217
standards ... yet ignore the haphazard operation of nuclear weapons plants",1 and concentrate on salmonella in eggs rather than on children at risk in substandard housing. Our irrationality over risks exposes us to manipulation-as Zeckhauser and Viscusi duly note,l we would not leave a baby alone in the house while we take a ten-minute drive to the store, although the risk of a car accident is greater than the risk of fire or other mishap in the house. Ultimately we have to balance our judgments on a profit and loss basis, comparing an action or policy with its alternatives. For this purpose figures are useful when they are applicable and assessable---often they are neither. Whatever the facts, the public impression that we live in exceptionally risky times is new: families in the early nineteenth century, who regularly lost eight out of ten children in infancy, and industrial workers with a massive occupational mortality did not have this impression. It is likely that the reduction in premature deaths due directly to modern technology is one factor in making those that still occur less tolerable. Another is the advent of nuclear energy. The bomb brought an eschatological perspective to a culture which had lost it, and the push for nuclear energy, accompanied as it was by much official secrecy, misstatement of risk, and downright falsification has done vast damage to the credibility of governments who continue to issue sedative statements. Lies have always been told and risks played down in the interest of profit, but when we are reminded that coal mining and natural gas storage also pose risks to the workforce and the public, we have to point out that release of radioactivity from a nuclear plant is the only event, at least at the civilian level, that could make a country the size of Britain permanently uninhabitable as a result of a single accident. Clearly the nuclear story, both civil and military, has done immense damage to the credibility of all official statements about public safety. We have seen some of the consequences in the series of fiascos over eggs, listeria, and bovine spongiform encephalopathy (BSE). When measures are expensive, unpopular, and hard to judge at the time, governments will always tend to shuffle and then plunge. Meanwhile, to the man in the street, whose suspicious nature is itself a sovereign risk-reducer, "perfectly safe" in the mouth of a minister or an official spokesman is taken to mean "dicey, but with reasonable luck we will get away with it"-the meaning of such platitudes at the time of
Chernobyl. It may be unlikely on scientific grounds that BSE will spread to the human consumers of beef and beef offal: if that prediction is wrong, the damage was probably already done when the feeding of scrapiecontaminated renderings to livestock was allowed to continue for several months after the association between high-protein feed and BSE was recognised. The danger of climatic change from the profligate use
of fossil energy sources is the next hurdle, and it is a high one. Governments with large investments in votes and cash seldom take preventive action until mischief is obvious and public opinion becomes militant-and sometimes not even then. Faced with growing public awareness of the assessability of risk, there are certain things we can do. The first is education, a difficult task in the existing climate of tabloid journalism, but one that was started as far back as 1984 by Urquhart and Heilmann2 in their book on risk. If studies such as this were made the basis of judgment we could avoid future overreaction. The second is the creation of sources of information expert unpolluted by political expediency-a difficult task, because experts can be and have been royally wrong, but probably worth attempting. A Food Council and an Environmental Council with academic rather than quango status would be a start. The third is the creation of awareness in both politicians and experts that while the statistical risk of death from a particular source is 0-11 % overall, to the individual it strikes that risk will appear to be 100%. We assume, protectively, that we bear a charmed life when we drive or smoke cigarettes, until we draw the short straw. 1. Zeckhauser RJ, Viscusi WK. Risk within reason. Science 1990; 248: 560-64. 2. Urquhart J, Heilmann K. Risk watch, the odds of life. New York: Facts on File Publications, 1984.
A SUITABLE CASE FOR INTIMACY Doctors and nurses have to work together satisfactorily, not only for good health care but also for the personal wellbeing of the professionals involved. However, the doctor-nurse relationship has changed dramatically, even irreversibly. The difficulty is that this change has been largely a one-sided affair, leading to tensions that need to be resolved for everybody’s sake. At one time doctors and nurses knew where they stood. The relationship was self avowedly hierarchic. Doctors were dominant; they were in charge. Nurses were their hand maidens; they were subordinate, subservient, and often submissive. Now things are different. It is no longer acceptable for doctors to refer to "my patients", or "my ward",1 or to talk about "my nurse". The new doctor-nurse relationship is characterised by the co-existence of selfdirected professionals, who are complementary and interdependent but also autonomous. The reasons could reflect wider changes in society. The role of women has fundamentally changed. There are more working mothers, and certainly more professional women—eg, nearly 50% of medical school entrants in the UK are women-and there is a stronger commitment to nursing by nurses as a career and as a profession. Family relationships, too, are different, with parental roles becoming blurred. The new man has emerged, adept not only at winning the bread but also at baking some at home. Elsewhere in health care there have been other changes that could be exacerbating tensions between doctors and nurses. Health professionals are being urged to become
218
patient centred;3 there is a greater emphasis on team work; and people’s expectations of health care reflect more more
those of
consumers
than of the
recipients of largesse.
