- Email: [email protected]
COMMUNICATION AS A METHOD OF MEDICAL AUDIT
1341
"organic" conditions. Moreover one must remember that schizophrenic patients are subject to catatonia from non-schizophrenic causes. For example, schizophrenics are at a higher risk for catatonia induced by antipsychotic drugs, can become exposed to toxic substances, and are as likely as anyone to develop an incidental medical or neurological disorder. ardous
awl. stated that in
where catatonia is secondary to organic brain disease there was "profound disorientation and marked cloudiness of the state of the consciousness ... not found in cases of catatonic schizophrenia." Our own observations, however, together with the case-reports of catatonia from organic causes which have been reviewed here, do not support this distinction on the basis of mental status. Intravenously administered amobarbital (amylobarbitone, ’Amytol’) has been used as a diagnostic test to distinguish between patients with and without organic brain disease,45 46 and its use has been suggested to distinguish between "psychogenic" and "organic" causes of catatonia.I7 Our experience in several cases has been consistent with the value of this procedure, "psychogenic" cases becoming more talkative in characteristic ways, while "organic" cases become more confused or obtunded. Yet because of the lack of systematic testing, the "amytal interview" cannot be counted on at this time as a reliable diagnostic instrument. There is, in fact, no way at present to determine, on the basis of mental status alone, whether catatonia may be caused by a serious organic illness or a functional disorder. Of the many causes of the catatonic syndrome, some are potentially life-threatening. Early detection is possible only if physicians maintain an awareness of the many possible causes of catatonia, and do not automatically diagnose schizophrenia and refer the patient to a psychiatrist. Antipsychotic medication or electroconvulsive therapy in an organic case may produce a temporary improvement, a worsening, or simply confuse the clinical picture, delaying definitive diagnosis and approHerman
et
Hospital Practice COMMUNICATION AS A METHOD OF MEDICAL AUDIT
IAN MCCOLL CHRISTINE MACKIE
cases
priate treatment.
L. CAROL FERNOW MAX RENDALL
Department of Surgery, Guy’s Hospital, London SE1 9RT
Advances in the practice of medicine the past forty years have rendered informal communication ineffective in setting and maintaining standards of clinical care. In the past five years, four methods in communication have been introduced in the department of surgery at Guy’s Hospital: problemoriented medical records, death-and-complications meetings, unit review meetings, and a clinical information service. It is suggested that these can achieve quality control.
Summary
over
INTRODUCTION
CLINICIANS have a responsibility to evaluate and improve standards of care and to teach these to new generations of clinicians. Forty years ago hospitals were run by a few close friends who knew their places in a well-defined hierarchy. Mutual recognition of their problems combined with a close working relationship engendered an atmosphere conducive to the best care possible at the time. Today the situation is quite different. Mastery of the huge volume of new medical and technical information is impossible. Surgery is an ever more technically based discipline as a consequence of antibiotics, reliable anaesthesia, better understanding of the principles of fluid balance, and the ability to support failing organ systems. Sound clinical judgment remains essential. Today, however, we can use a given technique repeatedly, and predict its outcome
Michel R. Mandel, M.D., Gerald L. Klerman, M.D., Ross J. Baldessarini, M.D., and Sherry A. Gelenberg, M.s.w., assisted in the preparation of this
manuscript.
Requests for reprints should be addressed
A.
J. G. Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts 02114, U.S.A. to
REFERENCES 1. Dorland’s Illustrated Medical Dictionary. Philadelphia, 1965. 2. Freedman, A. M., Kaplan, H., Sadock, B. J. Comprehensive Textbook of Psychiatry. Baltimore, 1975.
3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Washington, 1968. 4. Kahlbaum, K. Catatonia. Baltimore, 1973. 5. Kraepelin, E. Dementia Præcox and Paraphrenia. Edinburgh, 1919. 6. Bleuler, E. Dementia Præcox or the Group of Schizophrenias. New York, 1950. 7. Kirby, G. H.J. nerv. ment. Dis. 1913, 40, 694. 8. Herman, M., Harpham, D., Rosenblum, M. N.Y. State J. Med. 1942, 42, 624. 9. Hearst, E. D., Munoz, R. A., Tuason, V. B. Archs gen. Psychiat. 1973, 28, 39. 10. Morrison, J. R. ibid. p.39. 11. Guggenheim, F. G., Babijian, H. M.J. nerv. ment. Dis. 1974, 158, 291. 12. Brain, R. Diseases of the Nervous System. London, 1962. 13. Mettler, F. A. Psychiat. Q. 1955, 29, 89. 14. Kleist, K.J. ment. Sci. 1960, 106, 246. 15. Glaser, G. H., Pincus, J. H.J. nerv. ment. Dis. 1969, 149, 59. 16. Penn, H., Racy, J., Lapham, L., Mandel, M., Sandt, J. Archs gen. Psychiat.
1972, 27, 757. 17. Raskin, D. E., Frank, S. W. ibid. 1974, 31, 544. 18. Sours, J. A. Am. J. Psyciat. 1962, 119, 451. 19. Malamud, W., Body, D. A. Archs Neurol. Psychiat. 1929, 41, 352.
