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All the Cs

BMJ 2008; 336 doi: (Published 17 April 2008) Cite this as: BMJ 2008;336:0
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

It’s a trivial point, but many of the words that describe what makes a good doctor begin with the letter C. A cohort of UK doctors that has been tracked by the BMA since they qualified in 1995 has twice been asked to rank a list of core professional values ( Competence scores highest on both occasions, but caring, compassion, and commitment are all up there in the top six.

It’s right that competence is seen as a professional value and not as something to be assumed. Perhaps doctors have always taken responsibility for ensuring their own competence, but I find it encouraging that two thirds of junior doctors surveyed by the BMA think their training should be extended to take account of the soon to be imposed 48 hour week (Career Focus,

Caring sounds like the soft option on the list of values—but it isn’t when used in the sense of taking care. The American surgeon and writer Atul Gawande calls this diligence and sees it as essential to reducing medical error (BMJ 2007;334:1115; doi: 10.1136/bmj.39210.473264.59). Medical errors cost America between $17bn and $29bn a year, according to the US Institute of Medicine (doi: 10.1136/bmj.39551.680417.C2), and a recent project run by the NHS Institute for Innovation and Improvement found that failure to take care could be responsible for more than 10% of hospital deaths (doi: 10.1136/bmj.39549.618426.DB). Frighteningly, a survey of NHS staff published last week found that fewer than half of responders thought patient care was the top priority for their trust ( For doctors at all stages, taking care has to mean more than being responsible for one’s own actions. It means identifying areas for improvement, speaking up for the patient, reporting errors, taking a leadership role.

One C word not on the BMA’s list is communication. It may well need to be added by the time the cohort is next interviewed. Poor communication skills have been linked to an increased risk of complaints from patients, and Paul Kinnersley and Adrian Edwards say that good communication skills should be mandatory for qualifying doctors rather than something for which other skills and knowledge can compensate (doi: 10.1136/bmj.39525.658565.80). What to do about the poor communicators already practicing medicine is a more difficult challenge.

The most important communication skill for doctors may be the ability to say sorry, as emphasised in last week’s Healthcare Commission report ( and in our competent novice series a few months ago (BMJ 2008;336:326-8; doi: 10.1136/bmj.39455.639340.AD). This week’s Competent Novice article focuses on yet another C word, confidentiality, which, as Julie Bourke and Simon Wessely write, lies at the heart of the relationship between doctor and patient (doi: 10.1136/bmj.39521.357731.BE).

Three more C words are vying for a place on the list. Jennifer Dixon wants competition as an incentive for improving the quality of care (doi: 10.1136/bmj.39541.622917.80). Ike Iheanacho says we must learn to love and understand concordance (doi: 10.1136/bmj.39549.633530.94). And I would like to speak up for courage. You’ll find an account of an amazing medical life courageously lived at doi: 10.1136/bmj.39552.447928.BE.