poor treatments. At times the partnership approach will have it's difficulties but with goodwill on all sides it must inevitably lead to better quality services and increased respect all round. One argument which does surface with regard to who represents different groups is that the 'expert patient' as well as the 'expert practitioner' becomes unrepresentative. Perhaps all members of an editorial board should rotate in order to specifically undermine the development of cliques in positions of power. There are after all often rewards which go with membership of these committees be it financial, increased status, opportunities to influence other projects and so on. It is more than time a true partnership existed in the NHS which is oowned by us all and is a hugely symbolic representation of our culture. Competing interests: None declared |
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Paul R. Elliott., Senior Lecturer in Nursing. Canterbury Christ Church University College, Canterbury, Kent, CT1 1QU.
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When lecturing I regularly hear cries of, its the Doctors, from a range of practitioners regarding such issues as patient centred approaches to care and caring. However, I do not believe it is just Doctors who may or may not be patient centered in their practice. In my experience, many of those involved in the provision of health care fail to adopt a patient centered approach whilst vigerously asserting they do. It would seem to me that the concept of being patient centered needs to be viewed in a wider context on a multi-professional basis. In addition, following identification that many of those involved in the provision of health care (both clinical and non-clinical) are not patient centered in either their attitudes or behaviour the next step must be to reflect upon reasons why this is the case. In undertaking to do this it can be argued that the problem may be psychosocial in nature. For example: 1. The simple use of the term patient can be argued to create a cognitively economic (Roth et al 1992) way of thinking on the part of the practitioner. As Neuberger et al (1999) identifies, the use of such a stereotype presents a vision of suffering, unquestioning compliance and passivity. A patient centered approach is unlikely to be facilitated by such stereotypical labelling. To do so is both dehumanising and detracts from a persons individuality. 2. Although not all, many of those involved in the provision of health care continue to adopt a paternalistic (Charles et al 2000) or biomedical (Ogden 2000) approach to their practice. Such an approach advocates that recipients of health care should be excluded from the decision making process regarding their health and well being. Yet, who's mind and body are we dealing with ! To exclude the individual from involvement in their health care is unethical, unprofessional and not in keeping with the philosopies of a patient centered approach. If patient centered care is to be facilitated practitioners must adopt a biopsychosocial (Engle 1980, Ogden 2000) approach to their practice. This approach advocates that recipients of health care should be actively involved in the caring process and its outcome, should be encouraged to accept a degree of responsibility for their health/future well being and the individual/their relatives should be consulted on a regular basis. For example, individuals should have access to what we write about them and such writings should be undertaken as a partnership. From my own professional perspective Nurse's regularly make sweeping statements about their patients. For example, "had a good day". When challenged on this they openly acknowledge that the patient had no involvement in the drawing of such an inference and are quite happy to rationalise (Festinger 1962)the correctness of their perception. Such thinking and behaviour is most certainly not consistent with a patient centred approach. 3. An adaptation of the theory of health locus of control (Wallston et al 1982, McCormack-Brown 1999) may also provide an indication as to why the care many practitioners provide is not patient centered. The theory has two dimensions, Internal and External. Within the context of this discussion the establishment of an Internal Locus of Control could be the facilitation by practitioners of a true partnership where individuals participate in the promotion of their own health and well being. However, an External Locus of Control would be where no such partnership exists and the individual has their identity degraded for the convenience of meeting the practitioners needs. Certainly, during my 32 years as a Nurse I have, sadly, but all too often heard those involved in the provision of health care refer to individuals by their condition or health problem. For example, the neck of femur in bed 4 or the leg ulcer at number 79. The adoption of such an attitude is not consistent with a patient centred approach and is unethical. In contrast the facilitation of an Internal Locus of Control is both patient centred and ethical. Finally, in failing to adopt a patient centred approach are we placing ourselves in contravention of the Human Rights Act under Article 10, Freedom of Expression ? Are we restricting an individuals freedom of expression as a result of our care not being patient centred: "Everyone has the right to freedom of expression. This right shall include freedom to hold opinions and to receive and impart information and ideas" (Wilkinson et al 2001). In conclusion, irrespective of what we do, or do not do, as practitioners it must always be remembered that individuals who place their health and well being in our hands have the absolute right to make a choice, to know or not to know and to be involved or not to be involved which in itself would seem to be consistent with a patient centred approach. References: * Charles, C., Gafni, A. and Whelan, T. (2000), How to improve communication between doctors and patients, British Medical Journal, 320, 1220 - 1221. * Engel, G. (1980), The clinical