Choice

Getting closer to patients and their families

BMJ 2000; 321 doi: http://dx.doi.org/10.1136/bmj.321.7275.0 (Published 16 December 2000) Cite this as: BMJ 2000;321:0

“The whole structure of medicine has been based on the assumption that physicians have the current information and patients do not. The bottom line is, the consumer will have virtually all the information the professionals have. This is comparable to the way communism fell. Once people start getting in good communication you won't be able to play the game in the same way.” So said Tom Ferguson, a US physician who wrote recently for the BMJ (321: 1129). Don Berwick, another US physician, who has been advising the British government on modernising the NHS, sings a similar song: “When patients become coequal with their care providers in controlling care, making decisions, and treating themselves with coaching, outcomes improve, costs fall, satisfaction rises, and even physiological measures look better.”

This BMJ provides insight into these modern orthodoxies. Bart Thoonen and Chris Van Weel quote the UK's National Cancer Campaign at the beginning of their editorial on self management of asthma (p 1482): “Equipping people with asthma with the tools they need to manage their condition is as important as writing the correct prescription.” Yet, as a qualitative study from Alan Jones and others shows, this isn't what's happening in the real world (p 1507). Most professionals oppose self management plans for patients with asthma, and most patients don't use them. What's needed, suggest the authors, is plans that are more patient centred and less based on the medical model.

Should relatives be present when a patient is being tested for brain stem death? The immediate response of many is no, but it's not long since fathers were kept out during childbirth. Despite debate in the BMJ, it's also common for relatives to be excluded during resuscitation. Now Janet Pugh and others have asked about the presence of relatives during testing for brain stem death (p 1505). A third of consultants and 40% of nurses had experience of the presence of relatives, and more nurses (84%) than doctors (53%) thought that witnessing tests would help relatives accept that the patient had died. There is, of course, a gap between what people say should happen and what they do; and nobody in this study asked relatives what they thought.

The theme of getting closer to patients and relatives also surfaces in a study (p 1497) and an editorial (p 1483) on screening family members of patients with heterozygous familial hypercholesterolaemia and a study of the quality of web based information on depression (p 1511). It's also thrown up—in a chilling way—by a study that shows that doctors' economic needs rather than patient choice lead to high caesarean section rates in Chile (p 1501).

Footnotes

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