VIEWS AND REVIEWS
“Once doctors understood that medicine
was more opinion than science, so were
tolerant, supportive, and respectful of
differing perspectives”
Des Spence, p 49
PERSONAL VIEW Nadeem Moghal
What are mission, vision, and values statements for?
H
ealthcare organisations, probably
the world over but certainly in the
UK, have aped corporate behaviour
in other sectors in establishing statements of mission, vision, and values
that purport to describe why they exist and set
aspirational direction. Their statements can be
found on websites in the “about us” section, in
glossy annual reports, on posters staring at you as
you wait in the emergency department,
on headed paper, and maybe even on
corporate mugs. Some if not all of
these statements will have been
the result of earnest and meaningful executive and non-executive
soul searching on away days.
What is the primary
purpose of a healthcare
provider? Why does a
healthcare provider exist?
To coin a phrase, “To
provide healthcare,
stupid.” Who provides
that healthcare? “The
clinicians, stupid.” Do
the clinicians need mission, vision, and values
statements to remind
them why they do what
they do, why they come to
work, and why they exist?
Perhaps. After all, there seem
to be enough examples of
troubled services that would be
served by a mission statement to
remind staff why they are there.
One region’s mission, vision, and values
statements, filtered through a word cloud application, which gives visual weight to words in
proportion to their occurrence, reveals the most
dominant words to be: “patients,” “quality,”
“services,” “care,” “staff,” “health,” and “best”
(above right). If you were to read these statements either your eyes would glaze over as you
lost the will to live, or they would roll up as you
wondered if these imploring, aspiring statements
really would inspire and motivate the workers,
draw patients away from potential competitors,
and give meaning to the organisation. You would
recall, I suspect, very little.
BMJ | 30 JUNE 2012 | VOLUME 344
Despite these contorted and often duplicated
statements, every one of these organisations
surely has only one primary reason to exist: to
prevent illness, cure disease, and relieve suffering,
delivered by reliable systems of care, and delivered
by people who care. What is missing in this statement are marketing fodder words—“excellent,”
“the best,” “cutting edge.” What is in this statement is the word “reliable”—that is, a system in
which the patient sees the right person at
the right time in the right place for the right
care; an operational definition that can
be used to measure system reliability,
and it comes with a number.
More critically, a reliable system, by definition, delivers quality care. “Reliable” assumes an
understanding of its meaning in
healthcare so perhaps the statement could read: “To prevent
illness, cure disease, and
relieve suffering, delivered by quality systems
of care, and delivered
by people who care. A
quality system can be
delivered only by a reliable operating system.”
Is it necessary to be explicit
about healthcare being delivered by caring people? Surely
we all come to work to deliver
care, and caring is what we do.
Perhaps. But we know from a sea
of data, including complaints, litigation, seemingly failed and failing trusts,
investigative journalism, and patient feedback
tools, that we cannot assume that caring is part
of the DNA of all those who interact with and contribute to the care of patients.
If “To prevent illness, cure disease, and relieve
suffering delivered by quality systems of care, and
delivered by people who care” is what defines the
why and the how for a healthcare provider, how
can any individual provider possibly differentiate itself from its neighbouring trust or competing service? Does the mission, vision, and values
statement draw a patient into an organisation for
that cure or relief of suffering? Do the statements
indicate how a general practitioner or clinical
Delegating inspiring leadership to
mission, vision, and values statements
is not inspiring leadership. It isn’t any
kind of leadership
commissioning group is going to make a decision for the patient? Even if we get into a genuine
competitive market, are the mission, vision, and
values statements the basis of consumer choice?
The consumer is surely more interested in, we
are repeatedly reminded, how good the organisation is based on outcome data. We all want to
be the best. But how good are we now? And are
we improving?
If the staff delivering the work on the ground
know why they do what they do, and the users of
healthcare services continue to access the nearest and most convenient service rather than most
aspirational, then for whom are these statements
intended? Might they be for those who work in
healthcare organisations not delivering the clinical work but managing the organisation at some
distance from where the clinical work is done? Do
they, the managers, executives, and board members, need to define for themselves a purpose for
their existence? They go on away days to define
organisational purpose and come back with some
“groupthink” articulated in a mission statement—
the modern manifestation of the early 20th century factory floor poster, imploring and reminding
workers, the people who deliver the purpose of
the organisation, to work harder to deliver that
purpose. Delegating inspiring leadership to mission, vision, and values statements is not inspiring leadership. It isn’t any kind of leadership.
