1084 LEADING ARTICLE Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from Entertainment a patient due to operating while ...... addicted to drugs, and the agent says, ‘‘This is not how a doctor lives. No, this is squalor. I mean, you did go to medical Doctors in the movies school, right?’’ Dr Sands replies, ‘‘What, are you going to arrest me for failing to G Flores live up to my potential?’’. Money is not infrequently portrayed as ...... the prime motivation for becoming a doctor and choosing a medical specialty. Healers, heels, and Hollywood In Not As a Stranger (1955), medical school classmates discuss their career options: he world continues to have a pas- MAJORTHEMESINDOCTOR sion for movies. Moviegoers world- MOVIES ‘‘Personally, I’m for surgery. I just Twide spent $20.3 billion and Money and materialism got a look at Dr Dietrich’s car. You purchased 8.6 billion admission tickets Materialism and a love of money have know what he drives? A Bentley. 1 to see films in 2003. 2002 was a record pervaded cinematic portrayals of doctors $17,000 bucks.’’ breaking year at the UK box office, with dating back to the 1920s, and continue ‘‘That guy doesn’t take out a splinter 176 million cinema admissions, £755 to be prominent in recent movies. In for less than $1000.’’ million in total box office receipts, Doctor at Sea (1956), Dr Simon Sparrow ‘‘I’ll still take ear, nose, and throat. and 369 films released.2 In the USA in (Dirk Bogarde) states, ‘‘A Rolls Royce is The common cold is still the doctor’s 2003, there were 1.6 billion cinema the ambition of almost every newly best friend.’’ admissions, $9.5 billion in box office qualified doctor. And preferably a ‘‘Call it a virus. You make more receipts, 473 films released, and home Harley Street address to go with it.’’ In dough that way.’’ entertainment sales to dealers of 1.1 Carry on Again Doctor (1969), Dr Jim ‘‘Look, if you kiddies are all through, billion DVDs and 294 million video Nookey (Kenneth Williams) confides to 3 your old man here will really wise cassettes. a colleague: ‘‘Specialise, that’s what I’d Movies have a powerful influence on like to do! The whole Harley Street bit you up. It’s not what you practice, popular culture, due to their interna- with bags of lovely filthy rich women it’s where.’’ tional popularity, easy accessibility, patients.’’ In Doctor at Large (1957), the ‘‘What do you mean?’’ and profitability as an industry. doctor in charge of a Harley Street ‘‘I’ve done a little research on this Cinematic depictions of doctors thus practice advises Dr Sparrow, ‘‘You problem. The average doctor’s have the potential to affect public know, it’s a chastening thought, but income is 11 Gs. In the southwest, expectations and the doctor-patient good clothes are more important to a GP west, and more...’’ relationship. In a 2002 paper, I con- than a good stethoscope.’’ ‘‘Pebble Beach, Colorado Springs, ducted an in-depth analysis of the Indeed, it shocks and bewilders other Beverly Hills, that’s where the rich portrayal of doctors in the movies, characters when movie doctors do not are crackin’ up fast.’’ reviewing 131 films from nine countries display adequate wealth. In Playing God spanning eight decades.4 Key findings (1996), an FBI agent visits the home of Movie doctors even base treatment from this research included: (1) com- the surgeon Dr Eugene Sands (David decisions on patients’ ability to pay. In http://adc.bmj.com/ passion and idealism were common Duchovny) to arrest him for the death of Critical Care (1997), Dr Werner Ernst in early doctor movie portrayals but have become increasingly scarce in recent decades; (2) since the 1960s, positive doctor portrayals declined while negative portrayals increased; (3) doctors frequently are depicted as greedy, egotistical, uncaring, and on September 26, 2021 by guest. Protected copyright. unethical, especially in recent films; (4) a recurrent theme is the ‘‘mad scientist’’, the doctor-researcher who values research more than patients’ welfare; (5) because negative portrayals of doctors are on the rise, patients’ expectation and the doctor-patient rela- tionship may be adversely affected; and (6) films about doctors can serve as useful gauges of public opinion and tools for medical education. The aim of this paper is to use this extensive database, supplemented by several more recent films, to explore selected key themes about the portrayal of doctors in the movies. In contrast to the prior paper, however, this paper will also focus on humour in doctor films (both intentional and unintentional), and examine the few movies that have Figure 1 Paediatrician Dr Larry Quinada (James Mason) in Caught (1949). Reproduced courtesy portrayed paediatricians. of the Academy of Motion Picture Arts and Sciences.

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Norma, make sure there’s some- thing the matter with them so that I can send you a bill.’’ ‘‘You probably will anyway.’’ ‘‘Heh, heh.’’ ‘‘Come along boys, we’ll get no sympathy here.’’

Brown twice comments on the long hours he puts in as a paediatrician. After putting in a particularly long day, he says to his nurse, ‘‘Oh my, why didn’t I become a night watchman or a flagpole sitter or somebody with regular hours instead of a baby doctor.’’ After Brown’s cocktails with Anabel are interrupted by a call from a concerned mother, he says, ‘‘I’m sorry, Annabel, but that’s what it’s like being a doctor, no time for anything else’’, to which she replies, ‘‘but I think being a doctor is the most wonderful thing in the world a man can be!’’ Brown delivers a Figure 2 Dr R Wesley McLaren (Steven Seagal) confronts a paramilitary extremist in The Patriot (1998). Reproduced courtesy of the Academy of Motion Picture Arts and Sciences. lecture to mothers entitled, ‘‘The Parent’s Responsibility to the Child. A Lecture by the Eminent Pediatrician Madison W (James Spader), in the intensive care married one year after the film’s release Brown, MD’’. His concluding remark is unit (ICU), asks ‘‘ICU Chairman (Drake was Grant’s third wife and the impressive for revealing an insight privy Emeritus’’ Dr Butz (Albert Brooks) marriage lasted almost 13 years, the to the experienced paediatrician: ‘‘How- 5 why a comatose patient with a poor longest of Grant’s five marriages). ever, there is an instinctive wisdom in prognosis needs a procedure: Dr Brown is portrayed as a compas- most mothers which transcends all the sionate, dedicated paediatrician who science of doctors.’’ ‘‘If there’s no reasonable prospect of sometimes does not even charge for In Caught (1949), Leonora Eames cure, why should we proceed?’’ patient visits. Brown playfully scolds a (Barbara Bel Geddes) fulfils her dream ‘‘Where have you been all your life: mother of three who happily departs by marrying millionaire Smith Ohlrig It’s called revenue! He’s got cata- after a clinic visit: (Robert Ryan), but the marriage is a strophic health insurance. Long term disaster, so she goes to work in the health care. The works!’’ ‘‘Now before you bring these office of paediatrician Larry Quinada ‘‘What difference does his insurance youngsters of yours in here again, (James Mason), who has devoted his

make?’’ http://adc.bmj.com/ ‘‘What? It’s cash money. Not one of those ‘try and collect from the estate’ deals. And you want to yank his tubes!’’

Paediatricians The medical specialty of movie doctors most often is surgery (33%), psychiatry on September 26, 2021 by guest. Protected copyright. (26%), or family/general practice (18%), with paediatrics accounting for only 2%.4 It is informative to examine movies with a paediatrician as the main char- acter. Every Girl Should be Married (1948) was released with fanfare as RKO’s big Christmas offering, and was a financial success.5 Anabel Sims (Betsy Drake), a romantic woman determined to find the perfect husband, meets and falls in love with handsome paediatrician Dr Madison Brown (Cary Grant) when they both reach for a copy of ‘‘Better Babies’’ at a luncheonette. He resists her obvious advances, and she uses every trick and trap, including a fake romance with her department store boss, to finally land Dr Brown. In real life, Drake and Grant met in 1947 aboard Figure 3 Dr John Carpenter (Elvis Presley) speaks to Sister Irene Hawkins (centre, played by the luxury liner Queen Mary travelling Barbara McNair) and Sister Michelle Gallagher (Mary Tyler Moore) in Change of Habit (1969). from England to the USA, and were Reproduced courtesy of the Academy of Motion Picture Arts and Sciences.

