The collapse of capitalism, values – and peer review?
Authors: Kamran Abbasi
Journal: Journal of the Royal Society of Medicine (2008)

By the time you read this, world capitalism may have collapsed. If it has, you can be reassured that the JRSM is immune to the credit crunch. But what does the collapse of capitalism mean, and if it did collapse what would replace it? Since capitalism all but defeated communism there are few contenders for world domination. Perhaps a new humanity might emerge triumphant, one that encourages us to view our fellows with warmth, understanding, and compassion?

I guess Aidan Halligan would be attracted by these values. The rise of scientific medicine, he argues, has diluted the importance of values in healthcare (JRSM 2008;101:480−481). In the mid-20th century – when medicine could do a lot less than it can do now – kindness, caring, good communication and honesty were given much more attention. A survey by the General Medical Council in 2000 discovered that 60% of doctors believed those personal attributes to be important. What surprises Halligan, however, is that 40% of doctors did not.

While measures and indicators judge the NHS to be better than it ever was, what happens to patients when they reach their hospital or their doctor has remained invisible until now. The well-measured truth, says Halligan, tells the darker lie – which is that lack of values and uncaring systems and processes leave patients powerless, frustrated and frightened. The leadership that the NHS requires must place rediscovering lost values at the heart of its agenda.

Despite the rise of the internet in its role of providing health information, patients continue to value face-to-face consultations, and hence doctors should remain mindful of Halligan's call for values. The internet is forcing a redefinition of a doctor's role, from guardian of knowledge into gatekeeper to further and more specialized treatment that the internet cannot replace.

In their qualitative study, Donnelly and colleagues discover three dominant themes in people's experience of seeking information on the internet (JRSM 2008;101:501–506): decline in expert authority, pervasiveness of health information on the internet and patient empowerment. Study participants enjoyed the immediate benefits of health information but were reluctant to lose the opportunity of a consultation. These effects, however, will be limited by literacy and access to the internet, which is one example of the digital divide.

At this point, some hardened clinicians might be wondering about the values of medical journals. How do such ‘soft’ focus group studies come to be published when my earth-shattering case report was despatched to the reject bin? The peer review process, the edifice upon which the credibility of medical journals is erected, is increasingly studied and its flaws are exposed at every step. Peer review can help improve the quality of what the editors of a journal decide to publish but it isn't much good for anything else, including detecting major errors.

A trial conducted at the BMJ examines the ability of peer reviewers to detect major errors in research papers and the effect of training to improve their ability to detect them (JRSM 2008;101:507–514). Schroter et al. find that, on average, reviewers are able to detect less than three out of nine errors, and training makes little difference. Clearly, peer review is not the sacred process many clinicians imagine it to be. Capitalism might not have collapsed but your confidence in peer review may just have.