- Email: [email protected]
End of life decisions
CORRESPONDENCE
A clinician’s guide to NHS management Sir—Stephen Dorman (Dec 2, p 1940)1 suggests a fresh approach, namely managerial consultation, to get the most out of the doctor-manager relationship. His approach, however, omits an assessment of the behavioural features of this relationship, which I believe is quite important. When doctors and managers are engaged in a conflict, there are two major concerns that they take into account. First, achieving their personal goals and second, keeping a good relationship with each other. The importance of each concern determines how doctors and managers act in a conflict.2 Because of their different backgrounds, education, beliefs, and personality characteristics,3 they may react differently. I did a study to find out which strategies consultants and managers use to manage conflict. I sent a to 76 validated questionnaire4 consultants and 17 senior managers in my hospital to assess their strategies in management of conflicts. 52 (68%) consultants and 16 (94%) managers replied. Many consultants (65%) used a problem-solving and negotiating strategy, and the second most common strategy was accommodation, which was used by 27% of consultants (table). No consultant used a withdrawing or forcing strategy. More managers (82%) used the problem-solving and negotiating strategy, but the difference between them and consultants was not significant. My results show that, despite their different backgrounds, education, and personality characteristics, doctors and managers use similar conflict strategy in dealing with their everyday conflict. This finding suggests that at least the differences are acknowledged and that the gap created by the politicians, is perhaps narrowed. Stephen Dorman states that doctors and managers have always been somewhat reluctant bedfellows in the political games of National Health Service management. I think the time has come for doctors to realise that Conflict strategy
Consultants
Managers
p
Withdrawing Forcing Accommodating Compromising Problem-solving/ negotiating
0 0 14 (27%) 4 (8%) 34 (65%)
0 1 (6%) 1 (6%) 1 (6%) 13 (82%)
·· 0·23 0·10 1·00 0·36
Frequency of conflict strategies used by consultants and managers
640
managers are on the same side of the fence. If any change is required, it is not to the managers of our hospitals but to the politicians who use our managers as political pawns.
preferences to be transcribed into the clinical records. Ian Kunkler
Mourad Labib
University Department of Clinical Onoclogy, Western General Hospital, Lothian University Hospitals NHS Trust, Edinburgh EH4 2XU, UK (e-mail: [email protected])
Russells Hall Hospital, Dudley, West Midlands DY1 2HQ, UK
1
1 2
3
4
Dorman S. A clinician’s guide to NHS management. Lancet 2000; 356: 1940. Johnson DW. Resolving interpersonal conflicts. In: Reaching out: interpersonal effectiveness and self-actualisation, 7th edn. MA, USA: Allyn and Bacon, 2000: 249–303. Winkless AJ. Personality characteristics: medical consultants and NHS general managers. In: Sanderson D, Brown J, eds. Managing medicine. New Jersey, USA: FT Healthcare, 1997: 151–59. Johnson DW. Conflict strategies. In: Reaching out. Interpersonal effectiveness and self-actualisation, 4th edn. New Jersey, USA: Prentice-Hall International, 1990: 215–35.
End of life decisions Sir—D Martin and colleagues (Nov 11, p 1672)1 report on planning for the end of life focus on appropriate methods for recording patients’ wishes. They acknowledge that, despite providers and patients in principle supporting the idea of completion of advanced directive forms, only limited use of these forms is made in practice.2 This finding suggests that whatever the theoretical attractions of this approach, patients are reluctant to complete or physicians to proffer these forms. The process of coming to terms with death is intensely personal and a commonly difficult process, with a gradual realisation that the speed of metastatic or recurrent disease is accelerating. Assistance to patients through this period involves a continuous process of communication in which patients’ fears and concerns are gently elicited and addressed in a series of conversations with various health-care professionals. The confronting of patients with a series of questions that systematically address issues in advanced care planning does not seem to me to be a sensitive method of documenting patients’ preferences. It is not surprising that completion rates are low. Perhaps more acceptable to patients would be a series of informal structured interviews covering the same issues. The timing, frequency, pace and content of these conversations could be judged sensitively by the physician, while allowing the key features of a patient’s
2
Martin DK, Emanual LL, Singer PA. Planning for the end of life. Lancet 2000; 356: 1672–76. Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care: a case for greater use. N Engl J Med 1991; 324: 889–95.
