Straight thinkingBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39189.594178.BD (Published 19 April 2007) Cite this as: BMJ 2007;334:0
- Fiona Godlee, editor
In this week's Lesson of the Week, a glitch with a handheld computer caused a sick baby to get seven times the right dose of noradrenaline (doi: 10.1136/bmj.39104.625903.80). But, according to a new book by Jerome Groopman reviewed this week (doi: 10.1136/bmj.39184.586725.59), most medical mistakes are down to the way we think and not how we use technology. “Attribution errors,” “availability thinking,” “anchoring,” “diagnosis momentum,” “search satisfaction,” and “vertical line thinking”—you may not like the jargon, but you'll almost certainly recognise the behaviour it describes and the types of mistake that can follow. Groopman calls for us to put technology (and evidence based medicine) in its place and to get back to the patient's story.
Technology has no place when it comes to making the crucial distinction between delirium and dementia, say John Young and Sharon Inouye in their Clinical Review (doi: 10.1136/bmj.39169.706574.AD). There's no test for delirium, so diagnosis relies entirely on clinical skill and, in particular, on obtaining a proper history of recent deterioration and identifying clouding of consciousness. Delirium is the commonest complication of hospital admission for older people but is missed in more than half of patients, leaving many languishing under the potentially disastrous catch-all label of “confused elderly patient.” What makes the diagnosis crucial, of course, is that delirium is usually reversible once identified, but, even more important, say the authors, is that it's preventable in more than a third of patients. The “hospital elder life programme,” developed at Yale, is one effective approach.
There are other calls for clear thinking this week. Tom Treasure and colleagues scorn the muddled guidance for resection of lung metastases in people with resectable colorectal cancer, which they say has been extrapolated from weak evidence of benefit from resection of liver metastases (doi: 10.1136/bmj.39161.403218.AD). They say that this level of clinical uncertainty justifies a randomised trial. Robert Marcus and John Firth debate whether you should tell your patients about effective treatments they can't have (doi: 10.1136/bmj.39171.426690.AD and 10.1136/bmj.39171.511794.AD). Maheswaran and colleagues conclude that walk-in centres don't reduce waiting times in general practice (doi: 10.1136/bmj.39122.704051.55), and Daniel Sokol asks whether, in these days of patient choice, doctors are wise gatekeepers of medical expertise or unthinking service providers. He explores the ethical ground between telling a patient what you think is best for them and guiding them towards an informed decision (doi: 10.1136/bmj.39188.442674.94).
Finally, we need to rethink how we deal with death. Medical training is about conquering disease. Death is too often seen as failure, and impending death as our signal to withdraw from the scene. Daniel Munday and Jeremy Dale call for more funding for the United Kingdom's successful gold standards framework for community palliative care (doi: 10.1136/bmj.39174.605081.80). And, as observed by Tessa Richards (doi: 10.1136/bmj.39188.592940.59), the new book by Allan Kellehear calls for innovative thinking that puts death back at the centre of our lives.