20. deMorsier, G. Encephale, 1968, 57, 181. 21. Plum, F. Neurosci. Res. Prog. Bull. 1972, 10, 384. 22. Furtado, D., Freita, A. Rev. Neurol. 1946, 78, 499. 23. Newmann, M. A.J. nerv. ment. Dis. 1955, 121, 193. 24. Cairns, H. Brain, 1952, 75, 109. 25. Thompson, G. N. Biolog. Psychiat. 1970, 2, 59. 26. Reimer, D. R., Nagaswami, S. Psychosomatics, 1974, 15, 39. 27. Sutter, J. M., Barnedat, C., Pheline, C., Coudray, J. P. Revue neurol. 1959,
101, 504. Schilder, P. Am.J. Psychiat. 1934, 91, 155. Thompson, S. W., Greenhouse, A. M. Ann. intern Med. 1968, 68, 1271. Bender, L., Schilder, P. Archs Neurol. Psychiat. 1934, 91, 155. Zlotow, M., Kleiner, S. Psychiat. Q. 1965, 39, 466. 32. Cave, H. A. Archs Neurol. Psychiat. 1931,26,50. 33. Slater, E., Roth, M. Clinical Psychiatry. Baltimore, 1969. 34. Blau, A., Averbuch, S. H. Am.J. Psychiat. 1936, 92, 967. 35. Katz, S. E. Archs Neurol Psychiat. 1934, 31, 880. 36. Hockaday, T. D. R., Keynes, W. M., McKenzie, J. K. Br. med. J. 1966, 28. 29. 30. 31.
i,
85. 37.
Gatewood, J. W., Organ, C. H., Jr., Mead, B. T. Am. J. Psychiat. 1975, 132, 129.
Finkelstein, J. D., Mudd, S. H. New Engl. J. Med. 1975, 292, 491. 39. Jaffe, M. Dis. nerv. Syst. 1967, 28, 606. 40. Schwabb, J. H., Barrown, M. V. Am. J. Psychiat. 1964, 120, 1196. 41. Lindemann, R., Malamud, W. ibid. 1934, 13, 853. 42. Tatetsu, S. Folia psychiat. neurol. jap. 1963, 337. 43. Meltzer, H. Y. Psychopharmacologia, 1973, 29, 337. 44. Gelenberg, A. J., Mandel, M. R. Archs gen. Psychiat. (in the press). 45. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., Linn, L. Am. J. Psychiat. 1953, 109, 889. 46. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., Mahtz, S. Archs Neurol. Psychiat. 1954, 71, 217. 38. Freeman, J. M.,
1342
with considerable accuracy. To this extent surgery is a science, and we can use our experiences to add to the expanding body of medical knowledge. Communication is fundamental to this process of discovery and continuing education, and informal means of communication are no longer equal to the task. Several new formal methods have been introduced in the department of surgery at Guy’s Hospital. PROBLEM-ORIENTED MEDICAL RECORDS
The purpose of a medical record is to store and communicate information. In May, 1974, the use of the problem-oriented medical record (P.O.M.R.) became hospital policy because of dissatisfaction with the conventional hospital notes. It had already been in use in the surgical unit for two years. Some have argued that the problem-oriented system is no better than the traditional method of recording. The essential difference between the two is that the problem-oriented record is structured. Information correctly entered in the record can therefore be rapidly retrieved and used repeatedly in the management of the patient. Every clinician is concerned that the information he has about the patient should be as complete as possible. The preparation of a systematic history, examination, and problem list, especially where a prepared history sheet and check-list have been used, can ensure that all the available information has been gathered quickly. The continuity of the record, and, more important, its comprehensibility can be maintained even when several people are contributing to it; this feature is increasingly
important. With the reduction in the working hours of junior medical staff, division of labour is fragmenting care. By the use of the P.O.M.R., one doctor supervising another’s patient in his absence, or in consultation, can see what the problems are, and can see quickly what the plan of action is, what investigations have been done, what treatment has been ordered, and what the patient has been told about his condition. Experience with the P.o.M.R. has demonstrated the educational function of the record. It allows students the opportunity to simulate all aspects of patient care, by preparing initial plans, and recording each step in the management of the patient. It also reveals where plans for management are inappropriate and need correction. The need to demonstrate, even to oneself, the logic of each step in management becomes a constraint to better
practice. DEATH-AND-COMPLICATIONS MEETINGS
Death-and-complications meetings are held to examine all incidents which have complicated the smooth recovery of the patient. On the general surgical side of Guy’s Hospital we have met weekly for the past five years to consider the problems which we face indivi1 dually and which are often common to our colleagues.’ One of the consultant surgeons presides over each meeting, which is conducted in turn by the registrar of each of the five general firms. This avoids the disjointed contributions which would result if all firms presented their deaths and complications every week. The registrar is responsible for keeping throughout the five-week period a record of all incidents which have complicated the recovery of patients. He starts with a brief statistical report of the firm’s work and then presents the more
complicated cases himself, delegating others to the junior members of his firm. Histories are succinct, and irrelevant information on physical and laboratory investigations is omitted. A frank and friendly debate follows each presentation, and there is no attempt to apportion blame but only to profit from informed discussion and common experience. The admission of mistakes, particularly by senior clinicians, provides an example of self-criticism which is analogous to some choir practices where a member raises his hand when he sings a wrong note. The openness which characterises these meetings creates an ideal atmosphere for people to communicate their expertise and provides an interesting and economical method of clinical appraisal and continuing education. The great improvement in the recognition and management of respiratory failure in postoperative patients is a direct result of the discussions at these meetings. Beyond their obvious purpose they have stimulated studies of several problems. For instance, the frequent occurrence of postoperative burst abdomens suggested that the incidence was probably higher than it should have been. An inexpensive one-year survey was conducted into the methods of closing the abdomen. Although this was never published, simply looking at the problem reduced the incidence of this complication dramatically within five months. Another example of the constructive nature of these discussions was that we became aware of an unacceptable number of cases of pulmonary embolism. This led to a review of this problem, and the emergence of a policy for the use of prophylactic subcutaneous
heparin.
