CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ3. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Medical audit SIR,-The Secretary of State for Health and the Royal College of Physicians seem to have quite different views concerning the purpose of medical audit. The secretary of state places the emphasis on monitoring the cost effectiveness of clinicians and wishes to include hospital managers; on the other hand the royal college plans to audit the professional and technical expertise of medical staff and wishes to exclude hospital managers from the audit process, perhaps because their inclusion would be seen as managerial interference in the profession's independence. A medical audit based on patients' case notes has been started in our hospital, and some consultants are attending it. The professional questions that the royal college wishes to be discussed have, however, rapidly been relegated to the sidelines as it has proved almost impossible for the different specialties to audit each other's specialty practice. Thus a neurologist, for example, auditing a haematology patient who is undergoing bone marrow transplantation or a renal specialist auditing a patient with a complex cardiomyopathy has been quite unable to discuss in any depth the technical management of the case, the advantage or disadvantages of alternative forms of treatment, or the use of new drugs. In large hospitals medicine and surgery thus seem to have become so specialised that it is impossible for specialties to audit each other along the lines suggested by the royal college. Our audit process has therefore concentrated almost entirely on subjects such as how soon the discharge letter was sent to the general practitioner and whether the house officer has written his notes legibly. As many house officers are late sending their discharge letters and few write legibly our audits have become extremely repetitive. Some may well continue to attend the meetings merely to avoid the college disaccrediting their junior staff posts, but most are now beginning to see that real improvements in their own specialty will necessitate an audit by specialists in the same field as well as the inclusion of the hospital budget holders. In other words, the logistic problems that the secretary of state wants us to solve are precisely the problems that we need to solve. To give just a few examples in our own institution, some of us wish to examine the advantages of setting up an investigational day care unit, some the advantages of clinical budgets to maximise the efficient use of laboratory and radiographical investigations, and some the advantages of introducing smart cards and the close monitoring of expensive drugs. The royal college specifically emphasises a medical audit in general medicine, geriatrics, and paediatrics based on patients' case notes.' Unless this concept is widened to include the high spending specialised medicine and surgery departments and to complement the hospital
BMJ VOLUME 300
17 FEBRUARY 1990
cogwheel and resource management committees and include the hospital management the whole process of medical audit will be discredited and cynics will say that this was what the royal college intended from the outset. B J BOUGHTON
Department of Haematology, Queen Elizabeth Hospital, Birmingham B 15 2TH 1 Anonymous. Medical audit. College commentary. 7 R Coll Physicians Lond 1989;23:79-80.
that detracts from excellent clinical care. We need to look at our work at this basic level and perform simple audits of process to maintain and enhance standards. Clearly, discernible outcome is what health care is ultimately about, but, for the reasons we have given, its measurement at present may actually be at the expense of good quality individual care. We suggest that we should strive to see that audit of process is universally achieved, within the limits of individual doctors' constraints, abilities, and rights to organise things the way they wish. MALCOLM AYLETT
SIR,-Your new section on audit is just one more sign that audit is now accepted as an essential tool to improve professional standards and to enhance patient care. Donabedian described audit of structure, process, and outcome. The assessment of structure is easiest but least relevant to standards whereas measurement of outcome, though more difficult, is thought to be more closely related to the quality of care. Process lies between them and is often only grudgingly accepted as a proxy for outcome. Professor David Metcalfe suggests "two tracks" to audit-that of structure, which might be the main remit of the external auditors of our new contract, and that carried out in practices, which might seek to answer the question, "Is what I think I am doing what really gets done?"' He highlights a very real snag: that very few measures of process could be validated as measures of outcome. Dr Charles Shaw suggests that measuring clinical practice rather than outcome may be legitimate if a convincing relation between them can be shown.2 We would go further and suggest that in general practice process is virtually synonymous with outcome. We therefore invite the profession to draw back from its search for the ephemeral holy grail of measuring better outcomes and to look to the real world of process assessment. Much of the obsession with outcome has come from a preoccupation with what is thought to occur in the industrial sector. Yet we in medicine are not in the commodity business, and even industry has recognised that commitment to outcome alone is unhealthy. Better efforts at man management, encouraging and enhancing the worth of individuals taking pride in their work, is the real key to quality. The way things are done by the individual still matters, if not in the manufacture of bricks, then certainly in the care of patients. We are all aware of deficiencies in the clinical standards of both primary and secondary health care. For instance, both general practitioners and hospital clinics fail to measure blood pressure despite established evidence showing its value. In this, as in many other clinical areas-for example, immunisation rates, monitored repeat prescribing, and the follow up of chronic diseases with avoidable complications-it is the failure of the individual
Wooler, Northumberland PALI HUNGIN
Stockton-on-Tees, Cleveland 1 Metcalfe DHH. Audit in general practice. Br MedJ7 1989;299: 1293-4. (25 November.) 2 Blair-Fish D. Medical audit: outcome measures needed. Br-MedJ7 1989;299:1361. (2 December.)