application of the biopsychosocial model, American Journal of Psychiatry, 137, 535 - 544. * Festinger, L. (1962), Cognitive Dissonance, Scientific American, 207, 93 - 102. * McCormack, K. (1999), Health Locus of Control Available Online At: http://www.med.usf.edu/~kmbrown/Locus_of_Control _Overview.htm Accessed: June 2003. * Neuberger, J. and Tallis, R. (1999), Do we need a new word for patients ?, British Medical Journal, 318, 1756 - 1758. * Ogden, J. (2000), Health Psychology: A Textbook, Buckingham, Open University Press. * Roth, I. and Frisby, J. (1992), Perception and Representation: A Cognitive Approach, Milton Keynes, Open University Press. * Wallston, K. and Wallston, B. (1982), Who is responsible for your health ? The construct of health locus of control, in Sanders, G. and Suls, J. (eds), Social Psychology of Health and Illness, Hillsdale NJ, Erlbaum, PP: 65 - 95. * Wilkinson, R. and Caulfield, H. (2001), The Human Rights Act: A Practical Guide For Nurses, London, Whurr. Competing interests: None declared |
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Michael L Jenkinson, Consultant Physician QEQM Hospital, Margate CT9 4AN
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What a waste of paper and editorial time. One week a fairly useful look at the relationship between doctors and the pharmaceutical industry, this week the April fools joke that looked like and had content that seemed similar to a pharmaceutical sponsored glossy. Competing interests: Chair Drugs & Therapeutics Committee |
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Bill Tucker, Consultant Dermatologist Alexandra Hospital, Redditch . B98 7UB
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Dear Dr. Smith, when I pealed the wrapper off my BMJ last night, and flicked though it, a sense of deja vu overcame me; it took 'till this morning for my aged brain cells to realise that you have recreated the much loved format of World Medicine. Excellent, with yourself in the Mr.Hyde role. Patients used to love it, and I'm sure will like this issue. BUT, it isn't the BMJ as we've come to know and love it, faults, formality and all. PLEASE don't go to this format for the real thing! Competing interests: None declared |
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Paul A Duff, Principal Bright, Victoria, Australia 3741
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What a load of bollocks, Richard, with all these supermarket/carpark allegories! The BMJ is going/has gone "touchy-feely" soft!
I can't remember the last time the local supermarket invited me in to discuss their reasons for putting chocolate biscuits at the end of aisles or the milk way down the back so I have to walk through the whole damn shop, just to get a pinta!
Oh, and I don't remember taking half an hour to discuss the relative merits of a partnership approach to care the last time I administered thrombolysis at 3am, after getting to the local cottage hospital within 5 minutes of being phoned.
Competing interests: None declared |
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Jay LT Ritzema, SpR cardiology Portsmouth PO6 3LY
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Is the BMJ going to go on sale on newspaper stands and if so will my BMA subscription rates fall accordingly? Competing interests: None declared |
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Andrew D. Beggs, Final Year Medical Student Guys, Kings & St. Thomas' School of Medicine, London, UK.
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Sir, I opened my copy of the BMJ in eager anticipation this week after the excellent issue last week on the Pharmaceutical Industry. However I was confronted, rather disappointingly, with a journal more akin to Nursing Times than the BMJ. The British Medical Journal is paid in the majority for by the subscriptions of the members of the British Medical Association. It is the journal of the British Medical Association. It is not a forum for patient debate. There are many other sources that patients can express their views. It is all very well giving the patients view, and it is always important to make your care patient centered. However, to use an analogy, how many lay people do you find expressing themselves in Physics journals? I do not believe that it is appropriate to produce an issue such as this, as it does not serve the interests of the people who it is meant to be for. I want a journal that presents the latest medical information and papers in an unbiased format. This is what the BMJ was good at. It should keep to this format. I for one am not prepared to subsidise a journal with my BMA membership that continues in this format. Competing interests: I was Assistant Editor of the Guys, Kings & St. Thomas' Hospital Gazette (the oldest Hospital Gazette in the world) for 3 years. I retired from it recently. |
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Jane Smith, Deputy editor BMJ WC1H 9JR
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Thanks for the feedback, but it might be worth correcting a common misconception: in fact, members' subscriptions don't fund the BMJ. The journal is funded by advertising and non-member subscriptions. Jane Smith Deputy editor, BMJ Competing interests: I am employed by the BMJ Publishing Group |
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JK Anand, retired not applicable
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Bring back the BMJ of the pre-Richard Smith era. It was worth reading then. The present-day BMJ is almost useless. Like to carry out a poll of the paid-up members of the BMA? Surely their views should count? JK ANAND (retired doctor) Competing interests: None declared |
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David Elpern, Solo Practitioner Williamstown, MA 01267, USA, Ben Barankin: benbarankin@yahoo.com
