No quick fixes

When things go wrong there is an understandable tendency to want to prevent future disasters and a less commendable one to find a scapegoat and leap to obvious solutions. Two papers in this week's issue remind us of the limitations of that approach.

On p 499 Charlotte Paul uses the experience in New Zealand after a hospital disaster to warn “against believing that internal self regulation by the medical profession is useless and should be discarded.” In the 1960s a study into cervical cancer at the National Women's Hospital in Auckland was started without the women being aware they were in a trial and resulted in 160 women being inadequately treated. The subsequent inquiry report emphasised the need for external controls on doctors' practices, but Paul reminds us that “internal morality”—values intrinsic to the practice of medicine—did not completely fail. As in the Bristol paediatric surgery case (p 466), so in New Zealand it was other clinicians who raised the queries. The resulting external controls have proved to be blunt: if doctors feel they cannot be trusted, “there is a risk they will become less trustworthy.”

Similarly, after the Shipman murder case commentators have called for controls on general practice and monitoring of mortality. But Frankel et al show that monitoring the mortality of Shipman's patients would probably not have identified his murders. They illustrate again how large a part random variation plays in life, and warn that seeking hard endpoints may distract from “the more difficult task of measuring the more mundane attributes of care.”

Just as random variation is more prevalent than we think, so too are everyday misunderstandings in consultations. To explore how general practitioners and patients see prescribing, Nicky Britten and colleagues taped consultations, interviewed patients before and afterwards about their expectations, and interviewed the doctors (p 484). They revealed a host of misunderstandings, including patients thinking doctors had information when they didn't, doctors thinking patients understood something when they didn't, and misattribution of side effects. The authors blame many of these on wrong assumptions by both doctors and patients and make a plea for doctors to elicit more information from their patients.

The misunderstandings identified by Britten et al may be characteristic of most human interactions, not just consultations, but one limiting factor is surely identified in this week's letters. Last year Clare Rayner made a plea on patients' behalf for doctors to be willing to listen and to take time: our correspondents agree but point out that in a cash limited NHS the first commodity to go is time (p 510).