Change: both desired and resisted

BMJ 2001; 322 doi: (Published 26 May 2001) Cite this as: BMJ 2001;322:a

Change is a bugger. People often don't want to change even if they are unhappy with their lot. Nobody has described this better than Giuseppe Tomasi di Lampedusa in The Leopard, the story of the Sicilian Prince of Salina threatened with change by the arrival of Garibaldi in 1860. “The Sicilians,” says the Prince, “never want to improve for the simple reason they think themselves perfect; their vanity is stronger than their misery.” Moslem imams, King Roger's knights, Swabian scribes, Angevin barons, Catholic Kings, Spanish viceroys, and Charles III's reforming functionaries all tried to reform Sicily. Yet “Sicily went to sleep in spite of their invocations; for why should she listen to them if she herself is rich, if she's wise, if she's civilised, if she's honest, if she's admired and envied by all, if, in a word, she's perfect.”

Yet talk of change has never been more strident. No modern politician, no matter how conservative could declare the status quo to be the way forward. As Britain's current election illustrates (p 1268 and 1269), politicians must outdo each other with extravagant promises of change—usually both better services and lower taxes. Medical journals exist in a sense to promote change—and yet are often full of stories of change not being achieved. Change is simultaneously desired and resisted.

Health care, argues Jane Smith in an editorial, needs radical change—redesign even (p 1257).

“Health care systems fail to provide treatments that are known to work, persist in using treatments that don't work, enforce delays, and tolerate high levels of error.” She describes attempts on both sides of the Atlantic to change health care as fundamentally as the car industry was changed a decade or so ago. The people she has talked to are far from Sicilian: change is energising them.

But turn the pages and you read accounts of guidelines on infertility failing to achieve much change (p 1258 and p 1282), reluctance to use continuous subcutaneous insulin infusion pumps (p 1262), unwillingness by Australian doctors to let patients see their notes (p 1270), resistance by drug companies in the United States to allergy remedies becoming available over the counter (p 1270), and objections from research ethics committees to their meetings being open to the public (p 1294).

If you're a Sicilian at heart you'll grunt with satisfaction, but if you remain hungry for change read Trevor Jackson's review of an account of the pharmaceutical industry's “tricks of the trade” for getting doctors to prescribe their drugs (p 1312). The main message is the same as at the end of Jane Smith's editorial: leaders and leadership.


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