www.archdischild.com 1086 LEADING ARTICLE Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from life to serving impoverished children in ‘‘That’s because you don’t care lunchtime and tennis. Maybe they’ll have New York City (fig 1). They fall in love, about money.’’ more time to practice medicine.’’ The but Eames is pregnant with Ohlrig’s ‘‘Everyone’s got to care about Wedding Planner (2001) features Dr Steve child, which she finally miscarries, and money to a certain extent—how else Edison (Matthew McConaughey) as a then Eames and Quinada live happily can I take you out to dinner when I paediatrician who is engaged to another ever after. The portrayal of Dr Quinada want to. But I care more about other woman but eventually calls off the is noteworthy for his commitment to the things like doing the kind of work marriage because he has fallen in love under-served and lack of interest in that interests me.’’ with his wedding planner, Mary Fiore materialism. Eames’s interview with ‘‘Is that why you work on the East (Jennifer Lopez). This maudlin, forgetta- Quinada proceeds as follows: Side?’’ ble film is noteworthy for Edison inex- plicably hospitalising the adult Fiore on a ‘‘Sure. I can learn more there in one paediatric ward and using a paediatric ‘‘You know what the job is, Miss day than I can learn anywhere else cervical collar after Fiore suffers a con- Eames?’’ in one month.’’ ‘‘Receptionist.’’ cussion and loss of consciousness, and for ‘‘Yes, for Dr Hoffman and me. He’s Edison mentioning that he had to attend After this brief burst of paediatrician a diverticulitis seminar, a conference of an obstetrician, I’m a paediatri- movies, little attention has been paid to doubtful utility to a paediatrician. cian.’’ paediatricians as main characters. In ‘‘He brings children into the world, I Sunchaser (1996), which does not feature try to keep them here.’’ a paediatrician, a 16 year old with a Bureaucracy and healthcare ‘‘I’m sure you succeed, doctor.’’ retroperitoneal sarcoma who is impri- systems ‘‘Well, I don’t always. It’s easier to soned for murdering his stepfather is Movie doctors frequently face the frus- write prescriptions than to pay for referred to adult oncologist Michael trations and follies of having to confront them.’’ Reynolds (Woody Harrelson), whom he inefficient bureaucracies and healthcare later kidnaps. Angered that a paediatri- systems that hinder patient care. In cian will not treat the patient because Article 99 (1991), Dr Sturgiss (Ray Later, when Eames has become he is a murderer, Reynolds says, Liotta) explains to an intern why open- Quinada’s receptionist and lover, she ‘‘Paediatrics can’t just dump their over- heart surgery is being performed on a comments on his attitude to money: load on us. Tell them to cut down on their patient admitted for prostate surgery: http://adc.bmj.com/ on September 26, 2021 by guest. Protected copyright.

Figure 4 (A) Dr Constance Peterson (Ingrid Bergman) psychoanalyses a patient in Spellbound (1945). (B) Prison psychiatrist (Sidney Poitier) treats a racist Nazi psychopath prisoner (Bobby Darin) in Pressure Point (1962). (C) Dr Fritz Fassbinder (Peter Sellers) in What’s New, Pussycat (1965) takes notes on his patient, Michael James (Peter O’Toole). (D) Dr Patch Adams (Robin Williams) plays with paediatric patients in Patch Adams (1998). All photographs reproduced courtesy of the Academy of Motion Picture Arts and Sciences.

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Table 1 Annotated ‘‘top-ten’’ lists: doctor movies the author considers the best, most humorous, and most useful in medical education

Best Most humorous (intentionally and unintentionally) Most useful in medical education

1. Red Beard (1965) 1. M*A*S*H (1970) 1. The Doctor (1991) Arrogant young man in 19th century Japan Three surgeons in Korean war save lives, goof around A hotshot surgeon with a detached demeanour destined to be Shogun’s doctor learns true and engage in sexual antics. Directed by Robert learns about empathy and compassion when he meaning of being a doctor from senior mentor Altman, film won numerous awards and spawned contracts cancer. Based on autobiographical book who cares for poor (Toshiro Mifune). Directed TV series. by Ed Rosenbaum. by Akira Kurosawa.

2. The Hospital (1971) 2. Body Parts (1991) 2. Arrowsmith (1932) Searing examination of chaotic urban hospital Unethical surgeon-researcher transplants various From the Sinclair Lewis novel, film deftly explores a and doctor (played by George C Scott) pushed body parts, with (unintentionally) amusing doctor’s motivations and struggles with clinical to the edge. Won American and British consequences. Don’t miss classic line, ‘‘Can’t you versus research career, and thus inspirational and Academy Awards for Best Screenplay (Paddy see this arm is killing me!’’ enlightening for medical students. Nominated for Chayefsky). four Academy Awards and Directed by John Ford.

3. Article 99 (1991) 3. High Anxiety (1977). 3. The Citadel (1938) Doctors in Veterans Hospital try to care for Dr Richard Thorndyke (Mel Brooks), new Director Young, idealistic doctor (Robert Donat) becomes patients despite bureaucracy and stingy of Psychoneurotic Institute for the Very, VERY disillusioned after practicing in Welsh mining administrator. Nervous, is framed for murder in this parody of town, is corrupted by lucrative practice for London Hitchcock movies. hypochondriacs, and needs major shock to appreciate true meaning of being a good doctor. From AJ Cronin novel; nominated for four Academy Awards.

4. State of Emergency (1993) 4. The Patriot (1999) 4. Not As a Stranger (1955) Jaded emergency room doctor (Joe Mantegna) Steven Seagal plays an MD-PhD family practitioner/ Follows lives of several medical students, struggles to care for patients as he battles holistic healer who is also a single father, Native examining such issues as career choices, greed, budget cutbacks, overcrowding, and takeover American cowboy, and martial arts expert. He and racism. Star studded cast includes Robert by an HMO. single handedly conquers extremist paramilitaries Mitchum, Frank Sinatra, and Lee Marvin as and the most lethal viral outbreak ever. doctors.

5. Miss Evers’ Boys (1997) 5. What About Bob (1977) 5. Pressure Point (1962) Compelling drama about infamous Tuskeegee Multi-phobic patient (Bill Murray) follows Excellent examination of racial issues in which Study of untreated syphilis in African- nationally renowned psychiatrist (Richard Dreyfus) Sidney Poitier plays a prison psychiatrist forced to Americans. Made-for-TV movie won five on vacation, turning his life upside-down. treat a racist Nazi prisoner (Bobby Darin). Emmys and nominated for another seven.

6. The Elephant Man (1980) 6. Carry on Doctor (1968) 6. Whose Life Is It Anyway (1981) Biography of John Merrick (John Hurt) and his Among the most famous in the ‘‘Carry On’’ series, Superb vehicle for exploring medical ethics issues compassionate physician (Anthony Hopkins). filled with many gags (but not much of a plot). in this film about an artist (Richard Dreyfus) Directed by David Lynch, Hurt won British paralysed in an auto accident who wants hospital Academy Award for Best Actor. to let him die.

7. Panic in the Streets (1950) 7. Doctor at Sea (1956). 7. Miss Evers’ Boys (1997). http://adc.bmj.com/ Dr Clint Reed (Richard Widmark), a Public To escape romantic entanglement, Dr Sparrow Film about infamous Tuskeegee Study is Health Service doctor, determines an immigrant (Dirk Bogarde) becomes ship’s doctor, getting outstanding means for exploring informed killed by hoodlums had pneumonic plague, and involved with passenger (Brigitte Bardot) and consent, research ethics, and racism. to prevent a catastrophic epidemic, must track madcap shore adventures. British Academy Award down killers aided by reluctant police chief. Nominee: Best British Screenplay. Won Academy Award for Best Story.

8. Spellbound (1945) 8. What’s New, Pussycat (1965) 8. The Interns (1962). Hitchcock classic about psychiatrist (Ingrid Engaged philanderer (Peter O’Toole) seeks aid of Nice exploration of residency, sexism, racism, on September 26, 2021 by guest. Protected copyright. Bergman) who helps amnesiac accused of psychiatrist (Peter Sellers) who has problems of his ethics, and greed. Look for Telly Savalas and murder (Gregory Peck) uncover his past. own. Woody Allen’s first film as both actor and Buddy Ebsen as doctors. director; features Oscar nominated song of same name.

9. Death and the Maiden (1994) 9. Torture Ship (1939) 9. Critical Care (1997) Torture/rape victim (Sigourney Weaver) Research doctor who believes he has isolated Great mechanism for considering key end-of-life confronts her doctor torturer (Ben Kingsley) in ‘‘endocrine glands for criminality’’ recruits six issues, this film portrays travails of resident (James this adaptation of a play directed by Roman homicidal criminals to be research subjects on Spader) entangled in siblings’ dispute over their Polanski. board ship in exchange for passage to new terminally-ill, comatose father. country. Based on a Jack London short story, most humorous moments feature horribly coercive ‘‘informed consent’’ for research.

10. Guess Who’s Coming to Dinner (1967) 10. Malice (1993) 10. And the Band Played On (1997) African-American tropical medicine specialist Otherwise predictable thriller with nice plot twist, Provocative examination of history of HIV/AIDS in (Poitier) brought home by fiance´e (Katharine noteworthy for amusing soliloquy by surgeon Jed Hill USA that also considers intersection of politics and Houghton) to meet her parents (Spencer Tracy (Alec Baldwin) featuring, ‘‘You ask me if I have a God science. and Katharine Hepburn) shock and test parents complex? Let me tell you something: I am God.’’ with their interracial romance. Academy Awards for Best Actress and Screenplay and British Academy Awards for Best Actor and Actress.