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Congratulations BMJ! Following your P.I.G. (pharmaceutical industry giant)issue with a themed issue on patient-centered medicine is brilliant. Big Pharma would like to tell us what to treat and how to do it (for wealthy and insured patients); but a dialogue with patients will tell us what their concerns are. I doubt that this is a new concept; but it is new to medicine and new to medical journals. A few months back, a colleague (BB) and I, launched a journal that attempts to do this, too. When RS wrote: "There are doctors who work in a true partnership with patients, but there are no journals that do. Most have never even thought about it" he could not have known about our fledgling journal Dermanities (www.dermanities.com). From the outset, we had a number of patients on the editorial board and our goal was to create a journal that was a place where patients, their families and care givers (physicians, trainees and others)could gather for discussion of topics of mutual interest. We do not accept any advertising. Yeah, this probably dooms us to failure. Some of your readers are threatened by the approach you are advocating. They are smart people and eloquent. They can put you down with biting humor and irony. But, I believe that you will prevail. Some of our patients are looking for partnership. Once they recognize that we have abandoned strict paternalism, they will come to us for our expert knowledge when it is appropriate. Robertson Davies has a wonderful quote in his final novel - "The Cunning Man." "More humanism and less science, that's what medicine needs. But humanism is hard work, and so much of science is just Tinkertoy." The same goes for medical journals. So many articles about science are just Tinkertoy. But plenty of them are submitted and it is easy to put them together for an issue. Leavening the science with humanism is more difficult and few if any succeed. The BMJ as been at the vanguard in this respect. I suspect that this is because you are less dependent on Big Pharma than the major journals in the U.S. Our journals have 4-5 times the number of ads and this significantly impacts on content. Congratulations!! Competing interests: I am an editor of a journal that attempts to serve patients and doctors - www.dermanities.com |
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lynsey corless, sho aberdeen royal infirmary
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I await this Friday with baited breath to see if this weeks issue was just a disturbing dream. The bmj is a professional journal intended to inform and entertain health professionals. This week I thought I was reading the Guardians health supplement. This kind of journalism is available in hundreds of places already. I rely on the bmj for part of my continuing education. Bring back the old bmj before I cancel my subscription and get the lancet instead. Competing interests: None declared |
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Robert J Grimshaw, freelance GP Barmouth LL42 1PL
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Richard Smith may have been too long away from the coalface to remember the solace of eating away from the patients and their relatives – even parking away from them is appropriate. Because hospitals and doctors’ surgeries are not supermarkets. Mrs Thatcher tried to make out they were and has been proved wrong. We’re not selling milk and veg – the relationship is much more complex as he knows. He has written very laudably about how the doctor patient ‘compact’ has changed over the years. In times gone by we worked to the best of our ability to serve our population, earned a fair amount, accepted the status it gave us. Now we have to accept public scrutiny, the brickbats of the press, accountability, less status and money. If you’re going to write an editorial though you mustn’t fill it with muddle-headed ideas – you’d better commission someone to write it for you if you need authoritative patient advice. We don’t however need to involve every patient in every decision we make. Solicitors write to each other in vocabulary we don’t understand and we don’t need to know all the details. When you leave your car to be serviced you don’t need to know everything that happened either. I agree that involving the patient is important as far as it goes. But some patients want to know and some don’t. I’ve trained GPs and medical students for 10 years and I feel that the question ‘What did you think was going on?’ at the beginning of the consultation is a great and useful addition. (Always include it in your videos!) As is terminating the consultation with ‘Is there anything you want to ask me?’ But I’ve also seen young doctors fail the MRCGP for being ‘not patient centred enough.’ The issue was only a modest success – I couldn’t read get past halfway in most articles and I’m with my colleagues who say ‘stick to what you do well!’ Competing interests: None declared |
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David A de Berker, Consultant Dermatologist Bristol Royal Infirmary, Bristol BS2 8HW
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The editorial comment by Richard Smith is characteristic of the worst kind of wrong thinking - in that it is only half wrong and so escapes comment on the basis of the part that is half right. He is right that we all consider patient interests of the greatest importance and acknowldege the need to represent their views in clinical issues. He is right that the interests of individual patients have sometimes been placed second to the educational value of presenting them. And the recent departures with evolving case histories was interesting, including the patient's contribution. However, he is wrong on all the rest. He is wrong to scorn the NHS on the basis that it does not share the prorities and infrastructure of a commercial supermarket. He is wrong to consider it offensive to patients that doctors write professional letters to each other that contain information that is more complex and less accessible than a patient information leaflet. In fact it is offensive to doctors to read his proclamation of his mission to lead us into his perceived territory of our politically directed destiny. The general media is already full of poorly expressed and unrepresentative material that has more to do with the egos of journalists than the subject matter. The BMA has recently shown how unhitched it has become from mainstream doctors by the attempt to thrust politically engineered contracts down our throats. Perhaps Richard Smith's Comment is a warning of the same disease affecting the priorities in the editorial office of the BMJ. There may be a vacuum of effective medical leadership, but that is not an invitation to medical editors to step into the breach. Competing interests: None declared |