From time to time the discussions reveal a major administrative problem, which can be aired to good effect, as the clinical superintendent of the hospital always attends. These meetings provide an excellent forum for the dissemination and communication of knowledge, experience, and wisdom. Unquestionably, these meetings owe much of their popularity and success to the carefully nurtured atmosphere in which they are conducted. In any system which is punitive the surgeon will tend to think of protecting himself first and foremost. To a lesser extent he may alter his practice to guard against criticism and may thereby harm the patient, either by omission or by commission. For example, a decision that a certain colonic tumour is inoperable could be unduly influenced by the fear of criticism arising from complications after a difficult resection. Similarly, a clinician may feel constrained to search for a primary tumour in a patient whom he knows to have widespread metastases and who would be better served by symptomatic treatment alone. UNIT REVIEW MEETINGS
These sessions, which are attended only by the medical staff of the unit, are also held weekly for the purpose of examining any part of the firm’s work which is felt to be unsatisfactory. These closed meetings have revived the principles of true apprenticeship in which the intimate communication between tutor and student goes beyond narrow confines of subject matter. The focus of the session may, for example, be the use of a certain surgical technique, a discussion of investigations to be done before a patient is admitted to hospital, a more satisfac-
1343 or a detailed review of of a the long-term management problem patient. This unlike of any other, uncovers and resolves type meeting, of difficulties personal relationships within the group, as particularly they affect the management of patients. For example, it became apparent that there were inconsistencies in the way various members of the firm were dealing with patients who had malignant disease. These differing views, based on firmly held individual beliefs, led to unnecessary distress both to patients and to their relatives. Once this problem had been appreciated it was possible to evolve a policy which was acceptable to all members of the firm. It is hoped that this wide-ranging discussion of clinical, economic, and administrative issues will broaden the perceptions of junior staff as to their future roles in the profession and that, by including the concerns of other disciplines, interdisciplinary cooperation will be advanced. It is clear that, in the future, doctors will have to accept more responsibility for the management of the resources which they have at their disposal-a matter which receives scant or no attention in the undergraduate medical curriculum. Consultants can contribute their experience; all can bring forward their conclusions from their recent studies ; and these, combined with the common knowledge of day-to-day routine on the unit and the limitations of resources and manpower, can effect necessary improve-
tory format for business
rounds,
ments.
It is beneficial, and we would argue essential, to know what members of the firm really think. In the decades since the war the organisation of complex technology has fostered a de-personalisation, characterised by reticence and consciousness of rank, which has inhibited expressions of opinion. The introduction of these discussions, like any innovation in professional relationships, initially generated a certain amount of uneasiness. This gradually gave way to acceptance and then to enthusiasm, as it was appreciated that the atmosphere was one of free exchange in which personal criticism and recrimination were out of place, and that the views of all were equally important. We believe that franker communication leads not only to more satisfying working relationships within the group but also to improved clinical performance.
ments, and false positive or negative investigation results. The assumption is made, however (for which there is no contrary evidence to date), that these kinds of errors do not introduce a systematic bias. Variables used in this study include not only those on resource use routinely collected..in the hospital activity analysis (length of stay, numbers and kinds of operations, time in hospital before operation, secondary diagnoses) but also explicit criteria for the management of each study diagnosis and follow-up of abnormal test results. Nine measurements of the physiological and social status of patients on admission attempt to standardise them for purposes of comparison and permit assessment of the effect, if any, of the contribution of each of these risk factors to variables such as length of stay. It is essential to recognise that statistically significant findings do not in any way constitute proofs. They are appropriately viewed as allowing "an estimate of the conclusions drawn from inexact observations."2 As such, they merely support generalisations that may require closer scrutiny. The results and suggestions for their use are illustrated by a few of our findings for 1972. There was a statistically significant difference among firms in measurements of clinical management of patients operated on for gallstones. If this difference persisted in 1975 there could be profitable discussion among surgical consultants regarding recommended standards of practice. For example, operative cholangiograms were done on 72% of these patients. Are there circumstances where this practice is unnecessary? Liver-function tests were done on 73% of these patients. This would seem to be a relevant investigation for a patient undergoing cholecystectomy. Is there new information which makes this investigation redundant in the other cases? In short, large group analysis is yet another source of information to assist clinicians to assess the state of their art. We plan in future to feed back to interested firms strictly confidential information about their performance, compared with the rest of the group, in the use of hospital resources, inpatient management, and patient outcome. The sole reason for such an innovation is to stimulate professional communication, with a view to achieving the highest possible standards of patient care. CONCLUSION
CLINICAL INFORMATION SERVICE
Another
experiment in communication now being developed Guy’s is a clinical information service especially designed for consultants. This work is a byproduct of large group research into the effect of P.O.M. R. on the medical care process. Approximately 5000 casenotes are the source of information, and statistical methods are used for analysis. The findings of the first study year were of such practical value that, beyond testing whether the use of P.O.M.R. had affected the quality of care we felt that they would be useful to the cliniat
cians. Unlike death-and-complications meetings and unit review meetings which consider the minute detail of a
specific
case,
numbers of
statistical
techniques involving large
central tendencies in complex behaviour patterns. Even though every effort is made to minimise clerical error in abstracting data from the medical record, some research errors are introduced by such things as inaccurate recording, incorrect measurecases
identify
primary purpose of quality control in medicine is improve standards of care by educating clinicians. The basic belief underlying our innovations is that, for programmes of continuing education to be effective, the needs of the clinician must dictate the subject matter The
to
and the method. The profession properly resists the American concept of audit with its overtones of sanctions on individual performance. There are centres abroad where a witchhunt atmosphere has bred a type of doctor who is expert at avoiding blame rather than learning from his mistakes. At the same time we must recognise that the concept of clinical freedom never was, and is not now, an excuse for individual ignorance. We are entitled to exercise that freedom only to the extent that we assume the responsibility of contributing to and profiting from the collective knowledge which is the basis of the best clinical practice. To the credit of the profession this body of knowledge
1344
already outdistanced our ability to disseminate and absorb it through the informal means of communication. We must be willing to institute new means of communication, recognising that our individual and collective excellence depends upon it. has
REFERENCE 1.