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‘‘Here’s the problem: this patient needs ‘‘You won’t perform the operation to Michelle (Mary Tyler Moore), a social open-heart surgery. The administration remove the arm?’’ worker and speech therapist. Michelle of this hospital will only authorise a ‘‘No. And I’ll see you put in a mental falls in love with Carpenter, but does not prostate procedure. Now what good is institution before I let you undo what allow the relationship to start, and fixing his prostate if he has a heart I’ve done.’’ returns to her convent conflicted. She attack every time he tries to use it?’’ In attends a community church where Extreme Measures (1996), a hospital Carpenter is leading a musical mass, When you need a doctor who ‘‘really administrator confronts resident Dr and the movie ends with Michelle trying kicks butt’’, R Wesley McLaren, PhD, Guy Luthan (Hugh Grant) about the to decide between God and the god-like MD (Steven Seagal) is your man (fig 2). costs of multiple lab tests on a patient musician-doctor Elvis Presley, a difficult In The Patriot (1998), McLaren heads up who died mysteriously: choice indeed. the Montana Wellness Center, specialis- ing in family practice and holistic ‘‘Who the hell is Claude Menkins?’’ therapy. In addition, he is a Native COMMENT ‘‘It’s ‘was.’ I’m afraid he died.’’ American cowboy, single father, and Doctor movies continue to fascinate ‘‘Tell me he had insurance.’’ former world famous government because they can be humorous, thought ‘‘No. That’s not at all likely.’’ immunologist. When a paramilitary provoking, informative of the public’s ‘‘This is $2600 worth of lab work.’’ extremist releases a ‘‘highly contagious perception of doctors, and they never ‘‘Right. Could I…’’ [Reaches for viral agent’’ called NAM 37 that has ‘‘10 cease to entertain. Movie doctors pro- printout]. times the potency of anthrax’’, McLaren vide insightful and realistic portraits of [Snatches back printout]. ‘‘I had two must develop a ‘‘cure’’ and fight extre- the challenges, rewards, and excitement people tied up for eight hours.’’ mists in hand-to-hand combat and with of being a doctor, whether it’s Ingrid ‘‘Well, you know, Gene, what you firearms. Among the more unintention- Bergman playing a psychiatrist in Alfred do in the privacy of your own home ally humorous segments are McLaren Hitchcock’s Spellbound (1945), Sidney Poitier as a prison psychiatrist forced is really your business.’’ diagnosing a patient with ‘‘severe to treat a racist psychopath in Pressure ‘‘O.K. Let’s get it into your head. oedema of the abdomen and liver’’ before Point (1962), Peter Sellers as the wacky This is not England. This is not the palpating the patient’s abdomen, using psychiatrist in What’s New Pussycat National Royal Shakespeare tax- a light microscope to examine the virus, developing a treatment for the virus (1965), or Robin Williams as the physi- payers pick up the tab health care in an evening’s work which almost cian-clown Patch Adams (1998) (fig 4). system. O.K. Somebody has to pay instantly cures patients, and McLaren For the aficionado, I provide a series of for this s---!’’ killing the paramilitary chief with the annotated ‘‘top-ten lists’’ of doctor stem of a wineglass, then doing a flip movies I consider to be the best, most Humour: intended and unintended humorous, and most useful in medical In Body Parts (1991), psychologist Bill through a plate glass window, holding education (table 1). Chrushank (Jeff Fahey) loses his arm in his rescued daughter wrapped in a a car accident, but receives an ‘‘arm blanket. The ‘‘cure’’ is derived from a traditional Native American herbal ther- ACKNOWLEDGEMENTS transplant’’ by Dr Agatha Webb I am very grateful to the Academy of Motion (Lindsay Duncan), who is transplanting apy, and consists of a tea or injection of a red flower distillate. A whole army Picture Arts and Sciences for providing the body parts harvested from convicted outstanding movie stills, to Sarah Hallbauer troop is shown collecting red flowers in killers. After Chrushank recovers, he for her assistance in preparing the manu- finds that his ‘‘killer’s arm’’ has a life biohazard gear, and the entire commu- script, and to Alisa Flores for insights on the http://adc.bmj.com/ of its own, forcing him to strike his wife nity is saved when US Army helicopters movies and manuscript. shower the town with red flower petals, and murder the surgeon and anaesthe- Arch Dis Child 2004;89:1084–1088. which inhabitants are instructed to use siologist who performed his operation. doi: 10.1136/adc.2003.048843 Chrushank sets out to discover other to treat themselves with cups of tea. recipients of transplants from the donor, In Change of Habit (1969), Elvis Presley Correspondence to: Dr G Flores, Center for the Advancement of Urban Children, Department who it turns out was a serial killer. The plays Dr John Carpenter, a musically talented general practitioner who runs a of Pediatrics, Medical College of Wisconsin,

serial killer’s head is transplanted onto 8701 Watertown Plank Rd, Milwaukee, WI on September 26, 2021 by guest. Protected copyright. someone else’s body, and the killer free clinic in a tough section of New 53226, USA; [email protected] York City (fig 3). Dr Carpenter is in the starts slaughtering each transplant reci- Supported in part by grants from the Robert pient to get back his body parts. middle of a jam session with community Wood Johnson Foundation youths when he is called away: Chrushank eventually kills the resur- All figures provided courtesy of the Academy of rected serial killer. Perhaps the most Motion Picture Arts and Sciences humorous segment of the film is when ‘‘Hey Doc! You left us hanging in the Chrushank asks Dr Webb to detach his middle of our thing, man.’’ rogue arm transplant: ‘‘Just fake it for about 32 bars. I’ll be REFERENCES right back.’’ 1 Motion Picture Association Worldwide Market ‘‘Do you realise what I and my team ‘‘You’re the doctor?’’ Research. MPA snapshot report: 2003 have accomplished with that arm of ‘‘You don’t look like a doctor.’’ international theatrical market. Encino, CA: MPA Worldwide Market Research, 2004. yours? Don’t you realise that if a ‘‘Well, man doesn’t live by bread 2 UK Film Council. Film in the UK 2002. Statistical gun were put to my head I wouldn’t alone. Especially the kind of bread yearbook. London: UK Film Council, 2003. 3 Motion Picture Association Worldwide Market jeopardise the accomplishments that you make working at the free clinic. Research. U.S. entertainment industry: 2003 MPA your surgery represents?’’ John Carpenter, MD. Just like the market statistics. Encino, CA: MPA Worldwide ‘‘Can’t you see this arm is killing sign says.’’ Market Research, 2004. 4 Flores G. Mad scientists, compassionate healers, me!’’ and greedy egotists: the portrayal of physicians in ‘‘I’m sorry to put this so bluntly, Bill, Three nuns who also are healthcare the movies. J Nat Med Assoc 2002;94:635–58. but the pain you’re in just isn’t that professionals covertly are assigned as 5 Turner Classic Movies. Every girl should be married. http://www.turnerclassicmovies.com/ important when I balance it against laypersons to Carpenter’s clinic on a ThisMonth/Article/ the significance of the experiment.’’ religious mission, including Sister 0,,76183%7C76184%7C76189,00.html.