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Roger A Johnson, GP & Medical Manager, retired Abbotsford, Green Lane, Hyde, Cheshire SK14 3BD
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Working through 'The Patient Issue' was not easy. The layout is tabloid and distracting. I was powerfully reminded of 'World Medicine' when edited by Michael O'Donnell 20 years ago. And so to the heart of my concerns, that you would never have published many of these articles had they been from academic stables, without referenced facts and statements. There are pages of eclectic opinion, which is, of course, the problem when patient involvement is attempted in the NHS planning and protocol process. The BMJ is the most important medical journal in the English speaking world and the relationship between the patient and the doctor perhaps the most important topic to focus an issue on. Where was the serious debate about how to engage the parties, the extensive literature, the rationing debate? I saw the discussion around your editorial table six months ago; The sales representative demanding a sexy headline piece, ideas flowing, who is a world figure we could use to pull the punters in? The Pope with his Parkinsons, Ronnie Reagan with Alzheimers? No, both miss the younger market, what about 'Superman' Christopher Reeve?, excellent! Of course, this issue is a one-off, next weeks will be reassuringly normal. Sorry, marks are 2/10! Competing interests: None declared |
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susanne stevens, retired cardiff cf24 3pf, n/a
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One way of helping the BMJ with it's mission would be for all of us who agree with the aims expressed so admirably in this issue - or even those who don't - to take advantage of the 'Mail a Friend' facility. Also leave old copies as well as this one, in the waiting room with an invitation to respond. Competing interests: None declared |
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Frank O Wells, Semi retired Ipswich, IP9 2JJ
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Dear Editor After the bitter unbalanced edition devoted to relations with the pharmaceutical industry comes this enlightened, attractive and enjoyable edition devoted to The Patient. The whole edition is light years away from its immediate predecessor and is a joy to read. Keep up this adventure into modern journalism - i.e. making the BMJ a truly modern journal. Science does not need to be stuffy and good science will be more frequently read and retained if it is presented like this. Congratulations! Yours etc Competing interests: None declared |
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John Hopkins, GP Stockton TS17 6EY
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Dear Dr Smith, The central conceit of this edition of the BMJ is that its contributors have had no voice. In fact, the newsstands of Europe and North America are awash with articles about health and the Internet, empowerment and all the other preoccupations of the metropolitan middle classes. It's also easy to find good information in the general press about managing headlice or getting the best from your doctor. If the BMJ wants to shift the world a degree or two on its axis it might be better employed building on its role as a journal of public health or seeking to genuinely represent the dispossessed. You have already published themed issues on AIDS and plan to do one on the developing world. But, in truth, you have barely scratched the surface of human suffering from disease and war and famine. Closer to home you might consider giving editorial control to the Big Issue so they can explain what life is like for the down and out who have Third World health problems like TB and malnutrition. The articles wouldn’t be as sexy but it would probably be a better use of paper. Yours sincerely, John Hopkins Competing interests: None declared |
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Carol A Teasdale, N/A A chair at a computer
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Dear 'almost' Dr Beggs, It is through patient suffering that you are privileged to learn and do what you do, but it is through communication you will become a true healer of people. You cannot practice your craft without subjects to practice on, and you will not always be fortunate enough to have them unconscious or half-witted. I can only assume that you have a touch of final year arrogance, which will soon fade. I feel that it would serve you well to read a few of those Nursing Times magazines which you hold in such contempt, they are simply another learning tool. As a 'patient I will continue to read and make comment when I feel it is appropriate, as I often do in a diverse range of publications. As an intelligent human being I feel insulted that medical schools are still choosing people, who after years of training, haven't grasped the benefits of patient insight. This is not your failing though, but that of your teachers and school. In all walks of life the roads people travel on do not narrow. So if you want to grow in what you do you should not become narrow minded. Gaining your learning from one source will not make you a wise doctor, and without wisdom you will be lacking in decision. The greatest lesson you have yet to absorb, is how little you actually know and how much you have yet to learn. Don't be frightened of hearing a patient's perspective, voice, anger or opinion in what you read. It is simply another learning tool which will aid you with the most complex area of your work. Every ounce of respect a patient gives you has been earned by those doctors who have come before you. Unlike you, they were fortunate to be doctoring the uneducated. You and your colleagues have to leave a similar legacy for the next generation of doctors, but your patient's aren't uneducated. How do you intend to address this responsibility if you refuse to cross boundaries? All the best with the rest of your final year. Competing interests: None declared |
