Matt Morgan: Whose leg is it anyway? Ownership and medicineBMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1622 (Published 29 June 2021) Cite this as: BMJ 2021;373:n1622
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Morgan argues that shared ownership amongst a team allows shared decision making, and infers that if an example patient had care with shared ownership, then a better decision about their operative management could have been made .
However, we believe this is a reduction fallacy, where the cause of a problem is oversimplified, and other factors may influence the outcome . We argue the crux of Morgan’s argument is centred around communication. There was a failure of communication between the doctors and with the patient, as all the management options that were important to the patient were not discussed or known to the operating surgeon. Shared ownership may well have improved the outcome, but only by improving communication.
Shared ownership is a form of flat hierarchy, where authority and decision-making is distributed, as is accountability if errors are made . These working structures can be more innovative and responsive. However, they can also be associated with a lack of transparency and subsequent responsibility . In the absence of clear decision-making authority, new communication issues may be introduced.
Whilst we appreciate Morgan’s argument that the named consultant should not assume complete responsibility , there needs to be better communication amongst both clinicians and patients. Effective communication can improve shared decision making and allow teams to delegate authority and responsibility when appropriate. In doing so we can improve outcomes for patients while maintaining transparency and responsibility.
1 Morgan M. Matt Morgan: Whose leg is it anyway? Ownership and medicine. BMJ. 2021; 373 :n1622 doi:10.1136/bmj.n1622
2 Logically Fallacious. Causal Reductionism. Logically Fallacious [Internet]. Available from: https://www.logicallyfallacious.com/logicalfallacies/Causal-Reductionism Last accessed: 9th July 2021.
3 Bernstein E, Bunch J, Canner N, Lee M. Beyond the Holacracy Hype. Harvard Business Review. 2016; https://hbr.org/2016/07/beyond-the-holacracy-hype
4 Grey, Christopher. 2009. A very short, fairly interesting and reasonably cheap book about studying organizations. Los Angeles: SAGE Publications.
Competing interests: No competing interests
Matt Morgan's article raises 2 distinct salient features of clinical practice, namely decision-making and responsibility.
The decision-making process around clinical care, thankfully, now in the UK aims to put the patient front and centre. Interestingly, in the case he describes, I would argue it should be the next of kin or person with Power of Attorney who has the final say and not either of the surgeons.
However, ownership of decision-making is very different from clinicians being accountable to patients--ie, responsibility. Good leadership relies on the drawing of expertise and opinion from a multitude of resources, hence the absolute necessity of the multidisciplinary approach to patient care. But this can lead to dilution of responsibility and in the worst instance 'collusion of anonymity' . Not only does this impact enormously on coordinated clinical care where the patient ends up being 'lost' in the system but it is hugely frustrating for professional colleagues. GPs rightly pride themselves on their individual relationships with patients and, similarly, patients greatly value the fact they know whom to approach with their concerns.
Increasingly, these queries relate to the navigation of the labyrinth that is secondary care. There is nothing more frustrating for patients and GPs alike when it is unclear which consultant is responsible to and for the patient. Complex decision-making about patient care shared between specialties and disciplines is to be applauded, but a named clinician must always take ultimate responsibility for co-ordination of care and communication with the patient and colleagues. I would implore secondary care colleagues to include the details of the 'responsible clinician' in all their correspondence.
1. Michael Balint - 'The Doctor, His Patient and the Illness'. First Published 1957
Competing interests: No competing interests
I offer a different perspective to the opinions offered so far (including that of Dr Morgan).
Ultimately the patient is the decision maker if she/he is of sound mind, able to understand the issue and weigh the pro of cons of any management; and to be frank this should include non-operative treatment including medication.
For example, I have seen too many people on life-long anticoagulation where they were not given an opportunity to consider the alternative and the implications of the options available. Granted many of them SHOULD be on anticoagulation but (according to patients anyway) too many of these recommendation/decisions were simple fostered onto the patient as a cursory discussion in a hospital ward round or in a 6 minute GP consultation. These treatments, like surgery, are life changing and should be considered and discussed properly on their merits and risks.
In the village scenario, there is always a village head who is there not because of what he can actually do (rather what he promised he can do), a wise person who gives good advice but doesn't have the legal power to do things, a practical minded jack of all trades who sorts things out when asked to but simply does what was asked without questioning why, the person who goes around asking for advice from anyone and everyone until they come across the advice they like.
And yes this is the medical environment we are working in.
When the patient is not competent to make such decisions, particularly in an emergency, then for contentious decisions a surrogate should be sought for to try to replicate the patient's priorities, preferences and perception. This can be their close relatives or friends, but could also be their primary care providers/family physicians/general practitioners.
I hope there are still enough GPs out there in the NHS system where they know many of their 'flock' by name or face, but in the era of convenience, consumerism and group (hence 'shared') practice, I do not dare to have high expectations of this. In previous times, doctors may have known less medicine than what we know now, but they knew their patients more.
If such a GP does not exist, then hopefully a specialist previously treating the patient may step into the gap. She/he may not know the patient as well, but with good clinical practice and well written notes addressing ICE (ideas, concerns, expectations) the clinician can have a good feel of what the patient wants.
And, yes, I am aware that there are many clinician that view "ICE" negatively nowadays but I still value this approach, and wish I was taught this when I was in medical school decades ago.
In normal hospital etiquette, the person on call makes the call, unless another consultant takes over the care of the patient from the person on call. Both may have the patient's interest at heart, but the on-call clinician will be foolish if she/he does not allow an opportunity for the other clinician (who already has a prior therapeutic relationship with this patient) to express their opinion.
In this particular case, it would have been easily resolved; the on-call surgeon (who advocates surgery) transfers the care of the unconscious patient to the surgeon not on call (who does not advocate surgery) but continues to monitor the condition of this patient regularly until the call is over.
If the situation is reversed, however, then it is far more difficult, particularly when the surgeon not on call is advocating for surgery which the on-call surgeon does not agree with.
Perhaps such conflicts reflect the true nature of medicine, that nothing is always clear cut, and one can make no sweeping assumptions.
Competing interests: No competing interests
Thank you for publishing this piece by Dr Morgan.
There is a trend in calls for “team approach” to the wholistic care of any person, championed not least by the Society to Improve Diagnosis in Medicine. While many of us now practice in multidisciplinary teams and appreciate the innumerable benefits that brings, the “medicolegal buck” needs to stop with someone. This is perhaps more so in the U.S. where “ownership” of patient has payment implications as well as medical ones.
I look forward to the day when genuine “village care” of people Ivan be practiced for the betterment of patient safety and outcome with concurrent stoppage of finger pointing of culture of blame.
Competing interests: I am a doctor looking after patients in U.K.