- Email: [email protected]
NHS attitudes to good medical practice
RESEARCH LETTERS ~~
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history of recurrent abdominal pain, chronic diarrhoea, weight loss, and iron-deficiency anaemia. Corazza and colleagues’ study of 2237 adults aged 20-87 years shows a prevalence of coeliac disease of 1.79 per 1000 in the general population.b The statistical analysis of our data using Fischer’s exact test compared with those of Corazza, showed a significantlyincreased prevalence of coeliac disease in IDCM patients (p
Department of Clinical Sciences, University “La Sapienza”, Rome, Italy (M Curione MD); Department of Pediatrics, Division of Gastroenterology, University “La Sapienza”, Rome, Italy (M Barbato MD, F Viola MD, L LORusso MD, E Cardi Pm); and Department of Cardiology 2, University “La Sapienza”, Rome, Italy (L De Biase MO) Correspondence to: Dr M Curione, Via Lago di Lesina 57, 00199, Rome, Italy (e-mail: [email protected])
NHS attitudes to good medical
practice Allen Hutchinson, Melanie Williams, Keith Meadows, Rosaline S Barbour
Perceptions of good medical practice among senior NHS staff were collected through a survey. There are differences between the perceived seriousness of poor communication skills and poor technical skills.
Regulatory and quasi-regulatory changes affecting the British medical profession have increased rapidly since 1997, in the recognition that there are instances in which some doctors do not meet the standards required in the General Medical Council (GMC) statements in Good Medical Practice.I New procedures coming into place include the introduction of the GMC performance procedures’ in 1997 and the concept of clinical governance in 1998, the former established as a regulatory process for doctors to ensure the safety of the public in what is expected to be a limited number of cases, the latter a process to ensure quality improvement across the NHS.’ At the same time, a number of high profile cases relating to poor performance has raised public concern and further legislation is proposed that may radically alter the way in which the British clinical Professions are regulated in the f u t ~ r e . ~ Soon after the GMC performance procedures were introduced, a two-stage study was undertaken in late 1997 and early 1998 among senior NHS professionals with responsibility for handling poorly performing doctors, to find how respondents viewed good medical practice and to
THE LANCET * Vol354 -July 17,1999
Manner Communication Prescribing Diagnosis Management and outcome and attitude
75%
82%
95%
98%
98%
Trust (n=182) 81% Community Health 88% Council (n=67) Local medical 66%
89% 91%
98% 97%
98% 98%
98% 97%
88%
96%
99%
97%
Health Authority
(n=134)
cnrnmittee ln=7?J
Respondents who considered that a consistent and serious error in areas of clinical practice may constitute poor performance, by employing organisation
seek their experience on the type and extent of poor performance problems they encountered. In the first stage, 48 health professionals were interviewed (including directors of public health, medical directors of hospitals, and local medical committee (LMC) secretaries, representing general practice). Semi-structured interviews were used to seek views on the types of problems that were raised by doctors whose performance is poor and on the current methods of handling the problems. There was considerable frustration among participants at the difficulty of making changes that would improve patient care. Placing informal limits on a doctor’s work seemed to be the mechanism most favoured in hospital, although this was not possible in general practice. In the second stage of the study, questionnaires based on the results of the interviews were sent to directors of public health and complaints managers of all UK health authorities and boards, to LMC secretaries, to community health council chief officers (representing consumers) and to medical directors and complaints managers of a 50% random sample of NHS hospital trusts. Overall response rates from institutions ranged from 56% to 75%. Respondents were asked to consider whether the skills of professional consultation, particularly in the doctor’s manner and attitude to the patient, were of as much significance as were technical skills when considering how to act on a consistent and serious error in clinical