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THHG KOH, Neonatologist The Townsville Hospital, QLD 4814
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Dear Editor, Re Partnership in medicine is 2500 years old In the fourth century BC Hippocrates had what appeared to be contradictory views about partnership between doctors and patients. In his earlier teachings Hippocrates directed physicians to perform their duties "calmly and adroitly, concealing most things from the patient which you are attending to him. Give necessary orders with cheerfulness and serenity, turning his attention away from what is being done to him, sometimes reprove sharply and emphatically, and sometimes comfort with solitude and attention, revealing nothing of the patient's future or present condition" (ref 1). Yet later, like the BMJ, Hippocrates advocated “The layman must understand as much about diseases as befits a layman; and what it is fitting for the expert to understand, to administer, and to manage, about these matters, both what is said and what is done, let the layman be able to contribute an opinion with a certain amount of judgement."(ref 2). In his Dialogues Plato (c428 B.C.- 348 B.C.)described two types of doctors and patients "The slave doctors run about and cure the slaves, or wait for them in the dispensaries- practitioners of this sort never talk to their patients individually, or let them talk about their individual complaints. The slave doctors prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a tyrant, he rushes off with equal assurance to some other servant who is ill." In contrast the treatment of freemen or gentlemen focussed on partnership "but the other doctor, who is a freeman, attends and practices upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe to him until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure". When asked by Plato "Now which is the better way of proceeding in a physician?" the disciple chose the freemen doctor (ref 3). Thus private medicine and doctor-patient partnership was present 2500 years ago. Appreciating some of the challenges facing doctors Maimonides (1135 AD) expressed displeasure that "sometimes the patient is being attended by ten physicians according to his means, without one knowing the other. The patient then takes the advice of each of the doctors, makes his decision, and chooses what he finds good by his own judgement. This practice has disadvantages…" (ref 4). Yours sincerely Koh THHG Neonatologist The Townsville Hospital, QLD 4814 1) Jones WHS. Hippocrates II. Decorum XVI. London, William Heinemann;1967: 297. 2) Potter P. Hippocrates V. Camb Mass. Harvard Uni Press;1988:9. 3)Dialogues of Plato. Translated by Benjamin Jowett. Chicago, Encyclopedia Britannica;p685. 4) Dunn PM. Maimonides (1135-1204) and his philosophy of medicine. Arch. Dis. Child. Fetal Neonatal Ed. 1998 79: F227. Competing interests: None declared |
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David O Gebhardt, retired biochemist home address: Anna van Burenlaan 1, 2341 VE Oegstgeest, The Netherlands
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It is high time that patients should make their voice heard. Richard Smith's editorial article (BMJ 2003;326 (14 June)was overdue. The reticence of patients to improve medicine is probably based on their inferiority complex. I have always been amazed by the fact that doctors or pharmacists,(with a few exceptions) who are patients, do not publish about their treatment and its flaws. I have worked all my life in medical research and have always published about the need of change in medical practice. For instance I would like the doctor to put on the prescription the nature of the disease of the patient. This would enable the pharmacist to check whether the drug is approved for the use and would make the doctor realize when he is prescribing off label with its greater risk of complications. Needless to say the whole Dutch Medical profession opposes such a measure. I have now written a paper, which will appear soon in the American Journal of Ophthalmology with the title: Self-administration of eye drops; A patient's view. Who else but a patient could write such a paper? I show that the present method of delivering the drop in a pouch in the lower eye lid is asking for an eye infection. The method of choice is in my opinion to screw a funnel-device on the top of the bottle before administering the drop.This makes it impossible for the tip of the bottle to touch the eye The time is ripe for the doctors to learn something from their patients. D.O.E.Gebhardt Competing interests: None declared |
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Yoav Tzabar, Anaesthetist and patient Carlisle, UK
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Your editorial is full of these phrases: "patient editor"
So what exactly is a patient? Someone who isn't a doctor, maybe? But hang on, aren't doctors patients too? So maybe you mean an "ordinary" member of the public or perhaps someone who is currently undergoing treatment (MY definition of patient)? So what exactly do you mean, Mr Editor, when you say you have a "patient" editor? Did you pluck someone out from the waiting room of the local out- patient clinic or do you really mean you've appointed someone without a medical degree but is well versed in medical issues because they have worked with doctors for many years as a lawyer/journalist/politician/bureaucrat or somesuch and therefore considers themselves an expert on "patient" issues (whatever they are)? Y Tzabar