In
addition, public esteem for doctors seems to have diminished, whereas that for nurses and other health workers has increased substantially. Some of these forces may lie at the heart of the changing doctor-nurse relationship but they do not satisfactorily explain it, let alone account for the problems raised. Nor do they indicate a possible way forward. To do this one must look at other issues. Any interaction between people can be construed as a game,4even the relationship between doctors and nurses.5 The following example illustrates the point. Whilst it suits doctors to have nurses carry out their requests, nurses can be affronted by feeling their autonomy is constrained, so they initiate the treatment they would have wanted anyway but collude with their medical colleagues to maintain the belief it was the doctors’ decision all along. Games can help people cope with difficult situations, especially when there is something to be gained on both sides.4 However, usually someone loses, and the worry here is that it might be the patient. Moreover, if the game no longer satisfies one or both players it can no longer continue.6 At worst, it sometimes seems that with doctors and nurses the rules have been changed, the goal posts moved, the pitch invaded, people sent off for foul play, and someone has run off with the ball. Consequently the doctor-nurse game has had to be abandoned, leaving behind an eerie silence in the stadium. The changing doctor-nurse relationship can be reduced to a single issue—"roles"/ Some doctors, and many more nurses, are no longer doing what they did, and the people involved are ignorant of, misunderstand, or misconstrue the other person’s role or, even worse, make wrong assumptions about what they should be doing. As a result, the doctor may feel that the nurse is "never there", when in fact she is making a home visit, or is always "swanning off", whereas she is actually sitting on a national committee. Conversely, the nurse may think that the doctor does not take the patient’s feelings seriously but instead concentrates on a double-blind prospective study, or ignores team-building to concentrate on
on practice can initially appear highly We are not used to it, and our education, threatening. whether before or after registration, has not encouraged it. Very importantly, we have to learn to trust as well as to understand one another. This will take time, and there will be those who will see it as an unnecessary intrusion into an already busy schedule, but with commitment all round it can happen. What will be the benefits? There is evidence that patients respond favourably both physiologically and psychologically when allowed by health professionals to assume greater control of their illness,13 and there is even the suggestion that improved team working influences health outcomes positively.l4 Interpersonal relationships have also been shown to affect mortality rates of intensive care units. is Overall, however, there has been little research into the effects of professional relationships on health outcomes; such studies are much needed.
Reflection
1. Smith L. Doctors rule, OK? Nursing Times 1987; July 2: 49-51. 2. Nichols KA. Psychological care in physical illness, Beckenham: Croom Helm, 1984. 3. McWhinney I. The need for a trasformed clinical method. In: Stewart M, Roter D, eds. Communicating with medical patients, London: Sage, 1989: 25-40. 4. Berne E. Games people play. Harmondsworth: Penguin, 1964. 5. Stein, LI. The doctor-nurse game. Arch Gen Psychiatry 1967; 16: 699-703. 6. Stein LI, Watts DT, Howell T. The doctor-nurse game revisited. N Engl J Med 1990; 332; 8: 546-49. 7. Darbyshire P. The burden of history. Nursing Times 1987; Jan 28: 32-34. 8. Schon DA. The reflective practitioner, New York: Basic Books, 1983. 9. Coles CR. Self assessment and medical audit: an educational approach. Br Med J 1989; 299: 807-08. 10. Coles CR. Making audit truly educational. Postgrad Med J (in press). 11. General Medical Council. Recommendations on the training of specialists. London: GMC, 1987. 12. Greig DNH. Team work in general practice. Tunbridge Wells: Castle House, 1988. 13. Coles CR. Diabetes education: letting the patient into the picture. Pract Diabetes 1990; 7: 110-12. 14. Schmitt MH, Williams TF. Nurse-patient collaboration and outcomes for patients. Ann Intern Med 1985; 103: 956. 15. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centres. Ann Intern Med 1986; 104: 410-18.