practice. Although there were some differences of emphasis between the professional groups responding, overall there was a consistent finding that problems in manner and attitude of the doctor towards the patient were not seen as being of such serious significance as problems relating to technical skills (table). Furthermore, these differences of perception would also impact on the proposed actions of the respondents when managing a case of poor performance, because, when asked what action might be taken over such problems, there remained a clear difference towards these aspects of clinical practice, serious and consistent manner and attitude problems being less likely to generate a local investigation than technical problems. These findings were in contrast to respondents reporting that problems with manner and attitude constituted the more frequent type of problem. It must be of concern that even senior NHS professionals hesitate to view consistent and serious errors in consultation skills as requiring local action, in contrast with their more definite notions about action in the face of technical problems. Complaints from patients often arise as a result of communication problems and the GMC requires doctors to give consideration to the communication aspects of clinical practice. Perhaps the more recent introduction of clinical governance throughout the NHS will provide the milieu for making changes to these aspects of practice where performance is poor, without having to resort to formal proceedings as a means of rectifying such problems. For if the medical profession does not address these issues then others assuredly wilL5 223
RESEARCH LETTERS 1 General Medical Council. Good Medical Practice. London: General Medical Council, 1998. 2 Department of Health. The Medical (Professional Performances) Act (1995). London: Department of Health, 1995. 3 Department of Health. A first class service. London: Department of Health, 1998. 4 Smith R. All changed, changed utterly. BMJ 1998; 316: 1917-18. 5 IUein R. Competence, professional self regulation, and the public interest. BMJ 1998; 316: 1740-42.
School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield S14DA, UK (Prof A Hutchinson FFPHM); and Department of Public Health and Primary Care, University of Hull, Hull, UK (M Williams BA, K Meadows PhD, R S Barbour PhD) Correspondence to: Prof Allen Hutchinson
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20
40
60
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100 120 140
160
Serum E2 (pg/mL)
Oestrogen and age estimations of perimenopausal women
Serum oestradiol concentrations in relation to the difference between estimated and real age in 100 perimenopausal women There were no significant differences between the estimates made by both observers, so the mean was used when two estimates were available.
Ludwig Wildt, Teresa Sir-Petermann We estimated the age of perimenopausal women at a first visit and measured the concentrations of oestradiol in serum. The accuracy of estimation of age strongly correlated with oestradiol concentrations: age was overestimated when oestradiol was low and underestimated when oestradiol was high.
The association between oestrogens and sexual attractiveness has been widely discussed in both scientific and popular literature.’ However, the question how oestrogens confer information and signals on attractiveness in the human female has seldom been addressed. Evidence has been accumulated in various species, including our own, that female attractiveness reflects reproductive competence. Reproductive competence gradually declines until menopause. Since this process is also associated with decreasing concentrations of oestrogens, and since the chronological age at which menopause occurs may vary considerably between individuals; we speculated that an observer’s estimate of biological age of a female may, to some extent, be influenced by their oestrogen concentrations. We therefore estimated the age of women when they first entered our office at our outpatient clinic at the Department of Obstetrics and Gynecology, University of Erlangen. The estimate was made within the first minute after entry and recorded by the observer. During subsequent endocrine diagnostic procedures, oestradiol serum concentrations were determined by specific immunoassays in blood samples taken during the early follicular phase of the