www.archdischild.com LEADING ARTICLE 1089 Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from Specialist registrar to take place across the sources of error...... It is also possible to mathematically model the circumstances that would be required (in terms of number of obser- How to assess your specialist registrar vations and numbers of independent observers) to achieve a given reliability. H Davies, R Howells This means that it is possible to plan assessment in a way that ensures ...... adequate reliability will be achieved. Conventionally a reliability coefficient Performance assessment requires careful thought and planning of 0.8 is desirable for high stakes assessments such as certification proce- his paper outlines the principles of PRINCIPLES OF GOOD dures, although a lower reliability may good assessment, including the ASSESSMENT be acceptable for widespread screening Timportance of defining the purpose Key characteristics of assessment tools assessments. of assessment as well as what should include reliability, validity, educational be assessed. It then considers how SpR impact, feasibility, and cost effective- Validity assessment should be undertaken, ness. The relative importance of these Validity is a measure of how completely including possible tools for assessment characteristics varies according to the an assessment tool measures what it such as peer ratings, patient assessment purpose of the assessment. purports to. There are a number of dif- mini-CEX, and portfolios. It concludes ferent types of validity including con- with a brief discussion of how to draw Reliability struct, content, and criterion validity.4 together the various aspects discussed Reliability is a measure of reproducibil- Reliability is essential to the defensibil- and some advice on remediation. ity—would you get the same results if ity of an assessment—but demonstrated There is a requirement for annual you administered the assessment again? validity is also a fundamental require- assessment of all specialist registrars Possible influences on reliability include ment. It doesn’t matter how reliable a (SpRs).1 However, this is undertaken on differences between observers (inter- test is, if it is not actually assessing the an ad hoc basis with wide variation in observer reliability), variation within area of interest it is not worth using. practice both between and within special- observers (intra-observer reliability), ties. Little of the assessment undertaken the nature of the test itself (test-retest Feasibility to date has been sufficiently robust to reliability), and the nature of the pro- Evaluation of feasibility is essential. withstand legal challenge. Annual assess- blem itself (case specificity). Case spe- Assessment methods that are highly mentforSpRsissoontobeextendedto cificity is a particular problem for feasible on a small scale may prove very SHOs through Modernising Medical clinical assessment of all types. It is difficult to implement on a larger scale Careers (MMC) and public, political, and important to realise that subjectivity in a range of different settings. Con- professional pressure to show that ade- and reliability are not incompatible. sultants are already hard pressed and quate self regulation has been important Subjective judgements, while not reli- the time they have available to commit in driving revalidation forward. A priority able on an individual basis may be to assessment limited. Use of peers and for the newly established Postgraduate reliable if sufficiently widely sampled. patients for assessment as well as other Education Training and Standards Board Within medical education, reliability is health professionals is an important part http://adc.bmj.com/ (PMETB) has been to provide a principles increasingly being evaluated using a of optimising feasibility. and standards framework for assess- technique based on analysis of variance; ment within postgraduate medical train- generalisability theory.3 By analysing Educational impact ing2 (box 1). Annual assessment for components of variance it makes use Tools used should generate educational trainees will be used to show continu- of all the data to quantify known feedback that informs professional devel- ing fitness to practice within the revalida- sources of error without multiple experi- opment planning. Because assessment tion framework. Assessment therefore ments. Identification of the sources of drives learning, robust assessment is increasingly recognised as a priority; error is important as it allows sampling which is seen to be valid and feasible on September 26, 2021 by guest. Protected copyright. what remains unclear is how this should be done—how will we measure success? Box 1: PMETB assessment principles The authors are part of a team responsible for implementing perfor- 1. The assessment system must be fit for a range of purposes mance assessment for paediatricians in 2. The content of the assessment (sample of knowledge, skills, and attitudes) will be training on behalf of the RCPCH. This based on curricula for postgraduate training which themselves are referenced article provides guidance on good prac- to all of the areas of Good Medical Practice tice in relation to postgraduate assess- 3. The methods used within the programme will be selected in the light of the ment with particular reference to SpRs purpose and content of that component of the assessment framework in paediatrics, although the principles discussed are generic in nature. Con- 4. The methods used to set standards for classification of the trainee’s sensus and clarity regarding the purpose performance/competence must be transparent and in the public domain of assessment (why), the content of 5. Assessments must provide relevant feedback assessment (what), and the method of 6. Assessors/examiners will be recruited against criteria for performing the tasks assessment (how) is essential. There is they undertake also a need for a clear framework to 7. There will be lay input in the development of assessment address problems for the minority of 8. Documentation will be standardised and accessible nationally doctors whose assessment raises con- 9. There will be resources sufficient to support assessment cerns about their ability to practice effectively.

www.archdischild.com 1090 LEADING ARTICLE Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from is likely to have a greater educational programme for SpRs could be app- impact and be more acceptable than one roached as well as illustrative discussion which is not. Tools which have low of some specific tools will be covered by Does feasibility on a wide scale may be very Behaviour discussion of how this problem has been useful in the context of remediation for Shows how approached within one, specific, post- doctors about whom there is concern. graduate setting: annual assessment

Knows how for paediatric SpRs in the UK. Areas on which to focus initial efforts PURPOSE OF ASSESSMENT Cognition in relation to tool development have Fundamental to the development of any Knows assessment process is clarifying the been informed by a range of sources purpose of the assessment process. For (box 2). It is intended that all paediatric trainees this means determining readi- Figure 1 Miller’s pyramid.7 SpRs will be assessed using high feasi- ness to progress to the next stage of bility ‘‘screening’’ tools such as peer 10 11 their training. The terms summative cedures requires careful thought and a ratings. Where a potential problem is and formative are widely used to des- detailed and structured plan is neces- identified, more detailed assessment in cribe the difference between assess- sary if this is to be done properly.8 There the area of concern can be undertaken ments which concentrate on making is currently a paucity of adequately (fig 2). This is important both to ensure pass-fail judgements (summative) and evaluated performance assessment that a real problem exists in this area those which concentrate on providing tools, and this is acknowledged world- and to provide a detailed profile of the feedback on an individual’s strengths wide.5 Tool development must be nature of the problem to inform plan- and weaknesses (formative). Summa- mapped to domains of competence, ning of remediation. tive assessment may produce feedback and guidance on these is available.5 Possible sources of evidence for per- which clarifies areas of concern or Within the UK, Good Medical Practice formance assessment can be divided excellence for doctors, but it is not (GMP) provides the framework for into two broad groups: generic and intrinsic to the process (as it is for a defining what a doctor is expected to specific skills. Examples of possible tools formative assessment process). Assess- be able to do.9 Mapping of SpR assess- in both groups are discussed. ment is the most powerful stimulus to ment to GMP will ensure that the learning—we should use this strategi- requirements for revalidation are ful- POTENTIAL TOOLS FOR cally. By assessing the areas of practice filled by the process. Details of SpRs’ PERFORMANCE (WORKPLACE that we consider to be the most impor- practice profiles in terms of both the BASED) ASSESSMENT tant we will inevitably stimulate learn- distribution of tasks (emergency versus Tools suitable for widespread ing in these areas. outpatient work, for example) and screening (level 1, fig 2) relative frequency of different clinical Peer ratings WHAT SHOULD BE ASSESSED? problems are not, however, currently Peer ratings refer to judgements made Guidance on SpR annual assessment available. by other health professionals about a to inform the Record of In-Training doctor’s performance. They are broadly Assessment (RITA) focuses on the HOW SHOULD WE BE DOING SpR equivalent to 360 feedback which has assessment of practice, rather than ASSESSMENT? been used in industry for many years. knowledge.1 For doctors in practice The principles of how the development They usually consist of a questionnaire there is a trend away from compe- of a rigorous performance assessment with some sort of scale against which http://adc.bmj.com/ tence assessment towards performance assessment. Competence assessment is a measure of what a practitioner is HIGH STAKES REMEDIATION capable of doing (the best he/she can DETAILED TESTING Carefully planned with do under controlled circumstances), TO DETERMINE clear aims and whereas performance assessment is a REMEDIATION objectives and

measure of what he or she actually does reassessment at a on September 26, 2021 by guest. Protected copyright. in daily practice.5 Competence assess- specified time Possible tools include: ment does not necessarily predict per- Video consultation formance.6 Miller provides a useful assessment framework for conceptualising the dif- Mini-CEX ference between performance (does) Detailed testing of technical skills and competence (shows how)7 (fig 1). MORE DETAILED Most entering this Chart stimulated recall TESTING stage will be OK. However, there continues to be confu- Portfolios sion about the use of the terms compe- Some will need tence and performance; workplace targetted training based assessment may be a better term as it avoids such confusion. Miller’s pyramid also emphasises the fact that performance is built on a foundation of SCREENING FOR Most will pass–some knowledge—without adequate knowl- ALL SpRs will require more edge it will not be possible to perform Possible tools include: detailed testing to Peer ratings satisfactorily across a range of situa- determine if they are Patient assessment tions. Workplace based assessment pro- OK. FEASIBILITY SAIL vides an authentic representation of the essential way in which a doctor functions within a complex environment where there are many potential influences on their Figure 2 High feasibility screening tools are followed by more detailed testing in areas of concern behaviour. Establishing assessment pro- to clarify problems and plan remediation where necessary.

www.archdischild.com LEADING ARTICLE 1091 Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from a doctor communicates with them. A Box 2: Areas on which to focus initial efforts in relation to tool vast number of patient satisfaction tools development for paediatric SpRs are available. However, there has been almost no work undertaken which These have been informed by a range of sources: robustly evaluates how to use the patient’s perspective as a defensible N Detailed review of performance assessment literature component of a rigorous assessment N Areas recognised as being central to the practice of most physicians, in process, a problem highlighted by particular the consultation Sitzia in his review of patient satisfac- N Good Medical Practice (GMP)9 tion data.17 The American Board of N Agreed international domains for performance assessment (which map to Internal Medicine (ABIM) has done 5 work to evaluate a patient assessment GMP) tool.18 A recent study of 351 paediatric N Areas recognised as being common areas of complaint/poor perfor- consultations using the Sheffield mance (communication and teamwork in particular) Patient Assessment Tool (SHEFFPAT) N Consensus exercise with paediatric tutors identifying key features of an has shown that 25 consultations are effective (paediatric) consultation sufficient for parents’ feedback to meet N Areas identified in GMC pilot for revalidation as being areas where the criteria required for inclusion in a performance assessment programme doctors found it difficult to provide evidence of adequate performance (reliability of .0.8 evaluated using (implying a deficiency of tools)—in particular, patient feedback and generalisability).19 Utilising patients/ teamwork carers not only meets criteria for perfor- N Areas where previous work suggests that performance assessment may mance assessment, but also fits well be undertaken in a feasible, reliable way across a range of domains—in with the GMC and PMETB require- particular, peer ratings10 11 ments and the concept of the expert patient. N Areas complementary to work being undertaken by the RCP, to avoid unnecessary duplication of effort Tools better suited for more detailed testing (level 2, fig 2) Performance assessment based on the doctor is judged in a number of to GMP. For SpRs 11 raters across a written records areas. Peer rating is an attractive means range of health professionals are needed Written records of assessing a broad range of compe- to achieve a reliability of 0.7 (generali- Medical records have huge potential for tencies for doctors in practice. It has sability analysis). SPRAT performs par- assessment, but ward based records may huge potential as a high feasibility tool ticularly well in the areas of team not represent the performance of the that is reliable and is able to assess areas working and communication, areas doctor making decisions (for example, that are otherwise difficult to assess, which are traditionally difficult to an SpR or consultant ward round such as teamworking. Ramsey studied assess. It is feasible and generates feed- recorded by an SHO).20 Furthermore, the clinical performance of physicians back which can be used to inform per- assessment of the medical record alone sonal development planning (fig 3). using written questionnaires mailed to does not allow an assessment of deci- http://adc.bmj.com/ professional associates of the physicians sion making/patient management skills (both doctors and nurses).10 11 Ramsey’s Performance assessment based on as record keeping is simply too incon- questionnaire consists of 11 categories, written records sistent. It may be important to assess an and the rater is asked to score the Correspondence between individual’s ability to keep adequate physician in each category from 1 to 9 professionals written records, but this does not (or score UA if they feel unable to Correspondence between health profes- necessarily reflect their decision making comment in a particular category). sionals is an important record of a skills. A potential way of using medical