McLachlan, G. (editor) A Question of Quality: Roads to Assurance in Medi-
2.
cal Care. London (in the press). Colquhoun, D. Lectures on Biostatics, p. 2, London,
1971.
Personal Book List PÆDIATRICS
N. M. JACOBY* Pembury Hospital, Tunbridge Wells
might have been said, and as a matter of fact it said by Dr Charles Cameron (of whom more anon) that "In London in 1916, the only thing known about paediatrics was Dr Still’s telephone number." The reason he said it was the introduction of meat rationing during the 1914-18 war when children with coeliac disease were allowed three times the ordinary ration, so as to provide the high-protein diet in vogue at the time. These were the years before general physicians had filched the title for their patients, and coeliac disease had a purely paediatric connotation. Adults with the same condition were diagnosed as "nontropical sprue" and were treated by other means which might even include a diet of bael fruit (Bengal quince). It has been one of the sorrows of my therapeutic career that I never had an opportunity to prescribe such treatment. But I digress. The point of Cameron’s remark was that when it became known that a triple meat ration was possible, Dr Still was inundated with inquiries as to the nature of coeliac disease and the means by which determined carnivores might acquire it. I record all this solely to underline the fact that paediatrics is a relatively new specialty in the United Kingdom. There was no chair of child health in London until after the end of the 1939-45 war, though Scotland and the Provinces were, as might have been expected, ahead in this matter. Leonard Finlay in Glasgow was the first, in 1924, and in Birmingham Leonard Parsons was made professor in 1929. These appointments seem very tardy when compared with the position abroad. For example, Henoch retired from the chair of paediatrics at Berlin University in 1873, and Abraham Jacobi, no relation I regret to say, became the first professor of paediatrics in the U.S.A. in 1870. It is also surely of interest to note that Escherich succeeded to the chair of paediatrics in Vienna in 1901. Over many years I have asked students and others what they knew about Escherich, and invariably the answer was "An eminent bacteriologist". It is not widely known that the eponymous E. coli are named after a paediatrician. IT
was
History If I have been somewhat critical of the British acceptance of paediatrics as worthy of academic status, we can claim that individually the triumvirate of Sir Thomas Barlow (1856-1945), John Thompson (1856-1926), and Sir Frederick *Present address: Kent.
Broomyfields, Horseshoe Green,
Mark Beech,
Edenbridge,
Still (1868-1941) would be names to conjure with in any historic paediatric discussion. If this sort of topic interests you, let me strongly recommend Veeder’s Pediatric Profiles. For our purely domestic history, Cameron’s British Ptsdtatric Association, 1928-1952 records the names and deeds of our founders, and many of the historic names mentioned were known personally to many paediatricians still alive-something that cannot be said of most other specialties. The B.P.A. was very wise in choosing Cameron as its first historian, for he had great facility with words, both spoken and written. His two most famous books on the nervous child are classic descriptions of that ubiquitous and investigation-defying entity, "the periodic syndrome". Though his concept of the aetiology as "glycopenic" was wrong, it has had a profound effect on much commercial and medical practice ever since. Cameron’s biography of Lister is worth reading: but his much more attractive treatise on Lord Byron’s feet was never published. He firmly believed that Byron was a spastic and not a talipes, and somewhere there must be a manuscript awaiting the light of day. Textbooks
After the joys of historical reading, it is a dreary matter to consider standard textbooks, which have always seemed to me a necessary evil. Why must they be so dull? I recall only two such works, neither paediatric, which really had character. They were the original editions of Bailey & Love’s A Short Practice of Surgery and Boyd’s Textbook of Pathology, both of which in newer editions happily still exist. The trouble with textbooks, apart from their dreariness is their cost, and the fact that they are obsolescent at the time of publication. They tend to be written by eminent members of the profession at a stage in their careers when they eschew the bedside of the acutely ill in the small hours of the morning. The result is that they are authentic on their own pet subjects, less so on others, and sometimes seem to have copied from others who have copied from others. Multiple authorship reduces these failings, and the best effort at overcoming them was Brennemann’s fourvolume loose-leaf book where every author was an expert, and any section could be replaced by a revised version, thus keeping the book up to date without having a complete new edition. The main disadvantage was the cost, which in the nineteen forties was over 20, and the equivalent now would be a staggering 200. If such books are no longer possible, what then? My preference has been for "Nelson"; but recently a strong competitor has appeared in Forfar and Arneil’s textbook. It is well written and reliable. When introduced to a new work I tend to look at those sections dealing with matters on which I consider myself to be an authority. The paragraph in this book dealing with the medical treatment of pyloric stenosis suggests, I hope wrongly, that the writer had no experience of the subject. A trivial matter no doubt; but is it the only such defect in the tome? The shorter textbooks seem to me to be undistinguished, and students should choose a recent publication before it is out of date.
Development Assessment is now the "in thing" of paediatrics, and there many works on the subject. Thirty and more years ago the experienced paediatrician could make a fair assessment of a child’s development, just from his clinical acumen and experience. Even now, occasionally he can be more accurate than the scientific measured approach. The whole thing has become so complex with the presence or absence of various reflexes at various ages, as well as the various abilities that should be shown with the passage of time, that some work of reference is essential. An eminent paediatrician is said to have had an assistant who knew no less than 120 different reflexes and signs that could be elicited in an infant, but the significance of any one of them totally eluded him. Illingworth’s book is excellent, written in his admirable style, and has always covered my are
requirements.