fund-raising.
that what is needed is better inter-professional communication. Of course it would, but how can this be made to happen? A more productive alternative would be for doctors and nurses to develop a greater sense of what has been termed "intimacy"-a relationship more rewarding than games. Put another way, health professionals should reflect on their practice.8 They should look together at what they do, learn from it, and if necessary change what they do and how they do it.9 They can make a start by describing their work to one another. Better still, they could present to their colleagues a video or audio recording of a consultation, an outpatient clinic, or a home visit. Then they need to engage in constructive criticism, in which the presenter identifies the strengths and weaknesses of his or her performance before others offer their opinion. Importantly, any negative criticism needs supporting evidence and realistic alternatives.1O Almost as a byproduct of this process of self-assessment and peer review," health professionals will get to know more about themselves and each other. Not only are they likely to come to understand their own role and that of others, but colleagues who until then had been working more or less independently could develop into a cohesive team.12 It would be trite
TOXIC EPIDERMAL NECROLYSIS— A PREMATURE REQUIEM?
to say
In 1956 Alan LyelP described four adults with a spontaneous eruption characterised by red, hot, peeling, tender skin; he called this syndrome toxic epidermal necrolysis (TEN). The condition subsequently became known as Lyell’s syndrome. The worst damage occurred in the epidermis, which showed severe necrosis; the peeling was due to either subepidermal or intra-epidermal splitting. LyelF introduced the term necrolysis to convey the idea of clinical epidermolysis with histological necrosis. A very similar syndrome was soon recognised in babies and children,3.4 but in these patients the longitudinal splitting of the epidermis always occurred just below the stratum
granulosum
and there
was
much less
epidermal
necrosis, so the term necrolysis was less appropriate. When further work showed that the syndrome in children was
always due to a circulating staphylococcal epidermolytic toxinthe disorder in this age group became known as the staphylococcal scalded skin syndrome (SSSS) to distinguish it from adult TEN. The adult syndrome is usually associated with a drug reaction or erythema multiforme; occasional cases are idiopathic or associated almost
standards ... yet ignore the haphazard operation of nuclear weapons plants",1 and concentrate on salmonella in eggs rather than on children at risk in substandard housing. Our irrationality over risks exposes us to manipulation-as Zeckhauser and Viscusi duly note,l we would not leave a baby alone in the house while we take a ten-minute drive to the store, although the risk of a car accident is greater than the risk of fire or other mishap in the house. Ultimately we have to balance our judgments on a profit and loss basis, comparing an action or policy with its alternatives. For this purpose figures are useful when they are applicable and assessable---often they are neither. Whatever the facts, the public impression that we live in exceptionally risky times is new: families in the early nineteenth century, who regularly lost eight out of ten children in infancy, and industrial workers with a massive occupational mortality did not have this impression. It is likely that the reduction in premature deaths due directly to modern technology is one factor in making those that still occur less tolerable. Another is the advent of nuclear energy. The bomb brought an eschatological perspective to a culture which had lost it, and the push for nuclear energy, accompanied as it was by much official secrecy, misstatement of risk, and downright falsification has done vast damage to the credibility of governments who continue to issue sedative statements. Lies have always been told and risks played down in the interest of profit, but when we are reminded that coal mining and natural gas storage also pose risks to the workforce and the public, we have to point out that release of radioactivity from a nuclear plant is the only event, at least at the civilian level, that could make a country the size of Britain permanently uninhabitable as a result of a single accident. Clearly the nuclear story, both civil and military, has done immense damage to the credibility of all official statements about public safety. We have seen some of the consequences in the series of fiascos over eggs, listeria, and bovine spongiform encephalopathy (BSE). When measures are expensive, unpopular, and hard to judge at the time, governments will always tend to shuffle and then plunge. Meanwhile, to the man in the street, whose suspicious nature is itself a sovereign risk-reducer, "perfectly safe" in the mouth of a minister or an official spokesman is taken to mean "dicey, but with reasonable luck we will get away with it"-the meaning of such platitudes at the time of
Chernobyl. It may be unlikely on scientific grounds that BSE will spread to the human consumers of beef and beef offal: if that prediction is wrong, the damage was probably already done when the feeding of scrapiecontaminated renderings to livestock was allowed to continue for several months after the association between high-protein feed and BSE was recognised. The danger of climatic change from the profligate use