Eleven raters are needed to achieve a healthcare event. From April 2004 it will records to test more complex skills such on September 26, 2021 by guest. Protected copyright. reliability coefficient of 0.7. be mandatory to copy correspondence as decision making, however, is through Other workers have evaluated the use between professionals to patients/carers, chart stimulated recall. of peer ratings in different settings, and many doctors are already doing this. mainly within the USA or Canadian A validated tool for the assessment of Chart stimulated recall healthcare system.12–14 In one of these outpatient correspondence has been Chart stimulated recall (CSR) consists studies 71% of surgeons followed up developed (Sheffield Assessment Instru- of assessment of performance through three months after administration of the ment for Letters, SAIL). It has been structured interviews, for which a selec- instrument contemplated or initiated shown to have good reliability and tion of medical records from a physi- change on the basis of the multi-source feasibility,15 although further work is cian’s caseload acts as the focus. feedback (based on self reporting).14 needed to determine how best to utilise Assessment may be based on the quality The GMC and PMETB advocate the SAIL in the context of widespread SpR of data acquisition, patient evaluation, use of peer ratings for work based assessment. Potentially other SpRs could the clinician’s choices about patient assessment, and the RCPCH intends to be used as raters, which has high management, and knowledge base. The utilise peer ratings as part of the feasibility and good educational impact. GMC and College of Physicians and standardised SpR assessment process. A small pilot study has shown a signifi- Surgeons of Ontario (CPSO) Canada A peer assessment tool developed and cant improvement in letter writing fol- incorporate CSR within their procedures evaluated with paediatric SpRs has been lowing training with SAIL.16 for evaluating poorly performing doc- shown to have good reliability and tors. Charts are reviewed by two asses- validity in a pilot study. The tool consists Patient and parent feedback sors, and used as the focus for of a 25 point questionnaire (Sheffield Patients and/or their carers are ideally discussions with the physicians. Peer Assessment Tool, SPRAT) mapped placed to provide feedback on how well Because case specificity (performance

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6 Doctor's mean Group mean Self

5

4

3

2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Question 10 asks the assessor to rate the doctor in relation to their ability to deal with stress, an area in which this doctor is performing less well than his/her peers and which could be a focus for development planning.

Figure 3 Example of feedback given to an individual doctor on the basis of peer ratings. of an individual which is dependent on culty of the clinical case encountered as difficulty in the area of communication the nature of the medical case around well as the nature of the problem. Wide identified by higher feasibility screening which the interview is based) is a sampling is essential and it is a method tools such as patient assessment and problem with this type of assessment that is relatively time consuming for peer rating. All trainees could, however, http://adc.bmj.com/ tool, CSR interviews would need to be senior doctors, potentially limiting its valuably be exposed to review of videos conducted on several occasions during feasibility. Work is being undertaken of their consultations as part of their training, in order to ensure that the by the Royal College of Physicians to training. method has adequate sampling validity. evaluate its measurement characteristics Norman and Salvatoori have shown in a UK training grade setting.24 Other skills satisfactory reliability using CSR, and Assessment of core technical skills is Many other attributes and skills make 21 22 found it to be feasible. Data on the clearly also important. A range of up a doctor’s practice and have not been on September 26, 2021 by guest. Protected copyright. use of CSR in the UK setting for potential methodologies for doing this discussed here. These include, for exam- performance assessment are not avail- have been developed within the surgical ple, teaching and training, research able, but CSR has the potential to allow specialties, and these could be modified skills, and critical appraisal. Portfolios assessment areas which are otherwise for a paediatric setting.25 The use of offer potential as a means of assessing a very difficult to assess. video also has potential for the assess- doctor’s overall professional profile, ment of technical skills.26 including these aspects of practice, as Clinical and technical skills Video has also been used for the well as, importantly, an individual’s Although the assessment of communi- assessment of consultation skills, most ability to learn from experience. How- cation, teamworking, and other generic widely within a primary care setting ever, while their usefulness as a means of skills is clearly essential, it is also within the UK, and also in the supporting professional development is important that core clinical skills are Netherlands and Australia.27–29 This has widely acknowledged, their role in per- 30 assessed. Possible tools available include tremendous potential for providing formance assessment is controversial. mini-CEX.23 Mini-CEX is utilised by the structured feedback that can inform ABIM to assess residents in training. Its personal development planning for doc- Putting it all together aim is to assess residents’ clinical skills, tors. Pilot work is underway evaluating None of these individual assessments on attitudes, and behaviours using a struc- a paediatric consultation assessment their own will be sufficient. In order to tured rating form completed by a senior tool based around existing models of obtain a representative picture of a member of faculty while observing a the consultation. It may be appropriate, doctor’s overall practice, a number of clinical encounter. It takes on average however, that the use of video for assessments sampling widely across the 20 minutes per encounter. Scores on the assessment purposes is reserved for doctor’s practice will be essential. These mini-CEX are influenced by the diffi- those doctors who appear to have should be planned well in advance, and