"organic" conditions. Moreover one must remember that schizophrenic patients are subject to catatonia from non-schizophrenic causes. For example, schizophrenics are at a higher risk for catatonia induced by antipsychotic drugs, can become exposed to toxic substances, and are as likely as anyone to develop an incidental medical or neurological disorder. ardous
awl. stated that in
where catatonia is secondary to organic brain disease there was "profound disorientation and marked cloudiness of the state of the consciousness ... not found in cases of catatonic schizophrenia." Our own observations, however, together with the case-reports of catatonia from organic causes which have been reviewed here, do not support this distinction on the basis of mental status. Intravenously administered amobarbital (amylobarbitone, ’Amytol’) has been used as a diagnostic test to distinguish between patients with and without organic brain disease,45 46 and its use has been suggested to distinguish between "psychogenic" and "organic" causes of catatonia.I7 Our experience in several cases has been consistent with the value of this procedure, "psychogenic" cases becoming more talkative in characteristic ways, while "organic" cases become more confused or obtunded. Yet because of the lack of systematic testing, the "amytal interview" cannot be counted on at this time as a reliable diagnostic instrument. There is, in fact, no way at present to determine, on the basis of mental status alone, whether catatonia may be caused by a serious organic illness or a functional disorder. Of the many causes of the catatonic syndrome, some are potentially life-threatening. Early detection is possible only if physicians maintain an awareness of the many possible causes of catatonia, and do not automatically diagnose schizophrenia and refer the patient to a psychiatrist. Antipsychotic medication or electroconvulsive therapy in an organic case may produce a temporary improvement, a worsening, or simply confuse the clinical picture, delaying definitive diagnosis and approHerman
et
Hospital Practice COMMUNICATION AS A METHOD OF MEDICAL AUDIT
IAN MCCOLL CHRISTINE MACKIE
cases
priate treatment.
L. CAROL FERNOW MAX RENDALL
Department of Surgery, Guy’s Hospital, London SE1 9RT
Advances in the practice of medicine the past forty years have rendered informal communication ineffective in setting and maintaining standards of clinical care. In the past five years, four methods in communication have been introduced in the department of surgery at Guy’s Hospital: problemoriented medical records, death-and-complications meetings, unit review meetings, and a clinical information service. It is suggested that these can achieve quality control.
Summary
over
INTRODUCTION
CLINICIANS have a responsibility to evaluate and improve standards of care and to teach these to new generations of clinicians. Forty years ago hospitals were run by a few close friends who knew their places in a well-defined hierarchy. Mutual recognition of their problems combined with a close working relationship engendered an atmosphere conducive to the best care possible at the time. Today the situation is quite different. Mastery of the huge volume of new medical and technical information is impossible. Surgery is an ever more technically based discipline as a consequence of antibiotics, reliable anaesthesia, better understanding of the principles of fluid balance, and the ability to support failing organ systems. Sound clinical judgment remains essential. Today, however, we can use a given technique repeatedly, and predict its outcome
Michel R. Mandel, M.D., Gerald L. Klerman, M.D., Ross J. Baldessarini, M.D., and Sherry A. Gelenberg, M.s.w., assisted in the preparation of this
manuscript.
Requests for reprints should be addressed
A.
J. G. Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts 02114, U.S.A. to
REFERENCES 1. Dorland’s Illustrated Medical Dictionary. Philadelphia, 1965. 2. Freedman, A. M., Kaplan, H., Sadock, B. J. Comprehensive Textbook of Psychiatry. Baltimore, 1975.
3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Washington, 1968. 4. Kahlbaum, K. Catatonia. Baltimore, 1973. 5. Kraepelin, E. Dementia Præcox and Paraphrenia. Edinburgh, 1919. 6. Bleuler, E. Dementia Præcox or the Group of Schizophrenias. New York, 1950. 7. Kirby, G. H.J. nerv. ment. Dis. 1913, 40, 694. 8. Herman, M., Harpham, D., Rosenblum, M. N.Y. State J. Med. 1942, 42, 624. 9. Hearst, E. D., Munoz, R. A., Tuason, V. B. Archs gen. Psychiat. 1973, 28, 39. 10. Morrison, J. R. ibid. p.39. 11. Guggenheim, F. G., Babijian, H. M.J. nerv. ment. Dis. 1974, 158, 291. 12. Brain, R. Diseases of the Nervous System. London, 1962. 13. Mettler, F. A. Psychiat. Q. 1955, 29, 89. 14. Kleist, K.J. ment. Sci. 1960, 106, 246. 15. Glaser, G. H., Pincus, J. H.J. nerv. ment. Dis. 1969, 149, 59. 16. Penn, H., Racy, J., Lapham, L., Mandel, M., Sandt, J. Archs gen. Psychiat.
1972, 27, 757. 17. Raskin, D. E., Frank, S. W. ibid. 1974, 31, 544. 18. Sours, J. A. Am. J. Psyciat. 1962, 119, 451. 19. Malamud, W., Body, D. A. Archs Neurol. Psychiat. 1929, 41, 352.
