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• W2017613766 abstract "I am not an epidemiologist, a social physician, or an economist. My work is in clinical radiology: I x-ray sick people. I am, I suppose, representative of the everyday doctor who spends large sums of money on his patients each year. The title given to me for this paper is not something that comes readily as part of a doctor's basic kit. Human interest, compassion, and curiosity are the sort of motives advanced by prospective medical students, but by long tradition these refer to the one-to-one relationship between the doctor and his sick patient. The Hippocratic oath says '. . . I will prescribe regimen for the good of my patients according to my ability . . .'. For 2400 years doctors have cared for individual patients who seek help with an immediate problem. That may not look like a wholly admirable stance now, but it is an interaction which has been established between the individual in trouble and the doctor as an honourable professional caring for that particular man or woman. It is probably the way many of us would still like to be treated if we have the misfortune to fall sick. It is of course easy to show that this traditional and respected picture is really riddled with holes. What compassion is there in caring extravagantly well for one patient, and then being unable to look after the next two? Or in tinkering with the late ill effects of disease instead of preventing it at source, like removing the handle of that cholera infested pump in Broad Street? As a malicious aside, I want to remind community medicine men that even their best interventionist efforts, just like the clinician's, can come to look a trifle puny against the tide of natural history. It seems that the Broad Street cholera outbreak was already past its peak and on the wane when John Snow had that pump handle removed in 1854 (Bradford Hill, 1955). To the clinical doctor with his professional ancestry of thousands of years, the about-turn from trying to relieve individual suffering to working for Health with a capital H is a revolution that has not come easily. Radiologists have been worried for longer than those in some other disciplines, because the gulf between resources and needs has been brought home to them on their own doorstep. Demands for x-ray services are growing at 5% to 10% compound interest each year. Two-thirds of the whole population in the United States of America are estimated to have had a radiological examination in 1970 (British Medical Journal, 1977). Forty million units of x-ray work were carried out in the National Health Service in 1974 (one chest radio graph is one unit). There are about 1000 pairs of radiological eyes at all grades in the NHS, and it is increasingly hard for them to cope with the flood of cases which face them. The gap between limited resources and open-ended demand, between what is economically feasible and medically possible, is very wide in radiology departments. No wonder that radiologists are interested in clinical decision making, and have sometimes been in the forefront of exploring this process (Knowles, 1969; Lusted, 1971). We cannot be endlessly generous and continue to be fair (Acheson, 1978). Health care has moved, never to return, along a historical path from charity, via market economy, to corporate provision. Traces of the earlier systems remain, but today we have to discuss how corporate provision in the NHS might be made to work. I would like to examine decision-making as a bridge between resources and demands by three radiological examples: the routine chest x-ray, the investigation of hypertension, and the problem of finding a lump in the kidney. These have been chosen because they illustrate attempts to come to grips with problems of audit, decision analysis, and, indeed, scientific method in clinical medicine." @default.
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• W2017613766 date "1979-03-01" @default.
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• W2017613766 title "Resources and decisions in clinical radiology." @default.
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• W2017613766 doi "https://doi.org/10.1136/jech.33.1.59" @default.
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