www.archdischild.com LEADING ARTICLE 1093 Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from the nature and timing of the assess- important, so that assessment has a real physician performance. JAMA 1993;269:1655–60. ment processes made explicit to the influence on doctors’ practice and hence 12 Rodgers KG, Manifold C. 360-degree trainees being assessed as well as to the quality of care they provide for feedback: possibilities for assessment of the the assessors. patients. ACGME core competencies for emergency Training for assessors is essential and medicine residents. Acad Emerg Med 2002;9:1300–4. is likely to improve the reliability of the ACKNOWLEDGEMENTS 13 Violato C, Hall WG. Alberta Physician process. The nature and purpose of the Special thanks are extended to Dr Vin Achievement Review. CMAJ 2000;162:1803. assessments and the criteria against Diwakar for his thoughtful comments and 14 Violato C, Lockyer J, Fidler H. Multisource feedback: a method of assessing surgical which judgements are being made input. Thanks also are due to Dr Julian practice. BMJ 2003;326:546–8. should be made explicit to all partici- Archer, Dr Jim Crossley, and Miss Judith 15 Crossley GM, Howe A, Newble D, et al. Sheffield pants. Quality assurance processes must Ellis. Assessment Instrument for Letters (SAIL): performance assessment using outpatient letters. be built into the process and should Arch Dis Child 2004;89:1089–1093. Med Educ 2001;35:1115–24. evaluate reliability and validity as well doi: 10.1136/adc.2003.043232 16 Fox A, Palmer R, Crossley J, et al. Improving the as ensuring that the overall assessment quality of outpatient clinic letters using the ...... Sheffield Assessment Instrument for Letters (SAIL). programme is in line with the PMETB Med Educ 2004;38:852–8. assessment standards framework.2 Authors’ affiliations 17 Sitzia J. How valid and reliable are patient Detailed assessment should be under- H Davies, Sheffield Children’s NHS Trust, satisfaction data? An analysis of 195 studies. taken of possible problem areas identi- RCPCH lead for Performance Assessment, Int J Qual Health Care 1999;11:319–28. Sheffield, UK 18 Webster GD. Final report on the Patient fied by screening tools such as peer Satisfaction Questionnaire Project, American R Howells, RCPCH Education Fellow and ratings. Board of Internal Medicine, 1989. Honorary Clinical Lecturer, University of 19 Crossley J. Assessing the clinical performance of Cambridge, Department of Paediatrics, doctors. Thesis for Doctorate of Medicine, Oxford Remediation: principles and Cambridge, UK University, 2003. planning the process 20 Fernando KJ, Siriwardena AK. Standards of documentation of the surgeon-patient consultation Remediation should be offered to all Correspondence to: Dr H Davies, Consultant in in current surgical practice. Br J Surg doctors about whom significant concern Late Effects/Medical Education, Sheffield 2001;88:309–12. in any area of their practice has been Children’s NHS Trust, Western Bank, Sheffield 21 Norman GR, Davis DA, Lamb S, et al. raised, and adequate (or otherwise) S10 2TH, UK; [email protected] Competency assessment of primary care physicians as part of a peer review program. remediation confirmed by appropriate Accepted 23 December 2003 JAMA 1993;270:1046–51. assessment processes. Ideally each SpR 22 Salvatori P, Baptiste S, Ward M. Development of and SHO programme should have an a tool to measure clinical competence in occupational therapy: a pilot study? Can J Occup individual who is responsible for reme- REFERENCES Ther 2000;67:51–60. diation. A written, individualised, fra- 1 NHSE. A guide to specialist registrar training, 23 Norcini JJ, Blank LL, Duffy FD, et al. The mini- mework should be produced in line with NHSE, 1998. CEX: a method for assessing clinical skills. Ann Intern Med 2003;138:476–81. a nationally agreed outline framework 2 Southgate L, Grant J. Principles and standards for an assessment system for postgraduate medical 24 Wragg A, Wade W, Fuller G, et al. Assessing the for remediation. Additionally, it is of training, PMETB Subgroup on Assessment, performance of specialist registrars. Clin Med particular importance that an attempt is 2003. 2003;3:131–4. 3 Crossley J, Davies H, Humphris G, et al. 25 Martin JA, Regehr G, Reznick R, et al. made to measure an individual’s degree Objective structured assessment of technical of insight into areas of concern as this Generalisability: a key to unlock professional assessment. Med Educ 2002;36:972–8. skill (OSATS) for surgical residents. Br J Surg 1997;84:273–8. may significantly affect the success of a 4 Jolly B. The good assessment guide: a practical 26 Cronin C, Cheang S, Hlynka D, et al. remediation programme. Tools to assess guide to assessment and appraisal. London: Joint Videoconferencing can be used to assess http://adc.bmj.com/ Centre for Education in Medicine, 1997. insight are not yet well developed, but it neonatal resuscitation skills. Med Educ 5 Hays RB, Davies HA, Beard JD, et al. Selecting 2001;35:1013–23. is recognised as being a priority area for performance assessment methods for experienced performance assessment development.31 27 Campbell LM, Howie JG, Murray TS. Use of physicians. Med Educ 2002;36:910–17. videotaped consultations in summative 6 Rethans J, Sturmans F, Drop R, et al. Does assessment of trainees in general practice. CONCLUSIONS competence of general practitioners predict their Br J Gen Pract 1995;45:137–41. performance? Comparison between examination 28 Ram P, Grol R, Rethans JJ, et al. Assessment of Appropriate rigorous assessment of doc- setting and actual practice. BMJ general practitioners by video observation of tors is a challenge. Development and 1991;303:1377–80. communicative and medical performance in daily implementation of performance assess- 7 Miller GE. The assessment of clinical skills/ practice: issues of validity, reliability and on September 26, 2021 by guest. Protected copyright. competence/performance. Acad Med 1990;65(9 ment requires careful thought and feasibility. Med Educ 1999;33:447–54. suppl):S63–7. 29 Hays R, Spike N, Sen Gupta T, et al. A planning and a considerable investment 8 Schuwirth LW, Southgate L, Page GG, et al. performance assessment module for experienced of resources, both time and money. When enough is enough: a conceptual basis for general practitioners. Med Educ However, such investment is essential. fair and defensible practice performance 2002;36:258–60. assessment. Med Educ 2002;36:925–30. 30 Wilkinson TJ, Challis M, Hobma SO, et al. The Assessment is not only mandatory, it is 9 GMC. Good Medical Practice, GMC, 2001. use of portfolios for assessment of the competence the most powerful stimulus to learning. 10 Ramsey PG, Wenrich MD. Peer ratings. An and performance of doctors in practice. Med We should ensure that it is undertaken assessment tool whose time has come. J Gen Educ 2002;36:918–24. Intern Med 1999;14:581–2. 31 Hays RB, Jolly BC, Caldon LJ, et al. Is insight rigorously, but also that we assess not 11 Ramsey PG, Wenrich MD, Carline JD, important? measuring capacity to change simply what is easiest, but what is most et al. Use of peer ratings to evaluate performance. Med Educ 2002;36:965–71.

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Obstetrics BIRTH RITUALS AND THEIR ...... PRESENT DAY OBSERVANCE The origins and performance of Hindu rites are not only somewhat complex Hindu birth customs but often also differ between castes. Here, we attempt to present some A R Gatrad, M Ray, A Sheikh common features of these rites in order to help non-Hindu healthcare profes- ...... sionals to develop a working apprecia- Marriage, pregnancy, and birth rituals tion of these practices and their significance. Manu, the legendary author of the any expectant mothers have and Shiva (The Destroyer). In Britain, Sanskrit Code of Law10 created a num- fears and anxieties about their the majority of Hindus are Vishnuvites.5 ber of sacraments or Samskaras—a word Mpregnancy. For Hindu pregnant Many Hindus believe that a person is which means ‘‘perfection’’. These are women, these general concerns may be born into a caste or acquires it by ‘‘activities that help achieve ‘purity’ as a compounded by difficulties in commu- behaviour;6 for example, a person of a result of which the personality of the nicating with healthcare professionals. lower caste by being ‘‘pious’’ can go individual is developed to the full, from It is our aim in this paper to provide higher up the caste ladder. Although no conception to the grave’’.11 Each sacra- clinicians with a basic understanding of longer officially recognised and less ment involves a prayer and often a Hindu birth customs in the hope that visible in modern India than in the past, ritual. Although only some of these such appreciation will go some way to the caste system still has a strong hold sacraments relate to the present discus- facilitating provision of culturally com- on Hindu families, and the impact of sion of birth customs, for completeness petent and sensitive care. this on customs (including birth) also and contextualising the principle, the In their excellent paper Webb and extends to those who have migrated. first 10 of these that are relevant to the Sergison1 defined cultural competence There are broadly four main castes: paediatric age group are described as an evolving process that depends on Brahmins (highest), Ksatriya (ruling (table 1). self-reflection, self-awareness, and caste), Vaisya (farmers and merchants), and sudras (the untouchables); this acceptance of differences. They further MARRIAGE AND PREGNANCY latter group usually work as servants explain that such competence is based The Hindu Marriage Act (1955) prohib- in India.7 on improving understanding as opposed ited child marriages in India, stipulating Closely linked with the caste system is to an increase in cultural knowledge. that boys could only marry after the age the belief in reincarnation—a belief that While fully concurring with their views of 18 years and girls after 15. Previously, one’s deeds in a former life determine we would argue that knowledge of early ‘‘child marriages’’ were thought by the caste that one is born into. This cultural context can be helpful in many to be a check on immorality and philosophy of Karma8 is of fundamental providing a prototype (as opposed to a corruption. The introduction of this Act importance to Hindus, as, it is ‘‘deeds’’ stereotype) of factors which may be is believed to have contributed to a fall in this world that will decide how the important in the provision of patient in maternal and infant mortality, while soul is reborn in the future. It is believed centred care. simultaneously improving the chances that this cycle of birth, death and rebirth Hinduism—one of the oldest world of the young to further their education http://adc.bmj.com/ ultimately results in attaining a state of religions dating back to around before marriage.12 purity that allows the liberated soul to 1500BC—originates from around the Garbadhana—the fetus laying cere- 2 become ‘‘at one’’ with the Divine pre- Indus Valley in what is now Pakistan. mony is performed at the consumma- sence. Scriptures were originally written in tion of marriage and involves special Sanskrit, a language in which most prayers for fulfilling parental duties to Hindus of today are no longer literate, DEMOGRAPHIC perpetuate the human race. In ancient and therefore customs over the years CONSIDERATIONS times, the bridegroom did not approach have tended to be passed on by word of The 2001 (UK) census revealed that the bride until the fourth night, but on September 26, 2021 by guest. Protected copyright. mouth. Almost 14 centuries ago, many there are over 559 000 Hindus in today this practice is only symbolically Hindus converted to Islam and 600 Britain,9 the majority (467 000) of enacted at the marriage ceremony. years ago Sikhism was founded as an whom originate from the Indian sub- Punsavana—the ‘‘male making’’ rite is ‘‘off shoot’’ of Hinduism. It is therefore continent, with a sizable community performed during the third month of unsurprising that not only have original coming from East Africa. This East pregnancy, in the belief that the ‘‘deity’’ Hindu customs been diluted over the African Hindu group is somewhat aty- governing the sex of the fetus is years but that the practises of other pical in that it has undergone migration activated and a male ‘‘issue’’ assured. religious customs found within South twice in a relatively short timeframe— Sons are preferred because of the Asia have intertwined with remnants of first from India to East Africa and then carriage of the family name and the Hindu teachings. However we have not on to Britain. In Britain, areas such as hope that the son will light the funeral encountered any consanguineous mar- Harrow, Leicester, and Brent have sig- pyre of his parents. Manu says: ‘‘A man riages among Hindus in the UK, a nificant Hindu communities making up is perfect when he consists of three: practice common among Muslims the 14–19% of the overall population (Office himself, his wife, and his son’’.13 In fact, world over.3 for National Statistics, 2003). Although there is still a belief among many that in Hindus believe in a ‘‘transcendent’’ generally religious, allegiance to reli- the next world/birth, the happiness of a God who may be worshipped in a gious customs will vary according to the father depends on having a continuous variety of ways through different sym- extent of ‘‘acculturation’’ (whereby line of sons.14 Furthermore, birth of a bolic manifestations (for example, sta- migrants take on some of the character- girl, particularly in India, may generate tues). The three supreme Hindu deities istics of the host community), and also parental anxieties because of the heavy forming the Hindu Trinity4 are: Brahma on whether the family roots were in financial burden resulting from the (The Creator), Vishnu (The Preserver), urban or rural India. giving of dowries.

