Audit my shortsBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7013.1171 (Published 28 October 1995) Cite this as: BMJ 1995;311:1171
It is an innate desire of doctors to try to improve their service to their patients, and to continue to augment their knowledge and refine their skills throughout their careers. Medical audit started out as a way of encouraging this admirable professional attribute, and standardising it so that it could be applied in everyday practice and in all aspects of patient care. It is essentially a very simple idea. (a) We decide what we should be doing; (b) we find out what we are doing; and (c) we take the necessary steps to change (a) into (b). Clear as a bell, easy got as a wet foot.
But somewhere along the line this concept got hijacked, and now medical audit has a serious image problem; instead of being slim and sexy, it has become bloated and unattractive, like the caricature at the top of this column. Now if you mention the dreaded A-word, most doctors are in the land of nod quicker than you could say Virginia Who? … it has fallen prey to the Dark Side.
I recently was lucky enough to win an audit competition, run by another medical journal, the prize being a cardiology stethoscope. My audit was simple: to ensure the accuracy of the blood pressure monitors used in our practice. It was rough and ready, but a salutary exercise. The entry for this competition required only a five line summary, but after winning I wasn't surprised to be asked to write a full article on the subject.
“For God's sake!” I screamed. “It's not as if I won the lotto or a car or a luxury holiday or something--it's just a bloody stethoscope!” Thick black scopes may look smooth, but they are so damn short that measuring a blood pressure entails sticking your face in the patient's armpit--what bitter irony!
But this is all part of the befuddled audit ethos, isn't it? It just ain't good enough any moreto do a simple little audit by yourself, or with other consenting adults, in the privacy of your own surgery, which might actually mean something to your daily clinical practice. Rather everythinghas to be formalised, or presented to an audience with multicoloured overheads to beat the band, or written up for the journals with exhaustively researched gold standards.
The audit cycle has become a vicious circle, a noose to strangle any chance of it ever being a practical everyday tool. It has developed its own vernacular--gold standards, criteria, process measuring--the Newspeak of the nineties. It spawns committees, spores journals, spews conferences, secretes acronyms, and breeds facilitators and assistants; a whole service industry has mushroomed around this fatal flower, and with every new blossom it becomes more and more remote from real practice and from the people who are actually doing the work.
Reading an audit is like being a baby gazelle in the Serengeti when David Attenborough appears.”Hey, mom!” you shout in excitement. “We're going to be on TV! Ain't this great?” But mom knows better; soon something nasty with big sharp teeth is going to show up. Willy-nilly, audits always end with pious resolutions that the rest of us poor bastards should work even harder in the future, like Boxer from Animal Farm; and remember what happened to him.--LIAM FARRELL, general practitioner, Crossmaglen, County Armagh