20. deMorsier, G. Encephale, 1968, 57, 181. 21. Plum, F. Neurosci. Res. Prog. Bull. 1972, 10, 384. 22. Furtado, D., Freita, A. Rev. Neurol. 1946, 78, 499. 23. Newmann, M. A.J. nerv. ment. Dis. 1955, 121, 193. 24. Cairns, H. Brain, 1952, 75, 109. 25. Thompson, G. N. Biolog. Psychiat. 1970, 2, 59. 26. Reimer, D. R., Nagaswami, S. Psychosomatics, 1974, 15, 39. 27. Sutter, J. M., Barnedat, C., Pheline, C., Coudray, J. P. Revue neurol. 1959,
101, 504. Schilder, P. Am.J. Psychiat. 1934, 91, 155. Thompson, S. W., Greenhouse, A. M. Ann. intern Med. 1968, 68, 1271. Bender, L., Schilder, P. Archs Neurol. Psychiat. 1934, 91, 155. Zlotow, M., Kleiner, S. Psychiat. Q. 1965, 39, 466. 32. Cave, H. A. Archs Neurol. Psychiat. 1931,26,50. 33. Slater, E., Roth, M. Clinical Psychiatry. Baltimore, 1969. 34. Blau, A., Averbuch, S. H. Am.J. Psychiat. 1936, 92, 967. 35. Katz, S. E. Archs Neurol Psychiat. 1934, 31, 880. 36. Hockaday, T. D. R., Keynes, W. M., McKenzie, J. K. Br. med. J. 1966, 28. 29. 30. 31.
i,
85. 37.
Gatewood, J. W., Organ, C. H., Jr., Mead, B. T. Am. J. Psychiat. 1975, 132, 129.
Finkelstein, J. D., Mudd, S. H. New Engl. J. Med. 1975, 292, 491. 39. Jaffe, M. Dis. nerv. Syst. 1967, 28, 606. 40. Schwabb, J. H., Barrown, M. V. Am. J. Psychiat. 1964, 120, 1196. 41. Lindemann, R., Malamud, W. ibid. 1934, 13, 853. 42. Tatetsu, S. Folia psychiat. neurol. jap. 1963, 337. 43. Meltzer, H. Y. Psychopharmacologia, 1973, 29, 337. 44. Gelenberg, A. J., Mandel, M. R. Archs gen. Psychiat. (in the press). 45. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., Linn, L. Am. J. Psychiat. 1953, 109, 889. 46. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., Mahtz, S. Archs Neurol. Psychiat. 1954, 71, 217. 38. Freeman, J. M.,
1342
with considerable accuracy. To this extent surgery is a science, and we can use our experiences to add to the expanding body of medical knowledge. Communication is fundamental to this process of discovery and continuing education, and informal means of communication are no longer equal to the task. Several new formal methods have been introduced in the department of surgery at Guy’s Hospital. PROBLEM-ORIENTED MEDICAL RECORDS
The purpose of a medical record is to store and communicate information. In May, 1974, the use of the problem-oriented medical record (P.O.M.R.) became hospital policy because of dissatisfaction with the conventional hospital notes. It had already been in use in the surgical unit for two years. Some have argued that the problem-oriented system is no better than the traditional method of recording. The essential difference between the two is that the problem-oriented record is structured. Information correctly entered in the record can therefore be rapidly retrieved and used repeatedly in the management of the patient. Every clinician is concerned that the information he has about the patient should be as complete as possible. The preparation of a systematic history, examination, and problem list, especially where a prepared history sheet and check-list have been used, can ensure that all the available information has been gathered quickly. The continuity of the record, and, more important, its comprehensibility can be maintained even when several people are contributing to it; this feature is increasingly
important. With the reduction in the working hours of junior medical staff, division of labour is fragmenting care. By the use of the P.O.M.R., one doctor supervising another’s patient in his absence, or in consultation, can see what the problems are, and can see quickly what the plan of action is, what investigations have been done, what treatment has been ordered, and what the patient has been told about his condition. Experience with the P.o.M.R. has demonstrated the educational function of the record. It allows students the opportunity to simulate all aspects of patient care, by preparing initial plans, and recording each step in the management of the patient. It also reveals where plans for management are inappropriate and need correction. The need to demonstrate, even to oneself, the logic of each step in management becomes a constraint to better
practice. DEATH-AND-COMPLICATIONS MEETINGS
Death-and-complications meetings are held to examine all incidents which have complicated the smooth recovery of the patient. On the general surgical side of Guy’s Hospital we have met weekly for the past five years to consider the problems which we face indivi1 dually and which are often common to our colleagues.’ One of the consultant surgeons presides over each meeting, which is conducted in turn by the registrar of each of the five general firms. This avoids the disjointed contributions which would result if all firms presented their deaths and complications every week. The registrar is responsible for keeping throughout the five-week period a record of all incidents which have complicated the recovery of patients. He starts with a brief statistical report of the firm’s work and then presents the more
complicated cases himself, delegating others to the junior members of his firm. Histories are succinct, and irrelevant information on physical and laboratory investigations is omitted. A frank and friendly debate follows each presentation, and there is no attempt to apportion blame but only to profit from informed discussion and common experience. The admission of mistakes, particularly by senior clinicians, provides an example of self-criticism which is analogous to some choir practices where a member raises his hand when he sings a wrong note. The openness which characterises these meetings creates an ideal atmosphere for people to communicate their expertise and provides an interesting and economical method of clinical appraisal and continuing education. The great improvement in the recognition and management of respiratory failure in postoperative patients is a direct result of the discussions at these meetings. Beyond their obvious purpose they have stimulated studies of several problems. For instance, the frequent occurrence of postoperative burst abdomens suggested that the incidence was probably higher than it should have been. An inexpensive one-year survey was conducted into the methods of closing the abdomen. Although this was never published, simply looking at the problem reduced the incidence of this complication dramatically within five months. Another example of the constructive nature of these discussions was that we became aware of an unacceptable number of cases of pulmonary embolism. This led to a review of this problem, and the emergence of a policy for the use of prophylactic subcutaneous
heparin.
