Richard Smith: Doctors using safety and evidence for political ends

richard_smith_2014In my 40 years of messing around with medical journals I’ve tried to contribute to promoting patient safety and the use of evidence. Generally things seem better from a time when patient safety was largely ignored and evidence used haphazardly rather than systematically, but I fret now that doctors are using both safety and evidence for their own selfish ends.

The BMA is smart enough to know that simply asking for more money and better conditions for junior doctors and general practitioners is a poor strategy, and so it emphasises risks to patient safety. Junior doctors are striking not so much for better pay and conditions but for patient safety and to save the NHS. How striking will save the NHS is far from clear, but presumably the proposition is that they will unseat the secretary of state for health, who, they believe, is intent on destroying the NHS. There is some link with safety in that the government wants to reshape the financial penalty on trusts that require doctors to work long hours.

Longer hours may mean more tired and so less safe doctors, but among the many factors affecting patient safety the effect of slightly longer hours, which may not even happen, is likely to be small, possibly unmeasurable; and junior surgeons have recently campaigned to work longer hours, believing that otherwise they don’t get enough practical experience.

General practitioners too are threatening mass resignation to defend patient safety rather than to make their working lives bearable. There’s no doubt that general practice is under great strain, but just how much patient safety is affected is not clear because we know so little about patient safety in primary care. It’s largely unstudied; most studies have been of hospital care.

The sad truth is that it took a very long time to get doctors interested in patient safety, and it still isn’t a priority for most doctors.

A short history of doctors and patient safety

I made many errors in my short clinical career from 1976 to 1979, and so did the doctors I knew. Errors were a favourite topic of doctors’ dinner party conversations. But nobody studied errors until the 1980s when studies in the United States, particularly in New York hospitals, showed that some 10% of hospital admissions led to patient harm and that around 1% were killed. I encountered these studies in 1990 and wrote a BMJ editorial arguing that we needed such a study in Britain.

I also calculated that if similar rates of harm applied in Britain as in the US then some 45 000 people a year would be killed by hospital care. The Times picked up this figure in an editorial, greatly annoying the president of the Royal College of Physicians, who dismissed the whole thing as scaremongering.

No major study was undertaken in Britain, although a pilot study found results similar to those from the US. Further studies in other countries, including Australia and New Zealand, again found similar results, but no organisation in Britain, and none of those belonging to doctors, took the problem seriously. Eventually in 1999, a report from the US Institute of Medicine, To Err is Human: Building a Safer Health System, put patient safety on the global agenda. Doctors’ organisations in Britain began to respond, but the BMA was not prominent among them. England’s chief medical officer, Sir Liam Donaldson, took the lead, but he was dealt with roughly by the BMA over doctor training. It was not until 2000 that the first report on patient safety—the oddly named An Organisation With a Memory—appeared in Britain, and hospitals were slow to begin to report errors.

So you can see why doctors striking and threatening to resign on mass in defence of safety seems hypocritical. I’m not criticising their actions but rather the way they dress them up.

Evidence for political ends

It’s rather the same story with evidence. The realisation that much of what doctors did not only lacked evidence but often flew in the face of evidence emerged in the mid-1990s. Despite initial resistance from some, the concept of evidence based medicine swept through healthcare in Britain. There’s a PhD to be written on why safety was accepted so slowly and evidence based medicine so rapidly, but one explanation might be that doctors discovered more quickly how to use evidence to suit their own ends. Evidence became for doctors a universal excuse along with time, money, and confidentiality.

Where, doctors have cried, is the evidence to support the internal market, NHS trusts, clinical governance, revalidation, commissioning, or anything they didn’t like? There is legitimacy in asking for evidence but a failure to recognise (or to choose to recognise) that the kind of evidence needed for a new drug, randomised controlled trials, is not easily applied to a complex intervention like, say, commissioning. Plus any piece of evidence can usually be pulled apart by somebody determined to do so, and doctors are good at that. It’s also true that almost anything new is likely to lack evidence, and so the appeal to evidence can be used to oppose anything new that doctors might not like for whatever reason.

I shouldn’t be surprised by doctors using safety and evidence to suit their own political and selfish ends: they are simply human. The surprise lies in my lingering and essentially romantic belief that doctors might adopt a higher standard.

Richard Smith was the editor of The BMJ until 2004. 

  • Anand Bhopal

    The truth is this strike should not have happened. Not because it is in some way immoral for doctors to strike, but rather because of
    the painstaking irony that junior doctors should be campaigning for a better working conditions, not fighting grasp clutch onto what they have.

    Yes, doctors have for decades taken insufficient notice of evidence
    and patient safety, but to accuse current junior doctors on this basis is akin to Jeremy Hunt comparing the hostility he has received from the BMA to that laid out to Aneurin Bevan; times have changed, the makeup of the profession has changed. We have been trained in an era of compassionate, patient centred care with evidenced based medicine at its core. We should be as critical about the efficacy of drugs as of service reorganisation – indeed, often neither tend to work particularly well.

    Junior doctors may continue to have relatively little interest in the structural factors which influence public health and patient outcomes – to be fair, this surely in large part reflects the focus of medical curricula (though I suspect the contract dispute may make many more take note) – but their desire to deliver high quality face to face patient care with sincere intentions cannot be disputed.

    The reason why this strike resonates with so many junior doctors is little to do with aggregate health outcomes (e.g. stroke deaths, despite this already being addressed by clinician led changes, as detailed by Fiona Godlee), rather that many doctors feel that face to face care is already stretched. Increasingly thin staffing during the week, exacerbated by poor staff retention, will worsen this problem. This simple point illustrates one of several legitimate issues directly concerning patient safety.

    I therefore feel it is somewhat unfair to paint this dispute as a quixotic attempt by junior doctors to save the NHS, underpinned by ultimately selfish ends, and hope to have gone some way to re-instilling your belief in the higher standards of our profession!

  • Egerton Yorrick

    How incredibly disappointing to read this post.

    Junior doctors are not asking for “more money and better conditions” – they are asking that their members do not receive a pay cut and worse conditions.

    The idea that “patient safety [is still not] a priority for most doctors” is bizarre. I am consumed by concerns about “patient safety” all day, both in the hospital and outside of work. It is often (if not always) prioritised over my own education, meals, and bladder relief. I have no reason to think that my colleagues feel any differently.

    If the patient safety narrative has been misused by anyone then it is the Secretary of State who has used it as a stick with which to beat some of the most committed and hardest working elements in the public sector.

    Whether or not you believe the new contract is unsafe, it is manifestly unfair to accuse individual doctors of dishonesty because they believe otherwise. I have no doubt that this is about pay for some but others genuinely believe that it foretells the end of the NHS.

    I am sorry that Richard Smith was “surprised” to learn that doctors are not actually superhuman. Perhaps his surprise would have been lessened had he joined those of us at the coalface rather than shouting insults from the sidelines.