A straw poll of nurses, doctors, and healthcare
assistants confirms that no one can begin to recall
even a fraction of these statements, because they
have no obvious meaning or value for them. I
have not been brave enough to test an executive.
One day the “about us” section of a trust’s website
might be less about statements of mission, vision,
and values, and more about the data that show
the clinical and experience outcomes that reveal
the reliability (and therefore the quality) of the
systems of care that the healthcare provider exists
to deliver, and improve.
Nadeem Moghal is a consultant paediatric nephrologist,
Newcastle, UK [email protected]
Cite this as: BMJ 2012;344:e4331
31
VIEWS AND REVIEWS
PERSONAL VIEW Susie Gabbie
Lessons from a paediatrician-parent:
did I help or hinder in the care of my limping child?
32
GREENHILLS/ALAMY
A
few months ago my bright, active 4
year old started to limp. As a hospital
paediatrician, I ignored it and thought
he was being melodramatic. After a
few weeks, I decided that perhaps
he had hurt himself and needed an x ray. So
I duly took him to my work, and asked one of
our juniors to arrange radiography, which was
normal.
He limped on for a couple more weeks until
one day my medical family noticed that his
right ankle was hot and swollen. This was
intermittent, and by the time he saw another of
my colleagues, it was back to normal.
A couple more weeks passed, during which
time the ankle was hot and swollen, and he
could only hop. We were seen as a favour in
orthopaedic outpatients, where the opinion
was that this was most likely to be juvenile
idiopathic arthritis. Within a week we had
started down the arthritis road, and as a family
had to start adjusting to life with a child with a
chronic condition.
Magnetic resonance imaging had been
arranged, and by the time the slot came round
it seemed almost unnecessary because the
diagnosis seemed clear. So it was to our great
surprise when I was telephoned to say that our
son had osteomyelitis, not arthritis, and would
need surgery straight away.
Since then I have become an unwilling
expert at bones, long lines, antibiotics with
bony penetration, and life as a mother of
a child who needs frequent hospital visits.
But now that he is finally improving, I
have time to reflect on my experiences as a
paediatrician and a mother. And I wonder,
did having a medical parent help or hinder?
Most paediatricians fall into two camps
with regard to their own children: some
of us are extra neurotic, needing full
investigation for every last sniffle. But most
of us fall into the second camp: “It’ll be
better in the morning,” and “he just needs a
bit of paracetamol.” There is no doubt that
I took longer to acknowledge his symptoms
than an average parent would have. I wish
I had reacted quicker because he must have
been in pain, hopping along for months.
I didn’t go through my general
practitioner to get referred, so there was no
one holding everything together. It’s difficult
as a working parent to make time to go to
It’s difficult as a working parent to make time to go to the general practitioner,
when it is easier to just bring your child with you to work
the general practitioner, when it is easier
to just bring your child with you to work.
But as a result, when things got confusing,
there was no one person coordinating. And
our general practitioner was bombarded
with letters that made no sense, full of
contradictory diagnoses and plans.
The NHS is often a slow moving beast,
with referrals between teams dictated,
sent to India to be typed, approved, posted
internally, and sometimes finding their way
to the correct person. We were lucky to be
slotted into clinics quickly, and nothing was
too much trouble in terms of arranging for
us to be seen. But in retrospect, maybe had
we waited for the imaging before seeing
the rheumatologists, the correct diagnosis
would have fallen into place without the
initial confusion.
Diagnostic uncertainty is something
that parents have to deal with all the time.
During my spell as a specialist registrar
in paediatric oncology, one of the things
parents spoke about eloquently was that
the most difficult part was the time spent
knowing that your child is seriously ill
but having no idea of the details or a clear
plan of action. You cannot plan, or adapt,
or process what is happening. I thought
this too, and it contributed to my feelings
that I had to speed things up, see everyone
straight away, and not sit at home waiting
for imaging and answers while my child was
in pain.
