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Research Christmas 2019: Let it Be

Q fever—the superstition of avoiding the word “quiet” as a coping mechanism: randomised controlled non-inferiority trial

BMJ 2019; 367 doi: (Published 18 December 2019) Cite this as: BMJ 2019;367:l6446
  1. Charlotte R Brookfield, registrar in medical microbiology1,
  2. Patrick P J Phillips, assistant professor2,
  3. Robert J Shorten, consultant clinical scientist1 3
  1. 1Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Fulwood, Preston PR2 9HT, UK
  2. 2UCSF Centre for Tuberculosis, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
  3. 3Centre for Clinical Microbiology, University College London, London, UK
  1. Correspondence to: C R Brookfield crr5{at} (or @crbrookfield on Twitter)
  • Accepted 30 September 2019


Objective To determine the validity of the superstition that utterance of the word “quiet” in a clinical setting increases workload.

Design Prospective randomised controlled non-inferiority study.

Setting Microbiology department of a large teaching hospital in Lancashire, UK.

Participants Two members of the medical microbiology team carried out the duty work on any given week day and an on-call team member on any weekend day. 29 days were assigned in which staff were to say “Today will be a quiet day” and 32 days were assigned in which staff were to refrain from saying the word “quiet” in any context.

Interventions Each day was randomly allocated to either saying “Today will be a quiet day” (intervention group) or refraining from saying the word “quiet” (control group) in any context.

Main outcome measures The primary outcome was mean overall workload: a composite of number of clinically related telephone calls, clinically significant results, or validated results processed by the duty medical microbiology team during a 24 hour period referred to collectively as “clinical episodes.” A difference of 30 clinical episodes was considered as the margin of non-inferiority. Secondary outcomes included the individual components of the primary outcome.

Results Workload was measured each day over a 61 day period (1 May to 30 June 2019). A mean 139.0 clinical episodes occurred on control days compared with 144.9 on days when the experimental intervention was uttered, a difference of 5.9 (95% confidence interval−12.9 to 24.7). The upper bound was less than the specified margin of 30, providing evidence for non-inferiority. No evidence of a difference in workload was found between interventions with any of the four components, whether considering unadjusted or adjusted analyses, or looking at the subgroups of week days or weekends.

Conclusions The study findings refute the long held superstition that utterance of the word “quiet” impacts on clinical workload, and therefore it should not be avoided. In the era of considerable staff shortages and increased work related stress, doctors should look to other methods to increase resilience and protect their wellbeing and mental health.

Trial registration Lancashire Teaching Hospitals NHS Foundation Trust’s research department SE-259.


  • Contributors: CB and RS devised the study, supervised the distribution of the pre-sealed allocation envelopes, and collected the data. PP contributed to the study design, provided randomisation and power calculations, and conducted statistical analysis. All three authors contributed to the literature review and writing the protocol and manuscript. CB is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: None.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required. The study was registered with Lancashire Teaching Hospitals NHS Foundation Trust’s research department as service improvement since data collected will be used to enhance the trust’s clinical service.

  • Data sharing: Data will be available on request from the corresponding author for 12 months after publication.

  • The lead author and guarantor (CB) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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