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In a moving tribute to his sister on page 850, Dougal Jeffries quotes Anatole Broyard, an American critic who died of prostate cancer: ‘…all that he is really asking is for his doctor “to give up some of his authority in exchange for his humanity”.’ This month's BJGP opens with a similar plea from Angela Coulter, only this time it is for us to give up authority so that patients can participate more in decisions affecting their health (page 771). Shared decision making was the model favoured by both patients and doctors in the study on page 777. Unfortunately, the doctors in this study didn't prove very good at predicting patients' wishes in this respect. They tended, perhaps surprisingly, to overestimate patients' preferences more often than underestimating them.
Starting from a different perspective, Greaves and Campbell emphasise the value of collaborative work in supporting self-care and the importance of self-care in achieving a wide variety of outcomes (page 814). There is a need for better training for all health professionals, but for the time being: ‘As ever, the job seems to require the making of pragmatic decisions based on incomplete information.’
However, it's important to distinguish shared decision making from the idea of patient choice (page 822). The authors of this article suggest that framing decisions as choices in itself distorts decision making. They make practical suggestions to help GPs avoid this trap, such as changing the language in which decisions are presented. They also suggest that we should slow down the process: an interesting notion in the context of the other initiatives under way to speed everything up.
In a very personal Viewpoint, Suhayl Saadi is asking for doctors to be treated with humanity (page 839). I don't share his take on the Shipman enquiry — revalidation has been around as an idea for years and we should all be grateful that Janet Smith has given a decisive push to make us sort out the details. But we shouldn't be surprised at his reaction to the xenophobia revealed by recent events. Aneez Esmail charted the history of Asian doctors working in the UK in his William Pickles lecture (page 827), a sorry tale of discrimination and, in the end, unrecognised contributions to the country's health care. His plea to right this wrong is echoed in Joe Kai's editorial (page 774).
The drive to get doctors to give up some of their authority should not become an excuse for us to abandon our responsibilities, or to dump all the decision making onto patients. We should not, for instance, use it as an excuse to abandon efforts to reduce unnecessary antibiotic prescribing. I am one of those who considered antibiotic resistance to be exclusively the result of hospital practice. For those who share my view, the article on page 785 is a rude awakening. A large study of bacterial isolates from urine specimens provides convincing evidence that antibiotic prescribing by GPs increases bacterial resistance, albeit on a small scale.
The accompanying editorial on page 772 by Richard Wise emphasises the need to take all possible steps to reduce antibiotic resistance. One possibility is wider deployment of near-patient testing. Up till now this has looked like an expensive option, but perhaps factoring in the benefits of lower resistance might influence the economic analysis. Richard Wise also feels that extending prescribing authority to more health professionals is likely to make the problem worse. The finding of high rates of meticillin-resistant staphylococcal carriage among Irish GPs is another alarming symptom of the same problem (page 811). Infecting our patients with resistant bacteria is only one of the many ways in which we as doctors can damage our patients' health.
I too am old enough to remember Ivan Illich and the effect that reading Medical Nemesis had on some of us in the 1970s (page 843). But not enough of us, and not a big enough effect, according to Peter Tomson, who feels that our target-driven concern for prevention is turning even more healthy people into patients. His voice is not alone; there are others questioning the value of all this activity, but the need for a figure with a presence to command international attention is strong.
We have long bemoaned the lack of response from the readers. At last we now have an electronic discussion forum, and it is beginning to quite lively. Do visit it at www.rcgp.org.uk/bjgp and, better still, add some outraged response to, well, anything you like.