Stone fish bite SIR,-Drs T Llewellyn and A Fraser-Moodie reported the effects of a stone fish "bite" in a woman who was "bitten" while paddling on a Mauritian beach.' It seems improbable that it was a bite from this fish that caused these effects as envenomation is by stings from its spines in the dorsal, anal, and pelvic regions and the fish does not have fangs. Use of specific stone fish antivenin is useful only if the envenomation can be definitely ascribed to a stone fish or another scorpaenidae. Similar lesions can be produced by stings from unrelated fish. In all cases the use of a tourniquet to prevent spread of venom is relevant only if applied early but immersion of the wound in hot water to denature the venom is valuable. The authors do not mention control of pain, which can be severe, or treatment of the circulatory collapse that can accompany stings from many venomous fish. All of this may sound irrelevant to people who live in Britain, but venomous fish such as weever fish and (rarely) stingrays can be found in British waters. The stings from these can kill a child or an infirm person. Those planning to swim in British waters, however, should not be unduly concerned about the risks from venomous fish. Personal experience of diving in British waters for 20 years leaves me convinced that increased pollution has considerably reduced their numbers. PETER WILMSHURST British Sub-Aqua Club, London WC1H OQW I Llewellyn T, Fraser-Moodie A. Stone fish bite. Br Med j 1990;300:134. (13 January.)
463
Medical audit SIR,-The Secretary of State for Health and the Royal College of Physicians seem to have quite different views concerning the purpose of medical audit. The secretary of state places the emphasis on monitoring the cost effectiveness of clinicians and wishes to include hospital managers; on the other hand the royal college plans to audit the professional and technical expertise of medical staff and wishes to exclude hospital managers from the audit process, perhaps because their inclusion would be seen as managerial interference in the profession's independence. A medical audit based on patients' case notes has been started in our hospital, and some consultants are attending it. The professional questions that the royal college wishes to be discussed have, however, rapidly been relegated to the sidelines as it has proved almost impossible for the different specialties to audit each other's specialty practice. Thus a neurologist, for example, auditing a haematology patient who is undergoing bone marrow transplantation or a renal specialist auditing a patient with a complex cardiomyopathy has been quite unable to discuss in any depth the technical management of the case, the advantage or disadvantages of alternative forms of treatment, or the use of new drugs. In large hospitals medicine and surgery thus seem to have become so specialised that it is impossible for specialties to audit each other along the lines suggested by the royal college. Our audit process has therefore concentrated almost entirely on subjects such as how soon the discharge letter was sent to the general practitioner and whether the house officer has written his notes legibly. As many house officers are late sending their discharge letters and few write legibly our audits have become extremely repetitive. Some may well continue to attend the meetings merely to avoid the college disaccrediting their junior staff posts, but most are now beginning to see that real improvements in their own specialty will necessitate an audit by specialists in the same field as well as the inclusion of the hospital budget holders. In other words, the logistic problems that the secretary of state wants us to solve are precisely the problems that we need to solve. To give just a few examples in our own institution, some of us wish to examine the advantages of setting up an investigational day care unit, some the advantages of clinical budgets to maximise the efficient use of laboratory and radiographical investigations, and some the advantages of introducing smart cards and the close monitoring of expensive drugs. The royal college specifically emphasises a medical audit in general medicine, geriatrics, and paediatrics based on patients' case notes.' Unless this concept is widened to include the high spending specialised medicine and surgery departments and to complement the hospital
BMJ VOLUME 300
17 FEBRUARY 1990
cogwheel and resource management committees and include the hospital management the whole process of medical audit will be discredited and cynics will say that this was what the royal college intended from the outset. B J BOUGHTON
Department of Haematology, Queen Elizabeth Hospital, Birmingham B 15 2TH 1 Anonymous. Medical audit. College commentary. 7 R Coll Physicians Lond 1989;23:79-80.