Competing interests: None declared |
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Patricia M. Wilson, senior lecturer Centre for Research in Primary and Community care, University of Hertfordshire, Hatfiled, AL10 9AB
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I was saddened to see that many of the responses to the issue of patient partnership only served to illustrate a common theme critiqued through the majority of papers in the "Patient" issue; an absolute self- confidence in the superiority of medical knowledge and a disregard of any other perspective. However, despite the depressing nature of some of the responses it was also comforting to note the positive nature of many others and the very fact that medical practitioners are developing a self- critique in this field can only be applauded. I would like to add a word or two of constructive criticism about this issue. Whilst acknowledging accessibility for the lay reader was key I would agree with Rosetta Manaszewicz that the issue seemed to have travelled an unnecessarily long distance in this regard. Many of the papers, whilst sound in content, lacked the academic presentation that allows anyone to follow it up further. Just because a paper is correctly cited and develops a critical argument does not mean that it automatically becomes accessible exclusively to the professional. Finally, although a reasonably broad ranging look at this area was achieved, some key elements were omitted or only briefly mentioned. As the debate "Doctors as Sherpas" raises, barriers to patient participation occur at an organisational level as well as the patient-professional interface, and indeed the whole policy surrounding the Expert Patient has been open to critique (Wilson 2001). Initial data from a study looking at the professionals’ response to active and informed patients suggests that as well as concerns about time resources involved and the challenge to professional power, health care professionals also express anxieties about accountability, litigation and whether the "Expert Patient" can be trusted to self-manage their chronic illness (Wilson et al. 2003). Wilson P.M. (2001) A policy analysis of the Expert Patient in the United Kingdom : self-care as an expression of pastoral power? Health and Social Care in the Community 9, 3, 134-142 Wilson P.M., Kendall S., Brooks F.M. (2003) The Expert Patient and self-care: In whose interest? Paper presented at the "Research for Health in Primary Care: Reality, Impact and Future" Conference, University of Hertfordshire, 21/22 May 2003 Competing interests: None declared |
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Harold A. Weizel, Associate Professor of Surgery U.of Toronto 123 Eward St Suite 505 Toronot Canada M5G 1E2
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Your analogy of the hospital carpark and the supermarket carpark begs for a comment. Can you imagine a member of the market staff braving the elements of weather ,cold and storm to come down to the market at 2am to tend to the needs of the customer? H.Weizel MD Competing interests: None declared |
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Syed Viqar Ahmed, SpR (Medicine) Milton Keynes General Hospital
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Quoting from this article 'Doctors are not patient centered. Can somebody imagine a supermarket car park where customers have to walk past cars of the staff in order to buy! But that's normal in hospitals'. I think the system of NHS is generally not patient centered anyway. However I will restrict my comments on the above explaination. Currently the whole marketing concept is based on customer orientation(4C's) rather than product orientation (4P's). This also means to provide the product to the customer's satisfaction if you want to remain in the competition. This can only be achieved by providing the best service. This in turn is possible by having a work force that is motivated for the job to achieve the targets. This also means to look after your employees for their basic needs to concentrate on their job. If, for example, an employee coming to work in the supermarket is unable to park his car, do you really think he will be motivated to work hard and do his best!! Similarly if the doctors have to look for a parking place when they are coming to do their on-call or for an outpatient clinic, they will be stressed to find a parking place before they can start working! I believe the honourable editor was carried away while making these comments. Competing interests: None declared |
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mahalakshmi gopalkrishnamoorthy, sho in a&e N9 OGQ
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dear editor, if what you say has to be done then why not include chapters written by patients about their views and concerns in every medical textbook so that students can know about this so called "partnership" right from the start. doesnt it sound absurd. exactly! that it is how the editors comparison between doctor
patient relationship and consumer- supermarket relationship sounded.among
many reasons why this comparison doesnt work a few things that come to my
mind immediately are medical literature and literature for the patients should be dealt with separately in order to prevent misinterpretation and confusions. the patients and their carers have already adequate forums to air their concerns and view points. Competing interests: None declared |
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Remy McConvey, SHO Psychiatry Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL
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I found the patient issue thoroughly depressing. As doctor in training, I am presented, on a daily basis, with evidence suggesting that doctors are, variously, self-serving, arrogant, poor communicators, unconcerned with their patients, lazy, insufficiently expert, dangerous, negligent, in the pay of big business, reactionary, Luddite and rude. These stereotypes are peddled by the media and are becoming ingrained in the national psyche. I was disappointed to see very few (if any) contributions to the patient issue from doctors who currently face patients in an emergency, at unsocial hours, in dismal surroundings. These patients present with unrealistic expectations, which have been constantly inflated by Government spin and the gross commercialisation of society. I feel that the patient issue merely served to add insult to a group of healthcare workers who, in general, are striving to provide better care every single day, in difficult circumstances, and I was galled to have my perceived shortcomings yet again highlighted, in a journal so closely allied to my union/ professional organisation. It may well be that the BMA does not actually fund the BMJ directly, but I, for one, will be asking the Association to clarify this relationship in more detail. A better relationship between doctors and patients is a fantastic goal, but it will not be advanced by sending covert messages that doctors are always to blame when things don’t go right. Competing interests: I am a practicing SHO in the NHS |
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Adam Jacobs, Director Dianthus Medical Limited, London SW19 3TZ
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Seeing an article in the BMJ on hospital car parks prompts me to write about something that occurred to me the last time I had reason to visit a hospital, when I had to take my partner to our local hospital to have her acute pneumonia treated. After she had waited in A&E for 9 hours, she was finally admitted and I returned to the car to go home. I had to cough up a large amount of money for 9 hours' worth of parking charges. I couldn't help wonder what would happen to A&E waiting times if car parking charges were paid not by the patients' partners, but taken out of the salaries of the managers responsible for the A&E departments. I don't know if that counts as patient centred, but I bet A&E waiting times would fall spectacularly. Competing interests: None declared |
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Andrew D Beggs, Final Year Medical Student Guys, Kings & St. Thomas' School of Medicine, London, UK.
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Dear Sir, Having read the replies to my comments. I feel I must reply. In this kind of issue, it is always assumed that doctors have no comprehension of what it must be like to see things from the patients point of view. I have been quite badly ill in the past, and have experienced the medical system better than most would believe. I have sympathy with patients who wish to get involved in their treatment. I have no problem with that. But I would not believe it appropriate for me to dictate my treatment regime to a person who is much better qualified than me. I do not tell a mechanic how to repair my car. The doctor-patient is not as simplistic as that, but some in the government and in health care would like to see that, with doctors reduced to the level of technicians. It may not seem like that from the outside, but it certainly seems like that from the inside. As for the comments from Ms Teasdale, I find it particularly insulting in suggesting that I am not suitable for medical school. I came from a Comprehensive school background in the North of England, got 4 A's at A- Level and worked extremely hard through medical school to get (hopefully) to becoming a doctor. I am not your typical medical student entrant. In my short - oops, only six years at medical school, obviously that's not enough when your typical undergraduate course is 3 years - time at medical school, I have seen many patients with many terrible diseases, and in several thousand hours of learning, while not in any way as experienced as senior doctors, I have seen more suffering and disease than any single person will probably see in their lifetime. I find it sickening that the BMJ will publish a letter which resorts to being insulting to get it's point across. It cheapens the whole of medical journalism, and brings the reputation of medical journalism down another notch. It is perfectly alright for the general public to say what it likes about the medical profession. Just don't expect us not to be annoyed about it, and not to fight our corner. Competing interests: None declared |
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Declan P Fox, Peripatetic primary care physician O'Leary, Prince Edward Island,C0B1V0, Canada
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The supermarket analogy continues to befuddle even the most well- educated and intelligent brains. Richard Smith believes supermarkets do certain things to attract more customers while doctors--well, don't. Apart from the fact that I find many supermarkets deeply unattractive, can he not see the essential difference between opening all hours and offering excellent parking or whatever at those different premises? Supermarkets need to attract more customers to prosper. Doctors, mostly, at least in the NHS, need to attract _less_ customers. Most doctors are overworked, lacking the time and the energy to even attempt a partnership with patients. The last thing they need is to add to that load. In my present post here in Canada I see the effects of that up close. My colleagues are excellent GPs and patients come to them from miles away in preference to staying with their local GPs. End result is that my colleagues are working harder every year to keep up while increased funding isn't much good in the face of a doctor shortage. Yours etc
Competing interests: None declared |
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Jonathan C Bowling, SpR Dermatology Chelsea & Westminster Hospital London SW10 9NH
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Dear Sir I read with interest your editorial in last weeks BMJ “The patients Issue”. You may like to consider adding a footnote to the picture of the naked gathering, warning them about the risks of sunburn when participating in “outdoor naked art” as a number of people in the image are showing signs of sunburn. Should this art movement develop momentum in the UK it may add additional pressures on dermatological resources. Competing interests: None declared |
