was ud in8.7%of cas in intervention units and 25.1%in control units(difference16.5%;11.1%to 21.9%).Asssment of outcome criteria,t at30births per unit,was incomplete for sutures at the ont for 3.6%of women in the intervention units and for9.2% in the control units(difference5.6%;2.2%to9.1%). After the trial it was incomplete for sutures in5.6%of women in intervention units and in10.0%in control units(difference4.4%;0.6%to8.0%)and for antibiotic prophylaxis in12.8%of women in intervention units and23.8%in control units(difference11.1%;5.6%to 16.5%).Thus,there is only one outcome measure(u of corticosteroids)devoid of glaring imbalances in either a priori characteristics or ascertainment,but its asssment relates to no more than three births per participating unit.
People wishing to examine evidence before bowing to its aureole—which is what pursuit of evidence should promote—can find only one t of data,in figure3,that is detailed enough to be assd independently.This figure shows,firstly,the significant difference at baline between intervention and control units mentioned above.Secondly,22of the25units had a rate of u of ventou extraction at baline that was either at or outside the95%confidence interval for the average(36%to55%).Twelve of the units(8 intervention and4control)had ba rates at or below the95%range;all had a higher rate at follow up.Of the 10(3intervention and7control)above the range,all but2(1intervention and1cont
rol)had lower rates at follow up.Thirdly,of the25units,6had rates at follow up that differed10%or less from the ba rate:3were intervention and3were control units.Of the19others, 13(7intervention and6control)were more than10% higher at follow up and6(2intervention and4control) were more than10%lower.This certainly questions the relevance of the statistically significant increa in the rate of ventou extraction reported to be associated with the intervention.
Rather,the figure shows that the rate of childbirth interventions can vary considerably from one time to another irrespective of whether or not the people who allegedly control the rates have been made aware of the evidence about the interventions.It also indicates that asssing30maternity care procedures per unit is not likely to reflect practice in that unit adequately.This is not surprising as most people would dismiss concutive ries of no more than30common proce-dures,such as operative delivery and episiotomy,as appropriate indicators of practice.
Of cour,it would have been surprising if the authors had found a marked effect of their visit to a lead obstetrician and midwife.Indeed,the evidence on the outcomes that they addresd had been available electronically and in well publicid full7and abridged8 texts for veral years.Lead practitioners who had any rious interest in considering the evidence would surely have sought it out well before this study’s intervention.Perhaps it is too simplistic to expect that merely exposing pra
ctitioners to evidence will change practice—however intensive the exposure.Clinical practice changes all the time,but the momentum of change,and what drives it,are poorly understood.For some,change goes too fast,for others too slow,and for tho who want to have a significant impact on it,the methods for achieving it are still far from clear.
Marc J N C Keir Professor of obstetrics and gynaecology Flinders University of South Australia,Flinders Medical Centre, Bedford Park,SA5042,Australia(************************.au)
1Mercer BM,Arheart KL.Antimicrobial therapy in expectant manage-ment of preterm premature rupture of the membranes.Lancet 1995;346:1271-9.
2Egarter C,Leitich H,Karas H,Wier F,Husslein P,Kaider A.Antibiotic treatment in preterm premature rupture of the membranes and neo-natal morbidity:a metaanalysis.Am J Obstet Gynecol1996;174:589-97.
3Kenyon S,Boulvain M.Antibiotics for preterm premature rupture of membranes.In:Cochrane Library.Cochrane Collaboration;Issue 3.
Oxford:Update Software;1998.
4Wyatt JC,Paterson-Brown S,Johanson R,Altman DG,Bradburn MJ,Fisk NM.Randomid trial of educational visits to enhance u of systematic reviews in25obstetric units.BMJ1998;317:1041-6.
5Keir MJNC.Electronic monitoring:who needs a Trojan hor?Birth 1994;21:111-3.
6Schulz KF,Chalmers I,Hayes RJ,Altman D.Empirical evidence of bias.
JAMA1995;273:408-12.
7Chalmers I,Enkin M,Keir MJNC,eds.Effective care in pregnancy and childbirth.Oxford:Oxford University Press,1989.
8Enkin M,Keir MJNC,Chalmers I.A guide to effective care in pregnancy and childbirth.Oxford:Oxford University Press,1989.
Sticks and stones
Changing terminology is no substitute for good consultation skills
A s children many of us learnt the old rhyme
“Sticks and stones may break my bones
but words can never hurt me.”As we grew older we discovered that the adage was untrue.For most of us who profession involved interacting with other people it became obvious that clumsy or inapposite u of language could cau pain.An attempt to avoid such pain has provoked Hutchon and Cooper to suggest that distress in women who have miscarried would be reduced if changes were made in the language ud by their professional carers (p1081).1The writers recommend that the word “abortion”should be avoided becau the lay public interprets it as applying to a termination of preg-nancy.The authors cite alternatives that could be adopted in journal papers and medical records. The recommendations em harmless enough.But are they likely to be effective if implemented?And do they reprent the most effective intervention available?
A miscarriage is an example of a common event which is rarely a medical emergency and from a biomedical perspective may be viewed as a normal variation of early pregnancy,but the mother may view it entirely differently.2Furthermore,perceptions may differ radically from woman to woman depending on knowledge,expectations,and previous experiences. How a consultation is conducted may affect whether a
Editorials
Letters p1081
BMJ1998;317:1028–9
woman choos to reveal such fears,worries,and con-cerns to the doctor.3
There is ample evidence of patients’frequent dissatisfaction with doctors’communication skills.4 Despite increasingly liberal provision of information, many patients still want to know more than they are told,5whereas others do not want to participate in decision making:they need absolute,uncritical confidence in their doctors’skills.A skilful doctor will achieve the correct balance between autonomy and paternalism for each patient.T o determine the appro-priate balance it is uful to have a framework to help identify the necessary tasks and skills.
