Force and Presence in the World of Medicine.

Medicine can not only be read with a poetic imagination, but also configured as a poetic practice, moving beyond the instrumental. The poet Wallace Stevens made a distinction between 'Force' and 'Presence'-the former can be read as combative, the latter as pacific. Modern medicine has been shaped historically by the combative metaphor of a 'war against disease', turning medicine into a quasi-militaristic culture fond of hierarchy. This is supplemented by the metaphor of the 'body as machine', reducing the complex and unpredictable body to a linear, if complicated, apparatus. The two metaphors align medicine with the modern industrial-military complex that is masculine, heroic, and controlling in character. In an era in which medicine is feminising and expected to be patient-centred, collaborative (inter-professional) and transparent to the public as a democratic gesture, the industrial-military metaphor complex should no longer be shaping medicine-yet its influence is still keenly felt, especially in surgery. This continuing dominance of Force over Presence matters because it is a style running counter to the collaborative, team-based medicine needed for high levels of patient safety. Medicine will authentically democratise only as new, pacific shaping metaphors emerge: those of 'Presence', such as 'hospitality'. Hospitals can once again become places of hospitality.

Whistleblowing in medicine and in Homer's Iliad.

'Thinking with Homer', or drawing creatively on themes and scenes from Homer's Iliad and Odyssey, can help us to better understand medical culture and practice. One current, pressing, issue is the role of the whistleblower, who recognises and exposes perceived poor practice or ethical transgressions that compromise patient care and safety. Once, whistleblowers were ostracised where medical culture closed ranks. However, in a new era of public accountability, medicine looks to formally embrace whistleblowing to the point that not reporting transgressions can now constitute a transgression of professionalism. Where medical students identify with the history and traditions of medical culture, they inevitably find themselves in situations of conflicting loyalties if they encounter senior clinicians behaving unprofessionally. What are the implications of facing these dilemmas for students in terms of role modelling and shaping of character as a doctor, and how might a study of Homer help with such dilemmas? We suggest that a close reading of an opening scene in Homer's the Iliad can help us to better appreciate such ethical dilemmas. We link this with the early Greek tradition of parrhesia or 'truth telling', where frankly speaking out against perceived injustice is encouraged as resistance to power and inappropriate use of authority. We encourage medical educators to openly discuss perceived ethical dilemmas with medical students, and medicine as a culture to examine its conscience in a transition from an authoritarian to an 'open' society, where whistleblowing becomes as acceptable and necessary as good hygiene on the wards.

The embodiment of lyricism in medicine and Homer.

Improving the quality of communication between doctors and their patients and colleagues is of vital importance. Poor communication, especially within and across clinical teams working around patients in pathways of care, leads to avoidable medical error, where an unacceptable number of patients are severely harmed or die each year. The figures from such iatrogenesis have now reached epidemic proportions, constituting one of the major killers of patients worldwide. Despite 30 years' worth of explicit attention to teaching communication skills at undergraduate level, communication in medicine is failing to improve at an acceptable rate. The authors suggest a rather unusual approach to this dilemma of 'communication hypocompetence'­thinking medicine lyrically­as an extension of thinking with Homer's little-discussed lyrical aesthetic. A key part of the problem of communication hypocompetence is the well-researched phenomenon of 'empathy decline' in students, where 'hardening' and cynicism occur as over-determined ego defences. Empathy decline may be a symptom of the repression of the lyrical genre in medicine, where the epic, tragic and dark comic genres dominate. The lyrical genre emphasises coming to know the patient as a person and an individual. Importantly, central to performing the lyric genre is the heightened use of the senses in taking a history, physical examination and diagnostic work. Framing medicine as lyrical work challenges undue emphasis on 'cure' at the expense of humane 'care'.

The curriculum is dead! Long live the curriculum! Designing an undergraduate medicine and surgery curriculum for the future.