that detracts from excellent clinical care. We need to look at our work at this basic level and perform simple audits of process to maintain and enhance standards. Clearly, discernible outcome is what health care is ultimately about, but, for the reasons we have given, its measurement at present may actually be at the expense of good quality individual care. We suggest that we should strive to see that audit of process is universally achieved, within the limits of individual doctors' constraints, abilities, and rights to organise things the way they wish. MALCOLM AYLETT
SIR,-Your new section on audit is just one more sign that audit is now accepted as an essential tool to improve professional standards and to enhance patient care. Donabedian described audit of structure, process, and outcome. The assessment of structure is easiest but least relevant to standards whereas measurement of outcome, though more difficult, is thought to be more closely related to the quality of care. Process lies between them and is often only grudgingly accepted as a proxy for outcome. Professor David Metcalfe suggests "two tracks" to audit-that of structure, which might be the main remit of the external auditors of our new contract, and that carried out in practices, which might seek to answer the question, "Is what I think I am doing what really gets done?"' He highlights a very real snag: that very few measures of process could be validated as measures of outcome. Dr Charles Shaw suggests that measuring clinical practice rather than outcome may be legitimate if a convincing relation between them can be shown.2 We would go further and suggest that in general practice process is virtually synonymous with outcome. We therefore invite the profession to draw back from its search for the ephemeral holy grail of measuring better outcomes and to look to the real world of process assessment. Much of the obsession with outcome has come from a preoccupation with what is thought to occur in the industrial sector. Yet we in medicine are not in the commodity business, and even industry has recognised that commitment to outcome alone is unhealthy. Better efforts at man management, encouraging and enhancing the worth of individuals taking pride in their work, is the real key to quality. The way things are done by the individual still matters, if not in the manufacture of bricks, then certainly in the care of patients. We are all aware of deficiencies in the clinical standards of both primary and secondary health care. For instance, both general practitioners and hospital clinics fail to measure blood pressure despite established evidence showing its value. In this, as in many other clinical areas-for example, immunisation rates, monitored repeat prescribing, and the follow up of chronic diseases with avoidable complications-it is the failure of the individual
Wooler, Northumberland PALI HUNGIN
Stockton-on-Tees, Cleveland 1 Metcalfe DHH. Audit in general practice. Br MedJ7 1989;299: 1293-4. (25 November.) 2 Blair-Fish D. Medical audit: outcome measures needed. Br-MedJ7 1989;299:1361. (2 December.)
Stone fish bite SIR,-Drs T Llewellyn and A Fraser-Moodie reported the effects of a stone fish "bite" in a woman who was "bitten" while paddling on a Mauritian beach.' It seems improbable that it was a bite from this fish that caused these effects as envenomation is by stings from its spines in the dorsal, anal, and pelvic regions and the fish does not have fangs. Use of specific stone fish antivenin is useful only if the envenomation can be definitely ascribed to a stone fish or another scorpaenidae. Similar lesions can be produced by stings from unrelated fish. In all cases the use of a tourniquet to prevent spread of venom is relevant only if applied early but immersion of the wound in hot water to denature the venom is valuable. The authors do not mention control of pain, which can be severe, or treatment of the circulatory collapse that can accompany stings from many venomous fish. All of this may sound irrelevant to people who live in Britain, but venomous fish such as weever fish and (rarely) stingrays can be found in British waters. The stings from these can kill a child or an infirm person. Those planning to swim in British waters, however, should not be unduly concerned about the risks from venomous fish. Personal experience of diving in British waters for 20 years leaves me convinced that increased pollution has considerably reduced their numbers. PETER WILMSHURST British Sub-Aqua Club, London WC1H OQW I Llewellyn T, Fraser-Moodie A. Stone fish bite. Br Med j 1990;300:134. (13 January.)
463