What have I learnt? Firstly, everyone
needs to give up control eventually. I asked
a colleague to be our paediatrician so she
could advocate for me when things didn’t
make sense or when all the consultants
involved didn’t agree. Secondly, as a
working parent with three kids, life is a
finely tuned balancing act. And it doesn’t
take much to knock things off balance. The
logistics mean that you have to ask anyone
and everyone for favours that you might
never be able to repay.
And finally, I’ve learnt that in the end,
the care you get through the NHS is good.
It may take persistence and patience, but
all the staff had our best interests at heart,
and they went out of their way to help get us
back on two (non-limping) feet.
Susie Gabbie is consultant paediatrician, Royal Free
Hospital, London NW3 2QG
[email protected]
Cite this as: BMJ 2012;344:e4392
BMJ | 30 JUNE 2012 | VOLUME 344
VIEWS AND REVIEWS
BETWEEN THE LINES Theodore Dalrymple
MEDICAL CLASSICS
War and development
His burns were coated with
tannic acid, which formed a
hard dark crust over them and
which was thought to allow
healing underneath
BMJ | 30 JUNE 2012 | VOLUME 344
BETTMANN/CORBIS
How many lives have been saved, and
how many quality adjusted life years
obtained, from the medical advances
occasioned by war? It would be
obscene, even for a health economist,
to work it out, yet there is little
doubt that war has occasioned such
advances, especially in traumatology.
Plastic surgery in particular, advanced
by the work of Sir Archibald McIndoe
(1900-60) during the second world
war. One of his patients was Richard
Hillary (1919-43), whose memoir, The
Last Enemy, was published in 1942
and was instantly recognised as a
minor classic.
Hillary was a student at Oxford
when the war broke out and he joined
the air force. He was a fighter pilot
with five enemy planes to his credit
when he himself was shot down and
rescued from the sea, badly burned.
He became a patient of McIndoe, who
operated extensively on his face. Hillary
was sent to the United States to plead
the British cause, but in the event his
injured appearance was felt more
likely to arouse antiwar sentiment than
to help, and he was allowed only to
broadcast over the radio. Despite his
residual injuries, he insisted on a return
to flying, but was soon after killed in an
accident.
In the book, he does not present
himself as the perfectly stoical patient.
At one point he curses the whole of
the British medical profession for
having made him worse; he insults the
Irish nurses who look after him with
devotion. Perhaps he had some reason
to be angry with the profession. When
first rescued, and before he reached
McIndoe (who was a New Zealander),
his burns were coated with tannic
acid, which formed a hard dark crust
over them and which was thought to
allow healing underneath, until it was
generally realised that it ­promoted
infection instead and often ended in
septicaemia. McIndoe, who had not yet
The Seagull
A play by Anton Chekhov; first performed, in Russian, in 1896
Richard Hillary: facial operation
become world famous, is portrayed as
driven and kind in a bluff way suitable
for servicemen.
The book records the author’s
change in attitude to the war, brought
about in part by his experiences in
hospital. He started out with a brittle,
cynical outlook. He did not join up
from any motives of patriotism or to
fight evil. He did so, rather, as a form of
self development. Specifically denying
any other or selfless motive, he told a
friend: “I am fighting this war because
I believe that, in war, one can swiftly
develop all one’s faculties to a degree it
would normally take half a lifetime to
achieve.”
The end of the book is almost
unbearably moving. On short leave
from the hospital, Hillary takes a
London taxi ride, but because of an air
raid, goes for refuge with the driver in a
pub, the George and Dragon. The pub is
bombed, however, as is the house next
door. As he and the driver emerge from
the wreckage, a rescue worker says to
them, “almost apologetically,” “If you
have nothing very urgent on hand, I
wonder if you’d help a bit here. You see
it was the house next to you that was hit
and there’s someone buried in there.”
A little child is pulled out, dead, and
then the mother, still alive. Hillary gives
her a little brandy from his flask. “Then
she started to weep. Quite soundlessly,
and with no sobbing . . . ‘Thank you,
sir,’ she said, and took my hand in hers.
And then, looking at me again, she said
after a pause, ‘I see they got you too.’”
