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comment “The ‘hospital bad/home good’ narrative is disingenuous” DAVID OLIVER “Hancock should stop trying to distract us with new technology” HELEN SALISBURY PLUS Respecting patients’ health beliefs; managing pandemic panics WOUNDED HEALER Clare Gerada The GMC is no longer a bogeyman to fear or years I’ve been caring for doctors a doctor’s health problem will not lead to a GMC with mental illness. This has involved sanction if the doctor is receiving the necessary numerous interactions with the GMC. treatment and is managing any risks to patients. Years ago, together with others, I Even if a health case does get referred to the regulator raised concerns about the impact of its the chance of a doctor receiving a serious sanction Finvestigations on doctors’ mental health, including is immensely small. Over a five year period around links to suicide. 400 doctors were investigated for issues relating to Even I was frightened entering the GMC’s London substance misuse, resulting in three erasures and 20 headquarters (which I had to do fairly often)—but this suspensions. These would almost certainly include didn’t compare to the fear my patients felt when the issues other than health (especially conduct), and white envelope marked “confidential” landed on their the GMC will never erase doctors solely for matters doorstep or when they had to attend meetings or relating to their health. hearings at the GMC. It’s been nearly 20 years since Janet Smith chaired How things have changed. Over the past five years the Shipman inquiry. Her recommendations changed the GMC has undergone significant transformation our relationship with the GMC and essentially drove in how it interacts with and deals with registrants. It a wedge between us. But this is now changing, and has changed how it communicates and has amended I welcome it. By working together with the GMC, we its processes to include provisional inquiries and can improve the lives of our doctors and, in turn, the ability to pause investigations. The emphasis improve the care these doctors deliver on “local first” (local resolution to support efficient to patients. handling of cases) reduces the impact on doctors and Clare Gerada is GP partner, Hurley Group, achieves more timely resolution of complaints for London [email protected] patients. The GMC’s encouragement of employment Cite this as: BMJ 2020;368:m647 liaison officers and its training of staff, including how to connect with registrants and to recognise those The ethos is now who are distressed, has improved communication. The ethos is no longer simply “protecting patients”: “supporting instead, it is “supporting doctors to protect doctors to protect patients”—a massive shift of emphasis. patients” The GMC has also produced a suite of papers and independent reports through its Supporting a Profession Under Pressure initiative. These publications are of an incredibly high standard, containing data and analysis that would put most academic publications to shame. It is committed to implementing the recommendations of these independent reviews. Doctors still fear the regulator, and this is understandable. But, as it changes, maybe we should as well. We must start challenging our deeply held views and look at the facts. For example, disclosing the bmj | 29 February 2020 323 BAD MEDICINE Des Spence Why #healthbeliefs should be top of all our communications In the modern world doctors do not have a monopoly on truth t was 1986—before the preferred atheism has no monopoly on truth: truth cultural elements of health beliefs are pronoun, when # was an obscure is mercury. But our beliefs blind us, and conditioned directly through the actions wannabe on life’s keyboard, and when challenging them invariably leads to of a country’s medical profession: doctors avocados were never crushed but conflict. Best always to respect others’ attempting to extort as much money were eaten unripe at Christmas, with beliefs. as possible through over-investigation, Iprawns and Marie Rose sauce. Doctors are intelligent people—no, we overtreatment, and needless surgery. I reached for my near empty packet of truly are! Medicine is but a belief system Medicine’s core business plan is to make Marlboro beside a mug full of cigarette too, rife with false deities, leaps of faith, even well people think that they’re sick. ends. I struck a match, being careful not learnt incantations, and physical rituals. By our standards, North Americans often to torch my “big hair” laden with product, I don’t believe in quite a lot of it: most have aberrant medical beliefs (though and twisted my earring anxiously, thinking clinical examination; primary prevention normal to them). Antibiotics and scans at how it didn’t suit me. I clasped my cigarette treatment of cholesterol; bisphosphonates; every consultation, annual blood tests, and stained hands together and pressed them to migraine treatments; and, of course, all foot pre-emptive cancer