From time to time the discussions reveal a major administrative problem, which can be aired to good effect, as the clinical superintendent of the hospital always attends. These meetings provide an excellent forum for the dissemination and communication of knowledge, experience, and wisdom. Unquestionably, these meetings owe much of their popularity and success to the carefully nurtured atmosphere in which they are conducted. In any system which is punitive the surgeon will tend to think of protecting himself first and foremost. To a lesser extent he may alter his practice to guard against criticism and may thereby harm the patient, either by omission or by commission. For example, a decision that a certain colonic tumour is inoperable could be unduly influenced by the fear of criticism arising from complications after a difficult resection. Similarly, a clinician may feel constrained to search for a primary tumour in a patient whom he knows to have widespread metastases and who would be better served by symptomatic treatment alone. UNIT REVIEW MEETINGS
These sessions, which are attended only by the medical staff of the unit, are also held weekly for the purpose of examining any part of the firm’s work which is felt to be unsatisfactory. These closed meetings have revived the principles of true apprenticeship in which the intimate communication between tutor and student goes beyond narrow confines of subject matter. The focus of the session may, for example, be the use of a certain surgical technique, a discussion of investigations to be done before a patient is admitted to hospital, a more satisfac-
1343 or a detailed review of of a the long-term management problem patient. This unlike of any other, uncovers and resolves type meeting, of difficulties personal relationships within the group, as particularly they affect the management of patients. For example, it became apparent that there were inconsistencies in the way various members of the firm were dealing with patients who had malignant disease. These differing views, based on firmly held individual beliefs, led to unnecessary distress both to patients and to their relatives. Once this problem had been appreciated it was possible to evolve a policy which was acceptable to all members of the firm. It is hoped that this wide-ranging discussion of clinical, economic, and administrative issues will broaden the perceptions of junior staff as to their future roles in the profession and that, by including the concerns of other disciplines, interdisciplinary cooperation will be advanced. It is clear that, in the future, doctors will have to accept more responsibility for the management of the resources which they have at their disposal-a matter which receives scant or no attention in the undergraduate medical curriculum. Consultants can contribute their experience; all can bring forward their conclusions from their recent studies ; and these, combined with the common knowledge of day-to-day routine on the unit and the limitations of resources and manpower, can effect necessary improve-
tory format for business
rounds,
ments.
It is beneficial, and we would argue essential, to know what members of the firm really think. In the decades since the war the organisation of complex technology has fostered a de-personalisation, characterised by reticence and consciousness of rank, which has inhibited expressions of opinion. The introduction of these discussions, like any innovation in professional relationships, initially generated a certain amount of uneasiness. This gradually gave way to acceptance and then to enthusiasm, as it was appreciated that the atmosphere was one of free exchange in which personal criticism and recrimination were out of place, and that the views of all were equally important. We believe that franker communication leads not only to more satisfying working relationships within the group but also to improved clinical performance.
ments, and false positive or negative investigation results. The assumption is made, however (for which there is no contrary evidence to date), that these kinds of errors do not introduce a systematic bias. Variables used in this study include not only those on resource use routinely collected..in the hospital activity analysis (length of stay, numbers and kinds of operations, time in hospital before operation, secondary diagnoses) but also explicit criteria for the management of each study diagnosis and follow-up of abnormal test results. Nine measurements of the physiological and social status of patients on admission attempt to standardise them for purposes of comparison and permit assessment of the effect, if any, of the contribution of each of these risk factors to variables such as length of stay. It is essential to recognise that statistically significant findings do not in any way constitute proofs. They are appropriately viewed as allowing "an estimate of the conclusions drawn from inexact observations."2 As such, they merely support generalisations that may require closer scrutiny. The results and suggestions for their use are illustrated by a few of our findings for 1972. There was a statistically significant difference among firms in measurements of clinical management of patients operated on for gallstones. If this difference persisted in 1975 there could be profitable discussion among surgical consultants regarding recommended standards of practice. For example, operative cholangiograms were done on 72% of these patients. Are there circumstances where this practice is unnecessary? Liver-function tests were done on 73% of these patients. This would seem to be a relevant investigation for a patient undergoing cholecystectomy. Is there new information which makes this investigation redundant in the other cases? In short, large group analysis is yet another source of information to assist clinicians to assess the state of their art. We plan in future to feed back to interested firms strictly confidential information about their performance, compared with the rest of the group, in the use of hospital resources, inpatient management, and patient outcome. The sole reason for such an innovation is to stimulate professional communication, with a view to achieving the highest possible standards of patient care. CONCLUSION
CLINICAL INFORMATION SERVICE
Another
experiment in communication now being developed Guy’s is a clinical information service especially designed for consultants. This work is a byproduct of large group research into the effect of P.O.M. R. on the medical care process. Approximately 5000 casenotes are the source of information, and statistical methods are used for analysis. The findings of the first study year were of such practical value that, beyond testing whether the use of P.O.M.R. had affected the quality of care we felt that they would be useful to the cliniat
cians. Unlike death-and-complications meetings and unit review meetings which consider the minute detail of a
specific
case,
numbers of
statistical
techniques involving large
central tendencies in complex behaviour patterns. Even though every effort is made to minimise clerical error in abstracting data from the medical record, some research errors are introduced by such things as inaccurate recording, incorrect measurecases
identify
primary purpose of quality control in medicine is improve standards of care by educating clinicians. The basic belief underlying our innovations is that, for programmes of continuing education to be effective, the needs of the clinician must dictate the subject matter The
to
and the method. The profession properly resists the American concept of audit with its overtones of sanctions on individual performance. There are centres abroad where a witchhunt atmosphere has bred a type of doctor who is expert at avoiding blame rather than learning from his mistakes. At the same time we must recognise that the concept of clinical freedom never was, and is not now, an excuse for individual ignorance. We are entitled to exercise that freedom only to the extent that we assume the responsibility of contributing to and profiting from the collective knowledge which is the basis of the best clinical practice. To the credit of the profession this body of knowledge
1344
already outdistanced our ability to disseminate and absorb it through the informal means of communication. We must be willing to institute new means of communication, recognising that our individual and collective excellence depends upon it. has
REFERENCE 1.