cycle in menstruating women, during the first week of treatment in women on hormone replacement therapy, or at the time of first visit in amenorrhoic women. After the end of the observation period, the difference between the age estimated by us and the real age was calculated for each patient and plotted against serum oestradiol concentrations. For final analysis, the data of 100 white women 35-55 years of age were used. The results are shown in the figure. The age of women with low oestradiol serum concentrations was systematically overestimated; with increasing serum oestrogen levels the reverse was the case. Multiple-regression analysis using oestradiol and real age as independent variables showed a strong correlation between serumE2 concentration and the difference between real and estimated age (p
224
women with high oestrogen concentrations looked younger, women with low oestradiol concentrations older than they really were. The discrepancy between estimated and real age could be as high as 8 years in either direction. These data suggest that serum oestrogen concentrations have a pronounced impact on the estimation of age and, by inference, on the estimation of reproductive competence made by an independent observer. The variability of our estimations was low and the sex of the observer did not influence these estimates to a significant extent. We did not attempt to identify the factors by which oestradiol serum concentratioins could have influenced estimation of age. It has been shown, however, that oestrogen administration to postmenopausal women is accompanied by an increase in skin thickness as well as collagen and water content; in addition, a decrease in wrinkles of facial skin has been observed during oestrogen treatment.'^^ It has also been shown that thickness and collagen content of skin are more related to menopausal than chronological age.’ It is conceivable that these changes may influence the estimation of age of a woman by independent observers. At any rate, our finding may be of interest not only under behavioural aspects, but also with regard to the decision of patients to administer hormone replacement therapy in the perimenopause and postmenopause. 1 Wilson RA. Feminine forever. New York Evans, 1966. 2 McKinlay SM. The normal menopause transition: an overview. Maturitas 1996; 23: 137-45. 3 Schmidt JB, Binder M, Macheiner W, Kainz C, Gitsch G, Bieglmayer C. Treatment of skin aging symptoms in perimenopausal females with estrogen compounds: a pilot study. Maturitas 1994; 20: 25-30. 4 Castelo-Branco C, Figueras F, De Osaba MJM, Vanrell JA. Facial wrinkling in postmenopausal women: effects of smoking status and hormone replacement therapy. Macuritas 1998; 29: 75-86. 5 Brincat M, Moniz CJ, Studd JW, et al. long-term effects of the menopause and sex hormones on skin thickness. B r 3 Obstet Gynecol 1985; 92: 256-59.
Division of Gynaecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynaecology, University of Erlangen-Nurnberg, Germany (Prof L Wildt MD); and Department of Endocrinology, University of Chile, Santiago de Chile, Chile (T Sir-Petermann MD) Correspondence to: Prof Ludwig Wildt (e-mail: [email protected])
-
T H E LANCET Vol354 *July 17, 1999
~
~
~
~
~~~~~~
~
~
~
history of recurrent abdominal pain, chronic diarrhoea, weight loss, and iron-deficiency anaemia. Corazza and colleagues’ study of 2237 adults aged 20-87 years shows a prevalence of coeliac disease of 1.79 per 1000 in the general population.b The statistical analysis of our data using Fischer’s exact test compared with those of Corazza, showed a significantlyincreased prevalence of coeliac disease in IDCM patients (p
Department of Clinical Sciences, University “La Sapienza”, Rome, Italy (M Curione MD); Department of Pediatrics, Division of Gastroenterology, University “La Sapienza”, Rome, Italy (M Barbato MD, F Viola MD, L LORusso MD, E Cardi Pm); and Department of Cardiology 2, University “La Sapienza”, Rome, Italy (L De Biase MO) Correspondence to: Dr M Curione, Via Lago di Lesina 57, 00199, Rome, Italy (e-mail: [email protected])
NHS attitudes to good medical
practice Allen Hutchinson, Melanie Williams, Keith Meadows, Rosaline S Barbour
Perceptions of good medical practice among senior NHS staff were collected through a survey. There are differences between the perceived seriousness of poor communication skills and poor technical skills.