Such a framework is provided by the“three function”model of the consultation developed by Bird and Cohen-Cole6:gathering data to understand the patient;developing rapport and responding to the patient’s emotions(to enable the patient to feel under-stood);and patient education and behaviour manage-ment.The functions relate to the three purpos and effects of communication:informative(to exchange information);promotive(to bring about action);and evocative(to arou certain feelings)7and also to the three domains(cognitive,affective,and psychom
otor) widely ud by educationalists to categori edu-cational objectives.Each function has specific objec-tives and demands specific explicit skills of the doctor if they are to be achieved.Fortunately,considerable evidence now exists that such skills can be successfully acquired.8
However,no single model can fully convey the complexity of the doctor-patient relationship and the three function model needs to be expanded by drawing on other concepts of the consultation.The include the idea of the consultation as a“meeting between experts”9;the patient-centred clinical method described by Stewart et al10;the problem bad approach11;the stages of motivational interviewing described by Miller and Rollnick12;and the family systems approach,which emphasis the importance of taking into account the patient’s family and social networks.13
Finally,the individuality of the professional cannot be ignored.All sorts of factors,some bad on the pro-fessional’s own life experiences,can both consciously and unconsciously influence his or her behaviour and decisions.This has led to the notion of the doctor as a drug,14with both powerful effects and side effects. When listening and talking to patients,professionals need to be aware not only of the words they u,both to discover and convey information,but also their own feelings and how to cope with them.
Thus a recommendation to change terminology, while laudable in its intentions,may not be enough to alleviate mothers’dissatisfaction with the care that they receive.The risk is that mere u of the“correct”termi-nology,with no attention paid to the wider aspects of a consultation,could lead to professional complacency. Paul Freeling Emeritus professor of general practice
St George’s Hospital Medical School,London SW170RE
Linda Gask Senior lecturer in psychiatry
陈亢问于伯鱼
National Primary Care Rearch and Development Centre,University of Manchester,Manchester M139PS
1Hutchon DJR,Cooper S.T erminology for early pregnancy loss must be changed.BMJ1998;317:1081.
2Roberts AH.Managing miscarriage:the management of the emotional quelae of miscarriage in training practices in the West of Scotland.Fam Pract1991;8:117-20.
3Goldberg DP,Jenkins L,Millar T,Faragher EB.The ability of trainee gen-eral practitioners to identify psychological distress among their patients.
什么是职业素养Psychol Med1993;23:185-93.
4Audit Commission.What ems to be the matter?Communication between hos-pitals and patients.London:HMSO,1993.
5Stott NC,Pill RM.Advi yes.Dictate no.Patients’views on health promo-tion in the consultation.Fam Pract1990;7:125-31.
6Bird J,Cohen-Cole SA.The three function model of the medical interview:an educational device.Adv Psychosom Med1990;20:65-88.你说我说
7Browne K,Freeling P.The doctor patient relationship.2nd ed.Edinburgh: Churchill Livingstone,1976.
8Simpson M,Buckman R,Stewart M,Maguire P,Lipkin M,Novack D,et al.
Doctor-patient communication:the T oronto connsus statement.BMJ 1991;303:1385-7.
9Tuckett D,Boulton M,Olson C,Williams A.Meetings between experts:an approach to sharing ideas in medical consultations.London:T avistock,1985. 10Stewart M,Brown BJ,Weston WA,Mcwhinney I,McWilliam CL,Freeman TR.Patient centered medicine:transforming the clinical method.Thousand Oaks:Sage,1995.咖喱鸡饭的做法
中国豹
11Lesr AL.Problem bad interviewing in general practice:a model.Med Educ19985;19:299-304.
12Miller WR,Rollnick S.Motivational interviewing:preparing people to change addictive behaviour.New Y ork:Guildford Press,1991.
13McDaniel A,Campbell T,Seaburn D.Family orientated primary care:a manual for medical providers.New Y ork:Springer Verlag,1992.
14Balint M.The doctor,his patient and the illness.Pitman:London,1957.
Fluoroquinolone resistance
Overu of fluoroquinolones in human and veterinary medicine can breed resistance
F luoroquinolones are highly active,broad spec-
trum antibiotics with many us in both human
and veterinary medicine.As with other class of antibiotic,however,decread susceptibility or resistance to the agents has developed.Resistance is usually chromosomally mediated so the spr
ead of resistant bac-teria contributes to the high numbers of resistant strains reported by some institutions.Although for many infec-tions the changes in susceptibility of the bacteria have not had an immediate clinical impact,highly resistant strains have recently emerged.For some infections and bacterial species the clinical ufulness of fluoroquinolo-nes may be limited if their u is not curtailed.
Genetic and biochemical experiments have shown two enzymes that are the targets of fluoroquinolones.1 In Gram negative bacteria such as Escherichia coli,Pu-domonas aeruginosa,and Neisria gonorrhoea,the primary target is DNA gyra and the condary target DNA topoisomera IV;in Gram positive bacteria, such as Staphylococcus aureus and S pneumoniae,the pri-mary and condary targets are reverd.2DNA gyra and topoisomera IV are each enzymes compod of four subunits(two A and two B)encoded by gyrA and gyrB,and parC and parE respectively.Fluoroquinolone resistant isolates usually contain one or more mutations in a small ction of gyrA or parC;mutation
头孢克洛说明书Editorials
关于元宵节的日记行为研究BMJ1998;317:1029–30