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Richard Smith, Editor BMJ
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I'm sorry that we didn't make clear that all the copies of the Patients' Issue of the BMJ that were distributed to patients' organisations, members of parliament, and the like did not contain any drug advertisements. Nor do the copies that we are selling for doctors to put in their waiting rooms. Richard Smith, editor, BMJ Competing interests: I am the editor of the BMJ and accountable for all it contains and its finances. |
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Sheena Meredith, medical ethicist Reading
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Sir, I applaud the BMJ’s ‘The Patient’ issue (14 June) and the whole notion of allowing patients ready access to authoritative medical information, which indeed seems likely to play an increasing role in the co-operative model of future medicine. But do patients need a special issue to be ‘allowed’ to participate? I had noted that several items in this issue (pp 1284 x2; 1286; 1302- 3) addressed current conflicts surrounding ‘direct to consumer advertising’, and also that the BMJ was offering to supply an extra ‘waiting room’ copy of this issue, for a fee. This seemed anomalous given that this issue, as usual, contained advertisements for various prescription-only drugs. Richard Smith now points out that ‘waiting room’ and other copies intended for lay audiences will not contain pharmaceutical advertising, so avoiding conflict with current rules. However, does not the need for such manoeuvres suggest an inherent conflict with, and a major barrier to, such bold initiatives in information-sharing in future? Sheena Meredith MB BS
Competing interests: None declared |
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Stephen Due, Chief Librarian Library Service, Barwon Health, PO Box 281, Geelong, Vic 3220 Australia
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Editor, Have you gone mad? Soundings man! Where is it? And Minerva? What have you done with her? The corpse of the Journal itself, of course, is only too evident. Technicolour gore everywhere. Gone are more than 160 years of experience in the fine art of designing the printed page (not to mention selecting its content). “In with the new” you say. But is it new? This issue will remind your Australian readers of “Women’s Weekly” in the sixties. You are elevating sensationalism to an art form, over the body of a great tradition. “Last Laugh”, which replaces poor Minerva, is a sad reflection on the whole dubious enterprise. The author refers to Oliver Wendell Holmes as a “prominent American physician” (a truth only to the ignorant). Then we are subjected to his Parthian shot, a sadly familiar four-letter word. Reference: Bartrip PW. Mirror of medicine : a history of the British Medical Journal. Oxford : Clarendon Press, 1990. Competing interests: None declared |
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Chris Dabbs, Chief Officer Salford Community Health Cuoncil, 22 Church Street, Eccles, Manchester M30 0DF
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Dear Editor, I enjoyed “the patient issue” of BMJ (No. 7402, 14 June, 2003), and share your hope for a time when the Journal might publish in partnership with citizens. Many of the articles, not least those from clinicians with experience of long-term conditions, stimulated me. This highlights the oft-adopted simplistic approach that there are “patients” and “doctors”, as if they are from two different planets. There is, in fact, a contradiction between calls for a “patient- centred” approach and those for partnership. Virtually all the best clinical practice involves partnership working between clinicians and patients, with both reaching a concordance and then accepting their distinct responsibilities. In this context, a patient-centred approach makes as little sense as a doctor-centred approach. Not only will it have an imbalance of responsibilities, but also it limits effectiveness. Perhaps most importantly, it implies that the clinician is less important than the patient – a mirror image of the way in which many patients have been treated dismissively by some doctors in the past. The articles in “the patient edition” indicate different views about which direction doctor-patient relationships should develop. There is a strong need to clarify what such relationships might look like. It is critical to ensure that we do not seek a single “ideal” relationship, but instead establish key principles on which patients and clinicians can develop individual relationships that maximise mutual benefit. Such principles might include seeking an optimal balance of control and having equitable accountability. A true partnership focuses on the quality and appropriateness of the relationship between the people involved. Thus, for example, short-term contact might stress professional accountability to me as a consumer – if I break my arm, I look to the professional expertise of the clinician to listen to me but then to take appropriate action. A long-term situation, however, might lean towards guided self-management – professional support to me as an expert citizen – if I have had arthritis for 20 years, I have the experience and knowledge to make most decisions, upon some of which I will wish to seek professional advice. I look forward to the day when it is considered normal to have relationships based on mutual respect and responsibility between citizens holding professional and lay expertise. Perhaps lay people may even be described as people or citizens rather than as patients? Moreover, maybe we can consider more seriously the place of unpaid carers, who provide most health care to others. Competing interests: None declared |
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