surgery. Doctors have my head, praying to God that the brachial and shoulder surgery. All just post-truth, fixed health beliefs too: even suggesting plexus wouldn’t come up in my exam. fake scientific nonsense. (Getting angry?) that homeopathy is an effective placebo Then I raised my head and laughed. turns both sides of the medical divide into Had my anatomy revision come to this? My Cultural elements frothing banshees. And health beliefs are atheism had been usurped by Christian This model suggests that everyone has a set ubiquitous, in every consultation. Doctors conditioning. The thing is, beliefs defy of health beliefs, passed down in families frequently fail to understand patients’ reason. Many scientific people believe and from wider society too. Think of the health beliefs, dismissing those not in one of the many competing gods. And families who endlessly attend clinics. The congruent with their own. Predictably, this BMJ OPINION Robert Peckham Covid-19 has shown we need strategies to manage panic My local supermarket recently made the news. Panic is a word that’s been widely used There’s also a thin line between The grey metallic shelves, emptied of food, during this outbreak. We’ve heard the misinformation and uncertainty, were a stark reminder of the panic that covid- oft repeated injunction by experts and particularly in the midst of an epidemic 19 has sparked in Hong Kong and across the media commentators for people to stop region. People are bulk buying provisions, panicking. Throughout history people have us. Panic, in other words, can be a hair’s fearing the worst, and it’s contagious. The sight feared the spread of disease, but global breadth away from prudent concern. of a foodless food store is enough to make connectivity creates new possibilities for There’s also a thin line between anyone sweat. disruption. As the World Health Organization misinformation and uncertainty, particularly has noted, covid-19 is driving a social in the midst of an epidemic. The identity of media “infodemic.” In the tweet-a-second the causal pathogen may be unknown, its 21st century, information overload makes it epidemiology obscure, and the spectrum of increasingly difficult for people to distinguish clinical manifestations confusing. All of this is fact from fiction. grist to the panic mill. Communication, which is so central to In Hong Kong, long queues for face masks public health, also turns out to be key to form outside pharmacies from the early panic. Circuits of information can all too easily hours. Shops are emptied of rice, toilet paper, flip to become conduits of misinformation. and disinfectants. In part, this is triggered Public health messages that seek to jolt us by a self-fulfilling pre-panic panic: people out of complacency can all too readily alarm rush to forestall the effects of a future panic. 324 29 February 2020 | the bmj Medicine is ACUTE PERSPECTIVE David Oliver but a belief system too, Fixing the older inpatient narrative rife with false deities, knelt by the patient’s bed. Admitted among developed OECD nations, and leaps of four days earlier when acutely unwell, England has fewer still. Our hospitals are faith, learnt confused, and immobile, he was now too full, and we’ve not only closed too incantations, improving. “How are you today?” many beds but have put more out of action and physical “Doctor, I must say, I’m because of stranded patients who can’t rituals. I Iconsiderably transformed and substantially transfer to under-resourced community don’t believe restored. I almost feel ready to go home.” services. The problem is not that people in quite a lot Right now, in the language used around shouldn’t be admitted or can’t benefit from of it acute care, admission is relentlessly admission—it’s that they stay too long. portrayed as a bad thing, especially We should care about research evidence leads to dissatisfaction on all sides, and for older patients. It suggests they’d as much as ideology and policy pushes. doctors are seen as arrogant. always want to stay at home or get home Systematic review and meta-analysis of Thirty years on from my studies the sooner—though this barely considers the multidisciplinary, specialist led, geriatric fashions and habits have changed, but we patients who welcome admission or a assessment of frail older people in hospital still cram students’ heads full of irrelevant slightly longer stay, or family providing has repeatedly shown benefits lasting for factual details while avoiding the more care, who are often stressed, burnt out, months after patients leave. The comparable important concepts and ideas that make and unsupported. This narrative says evidence for this assessment in community us better doctors. My health belief is this: inpatients risk hospital acquired infection, settings, including “hospital at home” in the coming decades imaging, laboratory poor nutrition, deconditioning, delirium, models, is less convincing.

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