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Table 1 Hindu sacraments (Samskaras) relevant to children before breast feeding is commenced. We are aware of this practice in some Hindu Name Procedure Time when carried out families in Britain. The custom of not breast feeding the baby for the first two Grabadhana Sacrament of impregnation Before pregnancy Punsavana Second/third month of pregnancy Second/third month of pregnancy days is still rife in India, but in our Simantonnayana Fifth to eighth month of pregnancy Fifth to eighth month of pregnancy experience this is not the case in Britain. Jatakarma At birth At birth Certain foods are believed by many Namakarana Naming the baby 10–12 days after birth South Asians, including Hindus, to have Nisramana First outing of the child Third/fourth month Annaprassana Weaning of the child Sixth month either a ‘‘cooling’’ or a ‘‘heating’’ effect Chuda Karma Cutting of hair Occasionally at birth on the functions of various organs of the Usually between first and third year body, such as mood, personality, and Karnavedha Piercing of ears Third to fifth year physical wellbeing.17 Health profes- Upanayana Investiture of sacred thread From eighth year, denoting the beginning of manhood sionals would therefore do well to be aware of the concept of ‘‘hot’’ and ‘‘cold’’ foods, both during pregnancy and the puerperium. For example, when the mother is breast feeding, if a baby Simmanantannaya—also known as ‘‘former’’ confinement. It is believed by has a cold or a fever, in the former case Valaiakappu in some parts of India some that a child born in this month she may avoid ‘‘cold’’ foods and the involves the wearing of red or green could die on the eighth day, in the converse when the baby has a raised glass bangles from the seventh month of eighth month, the eighth year, or the temperature. This concept is quite gestation. The sound of these bangles is eighteenth year! Some Hindus therefore divorced from the actual temperature believed to reach the womb and comfort consider the number ‘‘eight’’ unlucky. of food or the intensity of taste of spices. the fetus. Traditionally, these are In India, when a male is born a Thali High protein, acid, and salty foods are removed after birth and given to the (a flat bronze utensil akin to a large considered ‘‘hot’’, whereas ‘‘cold foods’’ midwife. Historically it is of interest to tray) is beaten with a stick by friends are often sweet. Lentils, millet, auber- note that in this sacrament the mother and relatives. In the case of a girl, a fan, gines, and grapes are examples of ‘‘hot’’ is allowed to fulfil her last wishes, such used for winnowing, is beaten. foods, and cereals, potatoes, milk, and as any craving for certain foods, as she is Jatakarma—this ceremony welcomes white sugar are examples of ‘‘cold’’ now thought to be entering a hazardous the child into the family. The father foods. period.15 A pregnant mother is therefore touches and smells the child and whis- Karnavedha—this refers to the ear now expected to rest as much as pers religious verses (Mantras) into the piercing ceremony. Although usually possible. To this end, some women ears of the infant. All this is to promise carried out after the age of 3 years in return to their parental home, even in the baby a safe and comfortable envir- most castes, there are some families the UK, only to return to the marital onment. To ward off evil, a small ‘‘dot’’ where a father will not see the baby’s home 40 days after delivery. It may be often in the shape of ‘‘Om’’ (see fig 1) is face after birth until certain rituals have that some patients miss their antenatal drawn behind the baby’s ear using Kajal, been performed, including ear piercing. and postnatal appointments, partly as a a carbon based eye ‘‘make up’’. Even the piercing of ears may be in the result of this custom and the fact that This symbol may also be seen on a shape of Om. In India, a goldsmith clinics are often less accessible, with chain around a baby’s neck or indeed be performs this ritual for both sexes. http://adc.bmj.com/ poor language support. placed in a cot. A family member with Although girls often retain these holes, A study by Gatrad et al showed that ‘‘virtuous qualities’’ writes, with jaggery boys usually lose them in early child- there were significant differences in dipped in Ghee (a purified form of hood. birth weight between five subgroups of butter), the word ‘‘Om’’ onto the tongue 16 The sixth day after birth is considered South Asians. These groups were of the neonate in the hope that the the most auspicious in a person’s life. Muslim Pakistanis, Muslim Bang- person’s good qualities are passed on to On this day, a fragile white cotton ladeshis, Muslim Gujaratis, Sikhs, and the infant. thread is ceremoniously tied around Hindus. Although South Asian babies on September 26, 2021 by guest. Protected copyright. Symbolically, female members of the the wrist, ankle or neck—this will were generally lighter than the Euro- family wash a nursing mother’s breasts usually spontaneously fall off a few pean, Hindus had the lightest babies days later. It is on the same sixth day at birth. It should be remembered that that a pen and a blank piece of paper are many Hindu women are often strict placed in the baby’s cot, as it is believed vegetarians and therefore do not eat that on this day the goddess of learning eggs, fish, or meat which may, in charts the baby’s future. The mother addition to genetic and other environ- may observe a fast on this day. mental factors, partly explain the lower Namakarana—the name is selected in average birth weight of babies compared such a way as to inspire the child to to other South Asian subgroups. follow a righteous path. According to Hindu scriptures, a boy’s name should BIRTH have an ‘‘even’’ number of syllables and Our experiences suggest that, in com- a girl’s name an ‘‘odd’’ number. This mon with other South Asian women, custom is rarely followed in Britain, many Hindus prefer to be seen by although in Indian villages it is still female doctors during pregnancy and Figure 1 Om symbol. The most important practised. There are several ways of labour, on the grounds of modesty. Hindu symbol is Om; this has been described as naming a baby.18 One of the commonest, A premature birth in the eighth ‘‘an Aksara or the ‘Imperishable Symbol’; it is even in the west, is according to the the Universe, the past, the present and the month of pregnancy is sometimes future—all that is and all that will be is Om; Nakshatra or the sign of the Zodiac at the superstitiously attributed to a cat likewise all else that exists beyond the bounds of time of birth of the baby. It is believed having entered the mother’s room in a time—that too is Om’’.25 that certain planets govern certain days,

www.archdischild.com 1096 LEADING ARTICLE Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from for example Mars governs Tuesday. If Chuda Karma—the hair cutting cere- particularly in rural India, a cup of the Nakshatra for the time of birth is mony (removal of scalp hair) is per- water is placed at the head of the grave unfavourable, this may be a bad omen formed at any stage depending on of a baby. Women are never present at for the family necessitating certain family tradition, although according to burials, even in Britain. rituals, which may include a special the Samskara (table 1) it is performed prayer and the father not seeing the between the first and the third year. POSTMORTEM EXAMINATIONS baby for a few days.19 It is of interest to AND ORGAN TRANSPLANTATION note that the documents, containing the DEATH OF A NEONATE OR With any family, from whatever ethnic horoscope of the baby, are admissible as group or creed, whose beliefs and needs 20 INFANT legal papers of ‘‘proof of age’’ in India. At death, the baby is believed to leave at a time of crisis cannot be assumed or Furthermore, the horoscope will be the ‘‘earthly’’ realm into an ‘‘intermedi- inferred, this subject should be especially important for arranging a broached with sensitivity; this is parti- 21 ate’’ zone in readiness for its journey to suitable marriage later. the ‘‘Divine realm’’. Although Hindus cularly so in Hindus whose belief in From the Nakshatra the first letter of often prefer to die lying on the ground Karma may result in possible anxieties the name is ascertained. For example, if (Mother Earth), this custom is rarely about whether or not all organs will be it is a ‘‘G’’ then the name could be practised for babies dying in Britain. returned to the body after a postmortem Gyatri for a girl. The paternal aunt often Quality of palliative care, if indeed such examination. Generally there is no specific prohibition to postmortem plays an important part in the choice. care was necessary, has an impact on examinations or organ transplants in Children may have a middle name such death and bereavement.22 Hindus who Hindu teachings.24 as ‘‘Devi’’ for a girl or ‘‘Lal’’ for a boy; for have perceived what they witness as a example, Gyatri Devi and Babu Lal. bad death, may be very anxious about There are certain prohibited times for the ghost of the deceased.23 DISCUSSION naming the baby; for example, at the As a baby approaches death, the Although we appreciate that one cannot time of an eclipse or when the signs of family will chant ‘‘Ram Ram’’ or ‘‘Om’’ be expected to have detailed knowledge the Zodiac are changing. Hindu names and recite from the Bhagavad Gita—the of every aspect of the multicultural have meanings; for example, Ravi for a holy book for Hindus. A thread with a tapestry of present British society, there boy means sun and Madhu for a girl religious significance may be tied is a significant Hindu community in means honey. Some boys are named around the wrist or neck of the baby. Britain today and therefore some under- after gods; for example, the names Stillborns need the same religious standing of cultural norms and values is Krishna or Ram. Some girls may be ‘‘service’’ as adults. A leaf from a Tulsi important. Such knowledge, we believe, named Chandra in the belief that the shrub (basil leaf) is placed in the is important for health professional to moon (Chand) will bring them luck and baby’s mouth, occasionally with a gold respond to individuals by reflecting on good fortune. Table 2 lists some com- coin. After a ritual wash, new clothes their own culture, and recognising and mon male and female Hindu names. are put on the baby who is subse- respecting the difference. Learning to pronounce names and a few words, The naming ceremony takes place on quently wrapped in a white shroud. especially a greeting with a smile, is the tenth or twelfth day after birth, a The body of a baby may be taken from what the patient appreciates. We should time when the mother is considered the hospital straight to the cemetery. in addition develop a broad understand- ‘‘clean’’ in order to carry out normal However if the corpse is taken home, ing of the contexts and needs of Hindu household chores, such as cooking. This candles are lit and holy water from