of fossil energy sources is the next hurdle, and it is a high one. Governments with large investments in votes and cash seldom take preventive action until mischief is obvious and public opinion becomes militant-and sometimes not even then. Faced with growing public awareness of the assessability of risk, there are certain things we can do. The first is education, a difficult task in the existing climate of tabloid journalism, but one that was started as far back as 1984 by Urquhart and Heilmann2 in their book on risk. If studies such as this were made the basis of judgment we could avoid future overreaction. The second is the creation of sources of information expert unpolluted by political expediency-a difficult task, because experts can be and have been royally wrong, but probably worth attempting. A Food Council and an Environmental Council with academic rather than quango status would be a start. The third is the creation of awareness in both politicians and experts that while the statistical risk of death from a particular source is 0-11 % overall, to the individual it strikes that risk will appear to be 100%. We assume, protectively, that we bear a charmed life when we drive or smoke cigarettes, until we draw the short straw. 1. Zeckhauser RJ, Viscusi WK. Risk within reason. Science 1990; 248: 560-64. 2. Urquhart J, Heilmann K. Risk watch, the odds of life. New York: Facts on File Publications, 1984.
A SUITABLE CASE FOR INTIMACY Doctors and nurses have to work together satisfactorily, not only for good health care but also for the personal wellbeing of the professionals involved. However, the doctor-nurse relationship has changed dramatically, even irreversibly. The difficulty is that this change has been largely a one-sided affair, leading to tensions that need to be resolved for everybody’s sake. At one time doctors and nurses knew where they stood. The relationship was self avowedly hierarchic. Doctors were dominant; they were in charge. Nurses were their hand maidens; they were subordinate, subservient, and often submissive. Now things are different. It is no longer acceptable for doctors to refer to "my patients", or "my ward",1 or to talk about "my nurse". The new doctor-nurse relationship is characterised by the co-existence of selfdirected professionals, who are complementary and interdependent but also autonomous. The reasons could reflect wider changes in society. The role of women has fundamentally changed. There are more working mothers, and certainly more professional women—eg, nearly 50% of medical school entrants in the UK are women-and there is a stronger commitment to nursing by nurses as a career and as a profession. Family relationships, too, are different, with parental roles becoming blurred. The new man has emerged, adept not only at winning the bread but also at baking some at home. Elsewhere in health care there have been other changes that could be exacerbating tensions between doctors and nurses. Health professionals are being urged to become
218
patient centred;3 there is a greater emphasis on team work; and people’s expectations of health care reflect more more
those of
consumers
than of the
recipients of largesse.
In
addition, public esteem for doctors seems to have diminished, whereas that for nurses and other health workers has increased substantially. Some of these forces may lie at the heart of the changing doctor-nurse relationship but they do not satisfactorily explain it, let alone account for the problems raised. Nor do they indicate a possible way forward. To do this one must look at other issues. Any interaction between people can be construed as a game,4even the relationship between doctors and nurses.5 The following example illustrates the point. Whilst it suits doctors to have nurses carry out their requests, nurses can be affronted by feeling their autonomy is constrained, so they initiate the treatment they would have wanted anyway but collude with their medical colleagues to maintain the belief it was the doctors’ decision all along. Games can help people cope with difficult situations, especially when there is something to be gained on both sides.4 However, usually someone loses, and the worry here is that it might be the patient. Moreover, if the game no longer satisfies one or both players it can no longer continue.6 At worst, it sometimes seems that with doctors and nurses the rules have been changed, the goal posts moved, the pitch invaded, people sent off for foul play, and someone has run off with the ball. Consequently the doctor-nurse game has had to be abandoned, leaving behind an eerie silence in the stadium. The changing doctor-nurse relationship can be reduced to a single issue—"roles"/ Some doctors, and many more nurses, are no longer doing what they did, and the people involved are ignorant of, misunderstand, or misconstrue the other person’s role or, even worse, make wrong assumptions about what they should be doing. As a result, the doctor may feel that the nurse is "never there", when in fact she is making a home visit, or is always "swanning off", whereas she is actually sitting on a national committee. Conversely, the nurse may think that the doctor does not take the patient’s feelings seriously but instead concentrates on a double-blind prospective study, or ignores team-building to concentrate on
on practice can initially appear highly We are not used to it, and our education, threatening. whether before or after registration, has not encouraged it. Very importantly, we have to learn to trust as well as to understand one another. This will take time, and there will be those who will see it as an unnecessary intrusion into an already busy schedule, but with commitment all round it can happen. What will be the benefits? There is evidence that patients respond favourably both physiologically and psychologically when allowed by health professionals to assume greater control of their illness,13 and there is even the suggestion that improved team working influences health outcomes positively.l4 Interpersonal relationships have also been shown to affect mortality rates of intensive care units. is Overall, however, there has been little research into the effects of professional relationships on health outcomes; such studies are much needed.