McLachlan, G. (editor) A Question of Quality: Roads to Assurance in Medi-
2.
cal Care. London (in the press). Colquhoun, D. Lectures on Biostatics, p. 2, London,
1971.
Personal Book List PÆDIATRICS
N. M. JACOBY* Pembury Hospital, Tunbridge Wells
might have been said, and as a matter of fact it said by Dr Charles Cameron (of whom more anon) that "In London in 1916, the only thing known about paediatrics was Dr Still’s telephone number." The reason he said it was the introduction of meat rationing during the 1914-18 war when children with coeliac disease were allowed three times the ordinary ration, so as to provide the high-protein diet in vogue at the time. These were the years before general physicians had filched the title for their patients, and coeliac disease had a purely paediatric connotation. Adults with the same condition were diagnosed as "nontropical sprue" and were treated by other means which might even include a diet of bael fruit (Bengal quince). It has been one of the sorrows of my therapeutic career that I never had an opportunity to prescribe such treatment. But I digress. The point of Cameron’s remark was that when it became known that a triple meat ration was possible, Dr Still was inundated with inquiries as to the nature of coeliac disease and the means by which determined carnivores might acquire it. I record all this solely to underline the fact that paediatrics is a relatively new specialty in the United Kingdom. There was no chair of child health in London until after the end of the 1939-45 war, though Scotland and the Provinces were, as might have been expected, ahead in this matter. Leonard Finlay in Glasgow was the first, in 1924, and in Birmingham Leonard Parsons was made professor in 1929. These appointments seem very tardy when compared with the position abroad. For example, Henoch retired from the chair of paediatrics at Berlin University in 1873, and Abraham Jacobi, no relation I regret to say, became the first professor of paediatrics in the U.S.A. in 1870. It is also surely of interest to note that Escherich succeeded to the chair of paediatrics in Vienna in 1901. Over many years I have asked students and others what they knew about Escherich, and invariably the answer was "An eminent bacteriologist". It is not widely known that the eponymous E. coli are named after a paediatrician. IT
was
History If I have been somewhat critical of the British acceptance of paediatrics as worthy of academic status, we can claim that individually the triumvirate of Sir Thomas Barlow (1856-1945), John Thompson (1856-1926), and Sir Frederick *Present address: Kent.
Broomyfields, Horseshoe Green,
Mark Beech,
Edenbridge,
Still (1868-1941) would be names to conjure with in any historic paediatric discussion. If this sort of topic interests you, let me strongly recommend Veeder’s Pediatric Profiles. For our purely domestic history, Cameron’s British Ptsdtatric Association, 1928-1952 records the names and deeds of our founders, and many of the historic names mentioned were known personally to many paediatricians still alive-something that cannot be said of most other specialties. The B.P.A. was very wise in choosing Cameron as its first historian, for he had great facility with words, both spoken and written. His two most famous books on the nervous child are classic descriptions of that ubiquitous and investigation-defying entity, "the periodic syndrome". Though his concept of the aetiology as "glycopenic" was wrong, it has had a profound effect on much commercial and medical practice ever since. Cameron’s biography of Lister is worth reading: but his much more attractive treatise on Lord Byron’s feet was never published. He firmly believed that Byron was a spastic and not a talipes, and somewhere there must be a manuscript awaiting the light of day. Textbooks
After the joys of historical reading, it is a dreary matter to consider standard textbooks, which have always seemed to me a necessary evil. Why must they be so dull? I recall only two such works, neither paediatric, which really had character. They were the original editions of Bailey & Love’s A Short Practice of Surgery and Boyd’s Textbook of Pathology, both of which in newer editions happily still exist. The trouble with textbooks, apart from their dreariness is their cost, and the fact that they are obsolescent at the time of publication. They tend to be written by eminent members of the profession at a stage in their careers when they eschew the bedside of the acutely ill in the small hours of the morning. The result is that they are authentic on their own pet subjects, less so on others, and sometimes seem to have copied from others who have copied from others. Multiple authorship reduces these failings, and the best effort at overcoming them was Brennemann’s fourvolume loose-leaf book where every author was an expert, and any section could be replaced by a revised version, thus keeping the book up to date without having a complete new edition. The main disadvantage was the cost, which in the nineteen forties was over 20, and the equivalent now would be a staggering 200. If such books are no longer possible, what then? My preference has been for "Nelson"; but recently a strong competitor has appeared in Forfar and Arneil’s textbook. It is well written and reliable. When introduced to a new work I tend to look at those sections dealing with matters on which I consider myself to be an authority. The paragraph in this book dealing with the medical treatment of pyloric stenosis suggests, I hope wrongly, that the writer had no experience of the subject. A trivial matter no doubt; but is it the only such defect in the tome? The shorter textbooks seem to me to be undistinguished, and students should choose a recent publication before it is out of date.
Development Assessment is now the "in thing" of paediatrics, and there many works on the subject. Thirty and more years ago the experienced paediatrician could make a fair assessment of a child’s development, just from his clinical acumen and experience. Even now, occasionally he can be more accurate than the scientific measured approach. The whole thing has become so complex with the presence or absence of various reflexes at various ages, as well as the various abilities that should be shown with the passage of time, that some work of reference is essential. An eminent paediatrician is said to have had an assistant who knew no less than 120 different reflexes and signs that could be elicited in an infant, but the significance of any one of them totally eluded him. Illingworth’s book is excellent, written in his admirable style, and has always covered my are
requirements.