Personal View: Who'd be a reformer?
Authors: Jonathan Shepherd
Journal: BMJ (2003)

Ten years ago I was not prepared for the critical letter from the president of my surgical association, after the publication of a BMJ editorial I had jointly written ( 1994;309: 620-1) on surgical removal of third molars—one of the commonest operations. We said, on the basis of convincing evidence, that prophylactic removal should be abandoned. I had, apparently, been naive. He was certainly right in one respect: I had been naive enough to think that our conclusion—later reached by the National Institute for Clinical Excellence in its first technology appraisal—would, in the age of evidence based medicine, be welcomed.

The ensuing debate in the BMJ's letters pages was polarised by the media. A Times article starkly contrasted our conclusion with the opposite view of a consultant colleague in my own department. The headline in the Independent on Sunday, “Millions wasted on wisdom teeth,” spanned a whole page. This taught me something else: that professional and public controversy can be a powerful, even essential, component of reform. But public controversy needs a thick skin.


The evidence based reformer can still face isolation, ostracism, and cost


It is easier to engage in one controversy at a time; I am not sure I could have coped at the same time with the onslaught from the British glass industry that followed publication of our research finding that pub glasses were often used as weapons in assault and that toughened glasses were safer than non-toughened glasses (BMJ 1994;308: 932. [PubMed]). Before the UK glass industry switched to toughened pint glasses in 1997 I vividly remember picking up the office phone to hear the director of a glass company protesting that my research would put 500 of his employees out of work.

Researchers must weigh the cumulative evidence and select a suitable battleground if the evidence makes a strong case for reform. Real change, it seems, involves illumination by scores of professional and media searchlights and friendly as well as enemy fire. It helps, of course, to have allies—for example, in the Cochrane Collaboration and among clinical colleagues. The task of reform has been made easier by clinical governance, new national authorities, and a government intent on raising standards and making communities safer.

Other reforms I have been involved in relate to training and legislation. In the early 1990s a scarcity of potential senior lecturers in oral and maxillofacial surgery threatened the discipline. Survival demanded radical and concerted action by senior academics. The solution was a new specialist academic training programme, but it was only accepted and implemented after fierce debate. Now, not only have there been trainees in this programme in almost every UK university department but five have achieved chairs.

The only reform I have worked for that has not, so far, been characterised by controversy and antagonism at a personal level is the only one that has become statutory: the establishment of the NHS as a partner in community crime prevention. Evidence over several years showed that most violence resulting in treatment is not known about beyond the NHS. Here, the forum for debate was parliament, where a Home Office minister responsible for the Crime and Disorder Bill (1997) was persuaded that the NHS had an important role in the surveillance and prevention of violence. However, perhaps the lack of controversy is because few public health and emergency doctors and managers have yet to be engaged in implementation. Legislation is certainly not the end of reform.

Forceful public argument does not fit comfortably with the way that academics present the research findings that are the foundation for reform. However, clinical academics are used to making definite clinical decisions. Medicine and dentistry have a distinct advantage in this respect over almost all other public services, such as education, the law, and policing, where the generation of new knowledge is not integrated with practice. But the evidence based reformer can still face isolation, ostracism, and cost. Presidents of associations who write letters criticising reformers are not likely to back them for distinction awards. In relation to the campaign for the NHS to help prevent violence a professor of criminology called me a moral entrepreneur, which made me feel like an evidence averse goody two shoes. Reform can be easier outside one's own professional group—though, like charity, it usually begins at home.

New values, circumstances, and evidence constantly challenge inertia, conformity, and commercial interests in practice and in industry. Reform may not be achieved immediately or completely. But without advocates it will never happen. I pay tribute to those who have expressed strong views and debated the issues of my own professional times: in the British Association of Oral and Maxillofacial Surgeons, the BMJ, the Home Office, the faculties of dental surgery, and the media. Without them there would have been no controversy—and no progress.