Health and war in CongoBrazzaville Sir—P Salignon and colleagues (Nov 18, p 1762)1 highlight that about 800 000 people have been severely affected by the 2-year war that devastated Congo-Brazzaville between December, 1998, and January, 2000. In addition to repeated periods of malnutrition and widescale population displacements, many people have been injured by traumas or wounded by gunshots. They face lack of access to health-care facilities. Although primary care has slightly improved, since March, 2000, surgical treatment of more severe complications or diseases for which surgical care was delayed during the war, remains an unresolved challenge. The Comité International pour la Renaissance de Brazzaville organised a postwar partnership between the Department of Surgery of the Pierre Mobengo Hospital, Brazzaville, and a university surgical team from Hôpital Saint-Louis, Paris, France. Five surgeons, one anaesthesiologist, one internist, two radiologists, and three operating-room nurses go to work in the Congolese hospital for 3–5 days twice a year. Patients scheduled for difficult surgical interventions are operated on by two surgeons involved in the same specialty—one Congolese and one French teaching counterpart. The anaesthesiologists, the physicians in the postoperative intensive-care unit, the operating-room nurses, and the radiologists use the same tandemteaching approach. About 121 surgical procedures have been done, including visceral, renal, mouth, facial, and orthopaedic surgery. The efficacy of this policy has gradually improved during the three visits, and the average number of operations per day has increased from eight to 14·2. Average stays in the intensive care unit have shortened from 3·3 to 1·4 days, and postoperative care of patients by
THE LANCET • Vol 357 • February 24, 2001
For personal use only. Reproduce with permission from The Lancet Publishing Group.
A clinician’s guide to NHS management Sir—Stephen Dorman (Dec 2, p 1940)1 suggests a fresh approach, namely managerial consultation, to get the most out of the doctor-manager relationship. His approach, however, omits an assessment of the behavioural features of this relationship, which I believe is quite important. When doctors and managers are engaged in a conflict, there are two major concerns that they take into account. First, achieving their personal goals and second, keeping a good relationship with each other. The importance of each concern determines how doctors and managers act in a conflict.2 Because of their different backgrounds, education, beliefs, and personality characteristics,3 they may react differently. I did a study to find out which strategies consultants and managers use to manage conflict. I sent a to 76 validated questionnaire4 consultants and 17 senior managers in my hospital to assess their strategies in management of conflicts. 52 (68%) consultants and 16 (94%) managers replied. Many consultants (65%) used a problem-solving and negotiating strategy, and the second most common strategy was accommodation, which was used by 27% of consultants (table). No consultant used a withdrawing or forcing strategy. More managers (82%) used the problem-solving and negotiating strategy, but the difference between them and consultants was not significant. My results show that, despite their different backgrounds, education, and personality characteristics, doctors and managers use similar conflict strategy in dealing with their everyday conflict. This finding suggests that at least the differences are acknowledged and that the gap created by the politicians, is perhaps narrowed. Stephen Dorman states that doctors and managers have always been somewhat reluctant bedfellows in the political games of National Health Service management. I think the time has come for doctors to realise that Conflict strategy
Consultants
Managers
p
Withdrawing Forcing Accommodating Compromising Problem-solving/ negotiating
0 0 14 (27%) 4 (8%) 34 (65%)
0 1 (6%) 1 (6%) 1 (6%) 13 (82%)
·· 0·23 0·10 1·00 0·36
Frequency of conflict strategies used by consultants and managers
640
managers are on the same side of the fence. If any change is required, it is not to the managers of our hospitals but to the politicians who use our managers as political pawns.