She dies, and Hillary realises that self
development is the least of it.
Theodore Dalrymple is a writer and
retired doctor
Cite this as: BMJ 2012;344:e4328
Chekhov spent many years as a rural physician (BMJ
2009;339:b3395), a fact often cited in the examination of his
characters and their country life, and he famously said, “medicine
is my lawful wife, and literature is my mistress.” The Seagull is one
of a few of Chekhov’s plays to include a doctor. Dr Dorn is a curious
mix of the irascible and the compassionate. Having travelled the
world and spent many years in practice (and in various amorous
relationships) he has a somewhat detached air. He is genuine but
sometimes overly forthright, particularly with his longstanding
friend, Sorin. His assessment of Sorin’s wish to live on long past
62 is that it is “Foolish. Every life must have an end.” This is brutal,
and a risky strategy for communication in membership exams,
but most doctors will identify with this conflict between patient
expectation and medical reality. Likewise, his disbelieving response
to Sorin’s request for medical advice (“Treatment! At sixty!”) would
probably raise some eyebrows these days. We can perhaps forgive
him because this patient is also a friend, and the two make for
uncomfortable bedfellows.
Despite these outbursts, Dorn remains level headed in The
Seagull’s carefully constructed psychological drama about a closely
knit group, bound by ties of family, friendship, love, and habit, in a
provincial Russian village. It is Dorn whom the other characters look
to for support. In the opening act Dorn comforts a passionate and
frustrated playwright. Kostia’s desperation to break free of theatrical
and social convention had met with only
puzzlement and dismissal, but Dorn tells him
that he’s “got talent and must carry on.”
Sadly Kostia becomes estranged from his
family and friends and distanced from his lover,
Nina. Kostia’s mother, a minor celebrity, is too
busy with her own vanity and keeping happy
her younger lover, the famous writer Trigorin,
to engage with her son’s decline. In a tortured
effort at self expression, Kostia kills a seagull
and presents it to Nina as a gift. Horrified, Nina
pulls away and finds herself drawn to Trigorin,
whose whimsical possession, ruin, and rejection of Nina echoes the
pointless destruction of the seagull. In the last act, Kostia and Nina
realise they can never be together.
In the final scene, everyone is playing cards around the table
when a gunshot rings out. It is, once more, Dorn who rises to calm
people. He returns from investigating and reports that a bottle of
ether has burst in his medicine chest, then he manoeuvres Trigorin
to one side and reveals to him that Kostia has shot himself. Dorn’s
importance as a foil is felt throughout the play, but it means that
Dorn is never truly a full protagonist. Like all doctors, Dorn is both
inside and outside the lives of those around him. His intimacy
with the other characters is expedited, but also weakened in its
humanity, by the professional aspect of his perspective. Dorn’s
role reminds us that although we often have ringside seats to our
patients’ lives, we ultimately remain spectators.
Ben O’Leary is a core medical trainee, Whipps Cross University Hospital,
London E11 1NR [email protected]
Cite this as: BMJ 2012;344:e4329
bmj.com/archive
̻̻Medical Classics: Ionych by Anton Chekhov (BMJ 2009;339:b3395)
33
LAST WORDS
FROM THE FRONTLINE Des Spence
What happened to the doctor-patient relationship?
An old maxim of general practice
says that doctors get the patients they
deserve, because patients actively seek
out like-minded doctors who share their
own health beliefs. The health-anxious
seek health-anxious doctors; both value
so called thoroughness, and referral,
and refuse to accept any uncertainty.
Likewise, some doctors and patients are
bound together by a degree of fatalism.
Both are happy to accept risk; happy
not to treat, refer, or investigate. What
passes as denial to some seems like only
common sense to others. Once doctors
understood that medicine was more
opinion than science, so were tolerant,
supportive, and respectful of differing
perspectives. But this balance is under
threat, with any, even realistic, fatalism
increasingly deemed unacceptable.
Despite modern medicine’s supposed
so called patient centredness, the medical model (that all symptoms have a
pathological cause, to investigate, treat,
and cure) is absolutely still the prevailing mindset within m­edicine. This is
Once doctors
understood that
medicine was
more opinion
than science, so
were tolerant,
supportive,
and respectful
of differing
perspectives
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despite most contact with patients
being driven by abnormal health
seeking behaviours, cultural aspects
of care, or medically unexplained
symptoms—facts lost to the educators.
