Precise measurement and poetryBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7147.0 (Published 13 June 1998) Cite this as: BMJ 1998;316:0
To practise the best medicine you need to measure precisely what you are doing but also have a sense of poetry. In this issue the precise measurements come from tertiary care and the poetry from primary care.
Where is it best to look after patients with cystic fibrosis? Conventional wisdom (or could that be current fashion?) suggests a you show that such centres provide better care? You can't randomise people to receive or not receive the care. Teams from Manchester and Cambridge have cleverly attempted an answer by comparing referrals to a new adult centre in Cambridge with two groups: those who had attended the Manchester centre since they were children and those who had come as adults. The results showed that the amount of time spent in the centre correlated with a better clinical outcome. This is strong evidence supporting the centres, but a commentary cautions care before generalising from the data (p 1775).
On p 1759 another group of tertiary care specialists, cardiothoracic surgeons, describe the steps that they are taking to provide the public with information on their performance. This account comes while we await the final judgement in the Bristol case of the cardiac surgeons found guilty of continuing to operate while getting poor results. But ironically cardiac surgeons have been way ahead of almost all other groups in monitoring performance, and the authors conclude that “the major challenge will be determining realistic, measurable, and auditable outcomes for other medical and surgical specialties, where poor outcomes do occur but the process is less transparent.”
Philosophy and poetry come in a new series on core values in primary care (p 1807) and in an account of primary care in Montpelier in inner Bristol (p 1837). In starting the series on core values Ian McWhinney quotes the United States Institute of Medicine in defining the four essentials of good primary care as “accessibility, comprehensiveness, coordination, and continuity.” Much US primary care cannot do well when measured against such essentials.
Stefan Cembrowicz captures beautifully in his personal view the pleasure he takes from cultural diversity in Montpelier: “Survivors of Dachau or Siberia live next door to people who had to pay in gold to leave their country by open boat, or who chew mildly intoxicating khat leaves each afternoon, freshly flown in to Heathrow …. Patients may arrive at the practice in Cosworths with blackened windows, in cars with antiwhaling stickers, by skateboard, perambulator, or barefoot …. One patient had his own room in the Tate Gallery; others share rooms in Wormwood Scrubs or Broadmoor …. Life's flame burns very hotly here and we are very near it.”