1. Trisha Greenhalgh on implementing scientific knowledge as practice.
  2. Mapping coincidences, and a reminder to myself to read more Spiegelhalter.
  3. Value-Based purchasing & pay doesn’t improve mortality.
  4. There is no 4

It’s National Nurse Appreciation Week, so let me say: I should be reading the nursing literature more.  Here’s a good example. (OK, it’s not from a nursing journal, but there are similar studies that are).

The structure of a hospital’s medical ward is a complex hierarchy, and the basic process of fighting disease and caring for patients (two distinct tasks that are often conflated) can be broken down to a crude military metaphor: strategy, tactics, and execution. I’m not sure that the roles of medical professionals can be analogized to the military as neatly, but in general attending doctors tend to be involved with strategy, interns and medical students and nurses with various aspects of execution. Tactics (and residents) fall somewhere in-between.

This largely makes sense because everything we do is complicated and time consuming and requires practice and expertise, and the basic reality of modern medical practice is that it’s all made more difficult by demands of documentation, billing, interfacing with an unwieldy electronic medical record.  The upshot is that there are order-givers and order-takers, all of whom are stressed and busy. Often, decisions need to be made quickly, and even in non-emergencies there may not be time or desire to explain why something is being done the way it’s being done. “That’s why it’s called an order.”

It’s hard, in general, to know what the right thing is to do.  A lot of medical ethics training for physicians (at least mine, as far as I can recall) has dealt with this problem – theories of right and wrong, principles of bioethics. Some discussion of landmark legal cases.

But it’s harder still to do the right thing,  when you’ve been asked by someone in a position of authority to do something  wrong.  Theoretical knowledge is not enough. Goodness isn’t an intrinsic character trait or a virtue to be built by knowledge and reflection alone.  It’s a skill to be practiced.

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