communities such as language difficul- http://adc.bmj.com/ custom is still practised by some Hindu the River Ganges sprinkled onto the ties, modesty, and gender issues. The families in the West. The nursing body. use of trained interpreters/advocates mother is now allowed male visitors. Babies and young pre-pubertal chil- would further provide the necessary Annaprassana—this ceremony takes dren dying before the Upanayama stage support for a truly culturally competent place after six months when weaning are buried, whereas adults are cremated. care. Achieving effective communica- is believed to be necessary for the baby Upanayama is the tenth sacrament and is tion and striving towards improved to become more mobile. A delay in a stage in a child’s life when he/she access for such communities will go a weaning that one occasionally encoun- begins adulthood after the age of 8 on September 26, 2021 by guest. Protected copyright. long way to breaking down barriers by ters in Britain may be as a result of this years. It is a stage ritualised by wearing responding flexibly to all patients, belief. Although we have no evidence a religious thread called Janeo. Children whatever their need. Health profes- that Hindu babies in general are weaned who die before this stage do not need sionals should be confident enough to at around four months in Britain, it is purification by fire as they are classed as ask their patients: ‘‘Are we doing this our experience that this is so. being ‘‘without sin’’. As a general rule, the right way for you?’’ or ‘‘How would you like us to do this?’’. Professionals Table 2 Examples of common Hindu names should be prepared to learn from families they are supporting as well as Male Female provide advice and information. This is a Name Meaning Name Meaning true partnership and one path to cultu- rally competent practice.25 Abhijit A constellation of stars Anjali Offering Akaash Sky Anuradha Bright star Anand Bliss Priya Loved one CONCLUSIONS Rajiv Lotus flower Priti Satisfaction The process of acculturation continues; Rohit Red colour Puja Prayer for example, some Hindu children have Ravi Sun Madhu Honey Sameer Breeze Madhur Sweet western names. It does not always Deepak Lamp Meena Precious stone follow that because a patient is classed Mohan Charming Lakshmi Consort of Vishnu as belonging to a certain religion that he Harsh Joy Jaya Victory or she follows that faith. Some people may wish to maintain practices that are important to them while others may

www.archdischild.com LEADING ARTICLE 1097 Arch Dis Child: first published as 10.1136/adc.2004.050591 on 19 November 2004. Downloaded from only nominally express allegiance and Correspondence to: Dr A R Gatrad, Manor 13 Singh C, Nath P. Hindu manners, customs and are not concerned with orthodox prac- Hospital, Moat Road, Walsall WS2 9PS, UK; ceremonies. Delhi: Crest Publishing House, [email protected] 1999:13. tice—this being especially true for those 14 Flood G. An introduction to Hinduism. living in the West. Furthermore, reli- Cambridge: Cambridge University Press, 1996:203. gions are divided into different sects, REFERENCES 15 Chaudhery NC. Religious control of Hindu life. resulting in individual adherents having 1 Webb E, Sergison M. Evaluation of cultural London: Trinity Press, 1979:210–11. their own particular view and interpre- competences and anti-racism training in child 16 Gatrad A, Birch N, Hughes M. Preschool weights tation of their faith and culture. Indeed, health. Arch Dis Child 2003;88:291–4. and heights of Europeans and five subgroups of 2 Flood G. An introduction to Hinduism. Asians in Britain. Arch Dis Child different generations within the same Cambridge: Cambridge University Press, 1994;71:207–10. family may have differing views. 1996:21. 17 Henley A. Asian patients in hospital and at home. Nonetheless, there are particular cus- 3 Dhami S, Sheikh A. The family: predicament and London: Pitman, 1979:129. 18 Stutley M, Stutley J. A dictionary of Hinduism. Its toms and rites, which tend to bind promise. In: Sheikh A, Gatrad AR, eds. Caring for Muslim patients. Radcliffe, 2000:49. mythology, folklore and development. London: Routledge, 1977:202. members of a religious community, 4 Sharma A. Classical Hindu thought. Oxford: 19 Singh C, Nath P. Hindu manners, customs and and our experiences suggest that birth Oxford University Press, 2000:72. ceremonies. Delhi: Crest Publishing House, 5 Neuberger J. Caring for dying people of different customs continue to be important to 1999:128. faiths, 2nd edn. London: Moseby, 1994:24–9. 20 Singh C, Nath P. Hindu manners, customs and many Hindu communities, including 6 Lipner J. Voice of tradition caste and narrative. In: those in Britain. ceremonies. Delhi: Crest Publishing House, Hindu: the religious belief and practice. London: 1999:142. Routledge, 1994:108. 21 Shattuck C. Hinduism. Religions of the world. Arch Dis Child 2004;89:1094–1097. 7 Joicey J. A handbook of Hinduism. Newcastle doi: 10.1136/adc.2004.050591 London: Routledge, 1999:81. upon Tyne Education Committee, 1980:41. 22 Koffman J, Higginson IJ. Accounts of carer’s 8 Lipner J. Morality and the person. In: Hindu: the satisfaction with health care at the end of life: a ...... religious belief and practice. London: Routledge, comparison of first generation black Caribbean Authors’ affiliations 1994:233. and white patients with advanced disease. Palliat 9 Office of National Statistics. Census 2001. A R Gatrad, Manor Hospital, Walsall, UK; Med 2001;15:337–45. 10 Pandey R. Hindu Samskaras. Delhi: MLBD, 23 Firth S. Religious perspectives on end of life care: Hon Professor Paediatrics University of 1969:17–24. a Hindu patients spiritual and cultural values Kentucky, USA 11 Singh C, Nath P. Hindu manners, customs and during the end of life period. Lancet. In press. M Ray, Manor Hospital, Walsall, UK ceremonies. Delhi: Crest Publishing House, 24 Schott J, Henley A. Culture, religion and A Sheikh, Division of Community Health 1999:8. childbearing in a multicultural society, Sciences: GP Section, University of Edinburgh, 12 Singh C, Nath P. Hindu manners, customs and Butterworth-Heinemann, 1996:311. ceremonies. Delhi: Crest Publishing House, 25 Rathakrishnan S. The Bhagavad Gita. Delhi: Edinburgh, UK 1999:31. Harper Collins, 2000.

ARCHIVIST......

Teenage pregnancy http://adc.bmj.com/ he rate of teenage pregnancy is higher in Britain than in other European countries. Professional attitudes towards teenage pregnancy tend to be polarised with some Tconsidering it undesirable because of increased risks to mother and child while others have argued that teenagers may be well suited for pregnancy and that much harm comes from the stigmatisation of teenage parents. A study in Sweden (Petra Olausson and colleagues. British Journal of Obstetrics and Gynaecology 2004;111:793–9, see also commentary,

ibid: 763–4) has shown that teenage mothers there are more likely to die young. on September 26, 2021 by guest. Protected copyright. The study included 460 343 women born between 1950 and 1964 and alive in December 1990. All had had a first child before the age of 30. Between 1990 and 1995, 1269 of these women died at ages 30–45 years. Mortality decreased with age at birth of first child from 107 deaths per 100 000 person-years among women whose first child was born when they were 17 years or younger to 87 per 100 000 person-years (first birth at 18–19 years), 54 (20–24 years), and 42 (25–29 years). Overall, early adult mortality in teenage mothers was increased by 60% after adjustment for socioeconomic background at the time of the first birth and age in 1990. The main causes of premature death were violence, cervical cancer, coronary disease, lung cancer, suicide, and alcohol. Adjustment for socioeconomic factors operating after the birth of the first child reduced, but did not eliminate, the increase in risk. Teenage mothers in Sweden have an increased risk of premature death in later life. Much of the increased risk is associated with adverse socioeconomic and lifestyle factors. The writer of the commentary argues in favour of helping teenagers to avoid pregnancy but also of providing adequate support for pregnant teenagers during and after their pregnancies.

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