Reflection
1. Smith L. Doctors rule, OK? Nursing Times 1987; July 2: 49-51. 2. Nichols KA. Psychological care in physical illness, Beckenham: Croom Helm, 1984. 3. McWhinney I. The need for a trasformed clinical method. In: Stewart M, Roter D, eds. Communicating with medical patients, London: Sage, 1989: 25-40. 4. Berne E. Games people play. Harmondsworth: Penguin, 1964. 5. Stein, LI. The doctor-nurse game. Arch Gen Psychiatry 1967; 16: 699-703. 6. Stein LI, Watts DT, Howell T. The doctor-nurse game revisited. N Engl J Med 1990; 332; 8: 546-49. 7. Darbyshire P. The burden of history. Nursing Times 1987; Jan 28: 32-34. 8. Schon DA. The reflective practitioner, New York: Basic Books, 1983. 9. Coles CR. Self assessment and medical audit: an educational approach. Br Med J 1989; 299: 807-08. 10. Coles CR. Making audit truly educational. Postgrad Med J (in press). 11. General Medical Council. Recommendations on the training of specialists. London: GMC, 1987. 12. Greig DNH. Team work in general practice. Tunbridge Wells: Castle House, 1988. 13. Coles CR. Diabetes education: letting the patient into the picture. Pract Diabetes 1990; 7: 110-12. 14. Schmitt MH, Williams TF. Nurse-patient collaboration and outcomes for patients. Ann Intern Med 1985; 103: 956. 15. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centres. Ann Intern Med 1986; 104: 410-18.
fund-raising.
that what is needed is better inter-professional communication. Of course it would, but how can this be made to happen? A more productive alternative would be for doctors and nurses to develop a greater sense of what has been termed "intimacy"-a relationship more rewarding than games. Put another way, health professionals should reflect on their practice.8 They should look together at what they do, learn from it, and if necessary change what they do and how they do it.9 They can make a start by describing their work to one another. Better still, they could present to their colleagues a video or audio recording of a consultation, an outpatient clinic, or a home visit. Then they need to engage in constructive criticism, in which the presenter identifies the strengths and weaknesses of his or her performance before others offer their opinion. Importantly, any negative criticism needs supporting evidence and realistic alternatives.1O Almost as a byproduct of this process of self-assessment and peer review," health professionals will get to know more about themselves and each other. Not only are they likely to come to understand their own role and that of others, but colleagues who until then had been working more or less independently could develop into a cohesive team.12 It would be trite
TOXIC EPIDERMAL NECROLYSIS— A PREMATURE REQUIEM?
to say
In 1956 Alan LyelP described four adults with a spontaneous eruption characterised by red, hot, peeling, tender skin; he called this syndrome toxic epidermal necrolysis (TEN). The condition subsequently became known as Lyell’s syndrome. The worst damage occurred in the epidermis, which showed severe necrosis; the peeling was due to either subepidermal or intra-epidermal splitting. LyelF introduced the term necrolysis to convey the idea of clinical epidermolysis with histological necrosis. A very similar syndrome was soon recognised in babies and children,3.4 but in these patients the longitudinal splitting of the epidermis always occurred just below the stratum
granulosum
and there
was
much less
epidermal
necrosis, so the term necrolysis was less appropriate. When further work showed that the syndrome in children was
always due to a circulating staphylococcal epidermolytic toxinthe disorder in this age group became known as the staphylococcal scalded skin syndrome (SSSS) to distinguish it from adult TEN. The adult syndrome is usually associated with a drug reaction or erythema multiforme; occasional cases are idiopathic or associated almost
