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Rapid Responses: Rapid Responses published:
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Change yes......but incrementally!
- peter j mahaffey (13 October 2007)
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Re: Change yes......but incrementally!
- Sam Lewis (13 October 2007)
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Re: Re: Change yes......but incrementally!
- peter j mahaffey (14 October 2007)
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Medicine as culture
- Niyi Awofeso (15 October 2007)
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The king is dead. Long live the king.
- Richard Bartley (15 October 2007)
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peter j mahaffey, consultant plastic & reconstructive surgeon bedford hospital
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Any analysis of the present woes of the UK medical profession from a working clinician (rather than medical or government politician) is a breath of fresh air in an environment where most of us seem to have been cowed into submission. And Richard Hayward is absolutely right to focus on what it is that spurs a doctor to enjoy his or her daily work....to solve a problem by using one's skills, with beneficial fall-out for patient, doctor and health service. But after that, his analysis breaks down. The stimulus for the massive changes in our NHS were 'local' (getting down waiting lists etc) and 'big-picture', ie grappling with the spiralling health costs which have afflicted all nations. But the problem was not 'the culture of medicine' which, as Hayward defined, is about the self-gratification involved in diagnosis and treatment. Rather, it was the government of the day's error in inflicting repeated, wholesale, brutal changes to a complex ecosystem which had evolved over 60 yrs since 1947. No system could ever have withstood such an upheaval. All that was really needed was for wise government to make progressive nudges to the tiller. For better or worse, clinicians are far and away the best educated section of the NHS workforce. If someone had simply come to them and said "Look, what do you need to get your waiting lists down to a managable length?" they would have done it, and at a cost of one hundredth of what has been spent in the past 10 years. Moreover, doctors mostly also enjoy efficiency, and a similar direct appeal to them to 'help us get our budgets down for the good of us all' would very likely also have appealed to those self-same qualities. But now the damage wrought by those seeking to weaken the profession is too great. And we are almost in the end-game where the politicians need only to wrest the last powerful card from our hand, the doctor-patient relationship. Infection crises, generic referrals, clinical guidelines, repeated 'fat-cat' allegations.... and soon we will be fully fledged state employees just as in Scandinavia! And then perhaps the state will realise that it wasn't the 'culture of medicine' that lost it the priceless asset of an independent profession. Competing interests: None declared |
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Sam Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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I am busy writing a short piece for my 'Policy Analysis' course, contrasting the 'rationalistic' with the 'incrementalist' approach to decision-making... and then you come along , Richard, with a proposal that takes my breath away with its rational and incremental simplicity :- [ask the clinicians] "Look, what do you need to get your waiting lists down to a managable length?" - they would have done it, and at a cost of one hundredth of what has been spent Wow !! Didn't Gerry Robinson ask exactly that ? and didn't he hit a wall ?? so tell me Richard, how is it done ?? Competing interests: a doctor and a taxpayer |
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peter j mahaffey, consultant plastic & reconstructive surgeon bedford hospital
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Oh dear, I think Sam Lewis means me and not Richard Hayward! I recognise that Gerry Robinson hit the buffers and I was equally appalled at the resistance to change he encountered. But he forgot that one must set a thief to catch a thief and he knew nothing of the inner workings of the medical hierarchy. Moreover, when I suggested asking doctors for THEIR solutions to improving problems like waiting lists, I meant (and sorry if I didn't say so) that 'or else' was implied. That's to say "either set your house in order or we will". I still believe that doctors would have responded to that. And if not, then yes, we deserved all we have subsequently got. And at the point we have now reached I simply don't think even the most optimistic soul could assert that the medical profession is leaner and fitter, has an improved culture, or that there has been the slightest 'value' in what has been achieved during the past 10 years of truly massive extra NHS expenditure and wholesale change. Competing interests: None declared |
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Niyi Awofeso, A/Prof, School of Public Health and Community Medicine University of New South Wales, Sydney Australia
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Sir, Contemporary definitions emphasise a dynamic nature of culture as a process through which beliefs and practices are affected by social contexts and power relationships. That Hayward is keen to see a change in medical culture is in fact a recognition that the culture of medicine has changed significantly from being perceived as culturally neutral to a profession with a myriad of cultural facets.1 Such facets vary from the ‘culture of science’, established since the era of Robert Koch, and which sometimes creates the impression of doctors as omnipotent3, to a ‘culture of perfectionism’, which may encourage to a code of silence not only in relation to surgery waiting lists, but also in relation to admitting treatment errors.4 The culture of medicine is changing, albeit slowly as with all cultural changes. We see such cultural changers in the emergence of Clinical Governance Units in most Western hospitals, whose (predominantly non-clinical) staff share responsibility with physicians for seeking solutions to dismantle bottlenecks in patient flow through the hospital system, and for monitoring clinical standards. Cultural shift is also exemplified by the University of Sydney’s recent decision to incorporate training on complimentary and alternative medicine into undergraduate medical education. While cultural change in relation to public health focus by medical practitioners is slow, I believe there has been more progress in the past two decades compared with most of the 20th century. It is still vital that medicine maintains a predominantly biomedical culture, as most important advances in public health rely on the power of biomedical innovations, epidemiology and statistics. References 1) Taylor JS. Confronting “culture” in medicine’s “culture of no culture”. Acad Med 2003; 78: 555-9. 2) Hayward R. Why the culture of medicine has to change. BMJ, 2007; 335: 775. 3) Lupton D. Medicine as culture: Illness, disease and body in western societies. London, Sage Publications, 2003. 4) Gallaher TH, Garbutt JM, Watwerman AD et al. Choosing your words carefully. Arch Int Med 2006; 166: 1585-1593. Competing interests: None declared |
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Richard Bartley, Physiotherapist Wales
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QUOTE: .....when I suggested asking doctors for THEIR solutions to improving problems like waiting lists, I meant (and sorry if I didn't say so) that 'or else' was implied. That's to say "either set your house in order or we will". I still believe that doctors would have responded to that.... END QUOTE I am not so sure they would have. Richard Hayward's point is that the patient-doctor relationship is king. I believe it would have remained king and blurred all other considerations if clincians were left to solve the major issues of the NHS. Why leave sole responsiblity to politicans or clinicians? Freeing the Bank of England of political control was one of Gordon Brown's better ideas. Why not do the same with the NHS? Once the the government loses complete control of the NHS to an independent system, clincians may be more likely to become more confident about seeing the 'bigger picture'. Competing interests: None declared |
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