Regulatory and quasi-regulatory changes affecting the British medical profession have increased rapidly since 1997, in the recognition that there are instances in which some doctors do not meet the standards required in the General Medical Council (GMC) statements in Good Medical Practice.I New procedures coming into place include the introduction of the GMC performance procedures’ in 1997 and the concept of clinical governance in 1998, the former established as a regulatory process for doctors to ensure the safety of the public in what is expected to be a limited number of cases, the latter a process to ensure quality improvement across the NHS.’ At the same time, a number of high profile cases relating to poor performance has raised public concern and further legislation is proposed that may radically alter the way in which the British clinical Professions are regulated in the f u t ~ r e . ~ Soon after the GMC performance procedures were introduced, a two-stage study was undertaken in late 1997 and early 1998 among senior NHS professionals with responsibility for handling poorly performing doctors, to find how respondents viewed good medical practice and to
THE LANCET * Vol354 -July 17,1999
Manner Communication Prescribing Diagnosis Management and outcome and attitude
75%
82%
95%
98%
98%
Trust (n=182) 81% Community Health 88% Council (n=67) Local medical 66%
89% 91%
98% 97%
98% 98%
98% 97%
88%
96%
99%
97%
Health Authority
(n=134)
cnrnmittee ln=7?J
Respondents who considered that a consistent and serious error in areas of clinical practice may constitute poor performance, by employing organisation
seek their experience on the type and extent of poor performance problems they encountered. In the first stage, 48 health professionals were interviewed (including directors of public health, medical directors of hospitals, and local medical committee (LMC) secretaries, representing general practice). Semi-structured interviews were used to seek views on the types of problems that were raised by doctors whose performance is poor and on the current methods of handling the problems. There was considerable frustration among participants at the difficulty of making changes that would improve patient care. Placing informal limits on a doctor’s work seemed to be the mechanism most favoured in hospital, although this was not possible in general practice. In the second stage of the study, questionnaires based on the results of the interviews were sent to directors of public health and complaints managers of all UK health authorities and boards, to LMC secretaries, to community health council chief officers (representing consumers) and to medical directors and complaints managers of a 50% random sample of NHS hospital trusts. Overall response rates from institutions ranged from 56% to 75%. Respondents were asked to consider whether the skills of professional consultation, particularly in the doctor’s manner and attitude to the patient, were of as much significance as were technical skills when considering how to act on a consistent and serious error in clinical practice. Although there were some differences of emphasis between the professional groups responding, overall there was a consistent finding that problems in manner and attitude of the doctor towards the patient were not seen as being of such serious significance as problems relating to technical skills (table). Furthermore, these differences of perception would also impact on the proposed actions of the respondents when managing a case of poor performance, because, when asked what action might be taken over such problems, there remained a clear difference towards these aspects of clinical practice, serious and consistent manner and attitude problems being less likely to generate a local investigation than technical problems. These findings were in contrast to respondents reporting that problems with manner and attitude constituted the more frequent type of problem. It must be of concern that even senior NHS professionals hesitate to view consistent and serious errors in consultation skills as requiring local action, in contrast with their more definite notions about action in the face of technical problems. Complaints from patients often arise as a result of communication problems and the GMC requires doctors to give consideration to the communication aspects of clinical practice. Perhaps the more recent introduction of clinical governance throughout the NHS will provide the milieu for making changes to these aspects of practice where performance is poor, without having to resort to formal proceedings as a means of rectifying such problems. For if the medical profession does not address these issues then others assuredly wilL5 223
RESEARCH LETTERS 1 General Medical Council. Good Medical Practice. London: General Medical Council, 1998. 2 Department of Health. The Medical (Professional Performances) Act (1995). London: Department of Health, 1995. 3 Department of Health. A first class service. London: Department of Health, 1998. 4 Smith R. All changed, changed utterly. BMJ 1998; 316: 1917-18. 5 IUein R. Competence, professional self regulation, and the public interest. BMJ 1998; 316: 1740-42.
School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield S14DA, UK (Prof A Hutchinson FFPHM); and Department of Public Health and Primary Care, University of Hull, Hull, UK (M Williams BA, K Meadows PhD, R S Barbour PhD) Correspondence to: Prof Allen Hutchinson
a
: 2 OD
10-
..
8-
(‘3z6 .E t 4-a, $ 32 ta,
8 E 02 5-2-
22 a,
u-4-
u (‘3-6s
s
a,
8 L
-8-
b -10I
I
I
I
I
0
20
40
60
80
I
I
I
I
100 120 140
160
Serum E2 (pg/mL)
Oestrogen and age estimations of perimenopausal women
Serum oestradiol concentrations in relation to the difference between estimated and real age in 100 perimenopausal women There were no significant differences between the estimates made by both observers, so the mean was used when two estimates were available.
