Editor's Choice

Personal feelings and medical journals

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7440.0-g (Published 11 March 2004) Cite this as: BMJ 2004;328:0-g
  1. Richard Smith, editor (rsmith{at}bmj.com)

    A good poem will evoke different thoughts, feelings, and images in each reader. A medical journal is not like that. Mostly after reading an article we probably think thoughts that are similar and not so far from those the authors wanted us to think. But we do all bring something different to our reading, and those differences—particularly if they are powerful feelings—will influence our reading.

    As I read the paper by Jack Wennberg and others on death in highly respected American hospitals (p 607) I thought of the death of my father. He died last week aged 81. He was a good (and very funny) man who lived a good life and died a good death—courtesy of the NHS. In America he might not have been so lucky. Wennberg and others look at use of healthcare resources in the 77 “best hospitals” in the United States and find striking variation.

    Days in hospital in the last six months of life ranged from 9.4 to 27.1, while days in intensive care ranged from 1.6 to 9.5. The percentage of patients who saw 10 or more doctors varied from 17% to 59%, and the percentage of deaths occurring in hospital ranged from 16% to 56%. Hospital use was most intense in Manhattan, Los Angeles, and Washington and least intense in Minneapolis and San Francisco—suggesting (probably wrongly) that “liberals” go to their deaths with much less fuss. There is no evidence that greater use means better outcomes, and the worry is that higher use is driven less by patient preferences and more by the supply of hospitals and doctors. The variation suggests that there is lots of room to do things better—and probably at much lower cost.

    My father died at home after 14 days in hospital and no days in intensive care under the care of doctors and nurses to whom my family are tremendously grateful. The crucial point seemed to me the moment when we all agreed that the aim of management was a comfortable and dignified death. Sometimes that point may come far too late—or not at all.

    Emotion also influenced my reading of Chibuzo Odigwe's report on a study from the soon to be extinct Commission for Health Improvement of how children often feel ignored in the NHS (p 600). My 12 year old daughter, Flo, castigates me for not listening, failing to close my mouth when eating, never finishing my sentences, wearing awful clothes, and singing badly in the street. Children have a clarity of vision and a deep sense of values denied to many adults, and I believe that they should have the vote at 16, if not younger. And doctors shouldn't talk to the parents of teenagers rather than the teenagers themselves, especially when the teenagers say things like: “I know more than my mum, I know nearly everything.”


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