And the medical model is ever more
powerful; opinion is usurped by the
perceived infallibility of so called evidence. Despite the glaring weaknesses
and naked commercial interests found
within much research, “you can’t go
against the evidence.” The rise of the
superspecialist means absolutism is
now the norm not the exception. The
paradox is that medicine is supposedly
more enlightened, but it has never been
more tyrannical, hierarchical, controlled, intolerant, and dogmatic. Working
doctors who dissent are cowed because
failure to comply with the medical
orthodoxy threatens livelihood and
registration. Much of modern medicine
is an intellectual void.
The current situation is far worse
for medically sceptical patients, who
are denied the opportunity to consult
doctors who share their health beliefs.
Changes in working patterns mean continuity is broken and doctors are less
available and less experienced. Doctors’ consultations have been reduced
to some universal unit of medical time,
not a long term relationship of the
like-minded. In every consultation,
onscreen pop-ups prompt us to record
blood pressure, weight, screening, and
the rest. Payments provide incentive for
this intrusion, making refusal difficult.
Everyone is made into a patient; there
is no opt-out clause, no choice. Patients
complain that they are “pushed onto
pills”; captive to constant computer
generated recall, yet no one listens. Medicine shows no respect for any fatalism,
openly scolding patients if they have different health beliefs. This is all set to get
worse, more pervasive, more paternalistic, and less persuasive. Are patients
really getting the doctors they deserve?
Des Spence is a general practitioner, Glasgow
[email protected]
Cite this as: BMJ 2012;344:e4349
STARTING OUT Kinesh Patel
We’re too weak to strike
I don’t like armpits. Unpleasant things.
Especially when they’re not your own.
The result of the recent bus strike in
London was human beings foisted
further into each other’s armpits on the
tube than normal. This was only the
beginning. The insurrection of the bus
drivers is planned to carry on until they
get what they want.
The best phrase I can find to
describe the doctors’ strike—sorry, day
of action—is “damp squib.” Did the
public even notice on 21 June? Strikes
are nasty, aggressive things. If you are
going to go down this route, there are a
few (simple) rules. You have to publicly
commit to more action should your
grievance not be resolved. Admitting in
advance that it is a one off is probably
not the best negotiating strategy, nor is
announcing publicly that you are not
that committed to the cause.
Why did the miners, a group with
BMJ | 30 JUNE 2012 | VOLUME 344
much greater solidarity than doctors,
lose? It has got nothing to do with
politics or the waning power of the
trade unions in the 1980s. It was
for the simple reason that the lights
stayed on. Had we been plunged into
darkness, the dispute would have been
settled quickly, and the trades union
movement might well look different.
The bottom line is that doctors are
weak. The government knows that we
do not have it in us to do what it would
really take to make them acquiesce to
our demands: a shutdown of entire
general practices and hospitals. When
the other side knows you are weak,
why would it bother negotiating?
Unfortunately, we have been made
to look silly without any outside help.
The universally negative publicity was
entirely predictable, and given our
intrinsic weakness makes any further
action inconceivable.
This sort of
weakness is
probably something
to be proud of
bmj.com/archive
̻̻Head to Head: Are
doctors justified in taking
industrial action? (BMJ
2012;344:e3175, e3242)
̻̻Helen Jaques’s industrial
action live blog: bit.ly/L7idB5
No matter how much we grumble,
and we do like to grumble, we
generally like medicine and we like
our patients. We do not want them
to suffer, even if it means putting
ourselves at a disadvantage. Weakness
is usually presented as a negative
characteristic, but this sort of weakness
is probably something to be proud of,
and something the bus drivers could
learn from us.
But that is a fantasy. The government
is already talking about giving in to the
bus drivers, with extra money already
made available for them even before
the strike took place. Meanwhile,
resolve against doctors is hardening.
Make of that what you will but I would
suggest that you prepare yourself to
work longer for less.
Kinesh Patel is a junior doctor, London
[email protected]
Cite this as: BMJ 2012;344:e4387
49