Ludwig Wildt, Teresa Sir-Petermann We estimated the age of perimenopausal women at a first visit and measured the concentrations of oestradiol in serum. The accuracy of estimation of age strongly correlated with oestradiol concentrations: age was overestimated when oestradiol was low and underestimated when oestradiol was high.
The association between oestrogens and sexual attractiveness has been widely discussed in both scientific and popular literature.’ However, the question how oestrogens confer information and signals on attractiveness in the human female has seldom been addressed. Evidence has been accumulated in various species, including our own, that female attractiveness reflects reproductive competence. Reproductive competence gradually declines until menopause. Since this process is also associated with decreasing concentrations of oestrogens, and since the chronological age at which menopause occurs may vary considerably between individuals; we speculated that an observer’s estimate of biological age of a female may, to some extent, be influenced by their oestrogen concentrations. We therefore estimated the age of women when they first entered our office at our outpatient clinic at the Department of Obstetrics and Gynecology, University of Erlangen. The estimate was made within the first minute after entry and recorded by the observer. During subsequent endocrine diagnostic procedures, oestradiol serum concentrations were determined by specific immunoassays in blood samples taken during the early follicular phase of the cycle in menstruating women, during the first week of treatment in women on hormone replacement therapy, or at the time of first visit in amenorrhoic women. After the end of the observation period, the difference between the age estimated by us and the real age was calculated for each patient and plotted against serum oestradiol concentrations. For final analysis, the data of 100 white women 35-55 years of age were used. The results are shown in the figure. The age of women with low oestradiol serum concentrations was systematically overestimated; with increasing serum oestrogen levels the reverse was the case. Multiple-regression analysis using oestradiol and real age as independent variables showed a strong correlation between serumE2 concentration and the difference between real and estimated age (p
224
women with high oestrogen concentrations looked younger, women with low oestradiol concentrations older than they really were. The discrepancy between estimated and real age could be as high as 8 years in either direction. These data suggest that serum oestrogen concentrations have a pronounced impact on the estimation of age and, by inference, on the estimation of reproductive competence made by an independent observer. The variability of our estimations was low and the sex of the observer did not influence these estimates to a significant extent. We did not attempt to identify the factors by which oestradiol serum concentratioins could have influenced estimation of age. It has been shown, however, that oestrogen administration to postmenopausal women is accompanied by an increase in skin thickness as well as collagen and water content; in addition, a decrease in wrinkles of facial skin has been observed during oestrogen treatment.'^^ It has also been shown that thickness and collagen content of skin are more related to menopausal than chronological age.’ It is conceivable that these changes may influence the estimation of age of a woman by independent observers. At any rate, our finding may be of interest not only under behavioural aspects, but also with regard to the decision of patients to administer hormone replacement therapy in the perimenopause and postmenopause. 1 Wilson RA. Feminine forever. New York Evans, 1966. 2 McKinlay SM. The normal menopause transition: an overview. Maturitas 1996; 23: 137-45. 3 Schmidt JB, Binder M, Macheiner W, Kainz C, Gitsch G, Bieglmayer C. Treatment of skin aging symptoms in perimenopausal females with estrogen compounds: a pilot study. Maturitas 1994; 20: 25-30. 4 Castelo-Branco C, Figueras F, De Osaba MJM, Vanrell JA. Facial wrinkling in postmenopausal women: effects of smoking status and hormone replacement therapy. Macuritas 1998; 29: 75-86. 5 Brincat M, Moniz CJ, Studd JW, et al. long-term effects of the menopause and sex hormones on skin thickness. B r 3 Obstet Gynecol 1985; 92: 256-59.
Division of Gynaecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynaecology, University of Erlangen-Nurnberg, Germany (Prof L Wildt MD); and Department of Endocrinology, University of Chile, Santiago de Chile, Chile (T Sir-Petermann MD) Correspondence to: Prof Ludwig Wildt (e-mail: [email protected])
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T H E LANCET Vol354 *July 17, 1999