preferences to be transcribed into the clinical records. Ian Kunkler
Mourad Labib
University Department of Clinical Onoclogy, Western General Hospital, Lothian University Hospitals NHS Trust, Edinburgh EH4 2XU, UK (e-mail: [email protected])
Russells Hall Hospital, Dudley, West Midlands DY1 2HQ, UK
1
1 2
3
4
Dorman S. A clinician’s guide to NHS management. Lancet 2000; 356: 1940. Johnson DW. Resolving interpersonal conflicts. In: Reaching out: interpersonal effectiveness and self-actualisation, 7th edn. MA, USA: Allyn and Bacon, 2000: 249–303. Winkless AJ. Personality characteristics: medical consultants and NHS general managers. In: Sanderson D, Brown J, eds. Managing medicine. New Jersey, USA: FT Healthcare, 1997: 151–59. Johnson DW. Conflict strategies. In: Reaching out. Interpersonal effectiveness and self-actualisation, 4th edn. New Jersey, USA: Prentice-Hall International, 1990: 215–35.
End of life decisions Sir—D Martin and colleagues (Nov 11, p 1672)1 report on planning for the end of life focus on appropriate methods for recording patients’ wishes. They acknowledge that, despite providers and patients in principle supporting the idea of completion of advanced directive forms, only limited use of these forms is made in practice.2 This finding suggests that whatever the theoretical attractions of this approach, patients are reluctant to complete or physicians to proffer these forms. The process of coming to terms with death is intensely personal and a commonly difficult process, with a gradual realisation that the speed of metastatic or recurrent disease is accelerating. Assistance to patients through this period involves a continuous process of communication in which patients’ fears and concerns are gently elicited and addressed in a series of conversations with various health-care professionals. The confronting of patients with a series of questions that systematically address issues in advanced care planning does not seem to me to be a sensitive method of documenting patients’ preferences. It is not surprising that completion rates are low. Perhaps more acceptable to patients would be a series of informal structured interviews covering the same issues. The timing, frequency, pace and content of these conversations could be judged sensitively by the physician, while allowing the key features of a patient’s
2
Martin DK, Emanual LL, Singer PA. Planning for the end of life. Lancet 2000; 356: 1672–76. Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care: a case for greater use. N Engl J Med 1991; 324: 889–95.
Health and war in CongoBrazzaville Sir—P Salignon and colleagues (Nov 18, p 1762)1 highlight that about 800 000 people have been severely affected by the 2-year war that devastated Congo-Brazzaville between December, 1998, and January, 2000. In addition to repeated periods of malnutrition and widescale population displacements, many people have been injured by traumas or wounded by gunshots. They face lack of access to health-care facilities. Although primary care has slightly improved, since March, 2000, surgical treatment of more severe complications or diseases for which surgical care was delayed during the war, remains an unresolved challenge. The Comité International pour la Renaissance de Brazzaville organised a postwar partnership between the Department of Surgery of the Pierre Mobengo Hospital, Brazzaville, and a university surgical team from Hôpital Saint-Louis, Paris, France. Five surgeons, one anaesthesiologist, one internist, two radiologists, and three operating-room nurses go to work in the Congolese hospital for 3–5 days twice a year. Patients scheduled for difficult surgical interventions are operated on by two surgeons involved in the same specialty—one Congolese and one French teaching counterpart. The anaesthesiologists, the physicians in the postoperative intensive-care unit, the operating-room nurses, and the radiologists use the same tandemteaching approach. About 121 surgical procedures have been done, including visceral, renal, mouth, facial, and orthopaedic surgery. The efficacy of this policy has gradually improved during the three visits, and the average number of operations per day has increased from eight to 14·2. Average stays in the intensive care unit have shortened from 3·3 to 1·4 days, and postoperative care of patients by
THE LANCET • Vol 357 • February 24, 2001
For personal use only. Reproduce with permission from The Lancet Publishing Group.