Where changing social circumstances demand reform of medicine, this in turn provokes new thinking in medical education. Curriculum changes, however, are often ill conceived, consisting of syllabus (content) modification, rather than careful consideration of fundamental principles and theory shaping a curriculum process initiative. The undergraduate medicine and surgery curriculum of the future must address some basic fault lines in current provision, such as medical culture's failure to democratise work practices ensuring patient safety. While acquiring a reputation as innovative and progressive, and after a decade of success with current provision, Peninsula Medical School (UK) has recognised the need to develop its curriculum for the future. Such a curriculum will be guided by best evidence from medical education to inform pedagogical practices and by sophisticated curriculum theory. Drawing on social learning pedagogies and curriculum reconceptualisation models for guidance, and incorporating evaluation of its current provision and published evaluations of other curricula (particularly Longitudinal Integrated models), fundamental principles were conceived to guide curriculum reform.

Pre-surgery briefings and safety climate in the operating theatre.

BACKGROUND: In 2008, the WHO produced a surgical safety checklist against a background of a poor patient safety record in operating theatres. Formal team briefings are now standard practice in high-risk settings such as the aviation industry and improve safety, but are resisted in surgery. Research evidence is needed to persuade the surgical workforce to adopt safety procedures such as briefings. OBJECTIVE: To investigate whether exposure to pre-surgery briefings is related to perception of safety climate. METHODS: Three Safety Attitude Questionnaires, completed by operating theatre staff in 2003, 2004 and 2006, were used to evaluate the effects of an educational intervention introducing pre-surgery briefings. RESULTS: Individual practitioners who agree with the statement 'briefings are common in the operating theatre' also report a better 'safety climate' in operating theatres. CONCLUSIONS: The study reports a powerful link between briefing practices and attitudes towards safety. Findings build on previous work by reporting on the relationship between briefings and safety climate within a 4-year period. Briefings, however, remain difficult to establish in local contexts without appropriate team-based patient safety education. Success in establishing a safety culture, with associated practices, may depend on first establishing unidirectional, positive change in attitudes to create a safety climate.

"Who's on the team today?" The status of briefing amongst operating theatre practitioners in one UK hospital.

Accidents in health care are mainly due to systemic communication errors. Errors occur more frequently in the operating theatre (OT) than other clinical settings. Hence, it is important that preventive communication practices are adopted in OT teams. Formal team pre-briefing has been shown to improve safety in high risk settings such as aviation, but such briefing is not common practice in OT teams. This paper reviews key literature demonstrating the value of briefing in high-risk practices; presents and analyses the results of a questionnaire survey on the status of briefing after its introduction to OT teams in one UK hospital; and analyses processes that frustrate widespread adoption of briefing. In comparison with other OT practitioners, surgeons generally reported differing perceptions of the meaning and value of briefing, often holding broad notions of what constitutes a "brief", but also showing scepticism towards briefing. However, surgeons who had introduced briefing reported positive results such as greater efficiency, shared understanding, and increased team morale. Collaborative briefing that extends beyond the technical to include the interpersonal could be initiated in principle by any member of the OT team, but a number of factors inhibit this, and surgeons play a pivotal role in establishing briefing.

Improving teamwork climate in operating theatres: the shift from multiprofessionalismto interprofessionalism.

A multi-faceted, longitudinal and prospective collaborative inquiry was initiated in December 2002 with one half of the cohort of operating theatre personnel in a large, acute UK hospital serving a mainly rural population. The same intervention was introduced in January 2004 to the other half of the cohort. The project aims to improve patient safety through a structured educational intervention focussed upon changing teamwork practices. This article reports one critical element of the larger project - changing teamwork climate as a necessary precursor to establishing an interprofessional teamwork culture. The aggregate of individual, unidirectional attitude changes across a large cohort constitutes a change in climate. This shift challenges the conventional culture of multiprofessionalism, where uniprofessional identification (the "silo" mentality) is traditionally strong.