Doctors in the movies - BMJ · entertainment sales to dealers of 1.1 billion DVDs and 294 million...

Entertainment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Doctors in the moviesG Flores. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Healers, heels, and Hollywood

The world continues to have a pas-sion for movies. Moviegoers world-wide spent $20.3 billion and

purchased 8.6 billion admission ticketsto see films in 2003.1 2002 was a recordbreaking year at the UK box office, with176 million cinema admissions, £755million in total box office receipts,and 369 films released.2 In the USA in2003, there were 1.6 billion cinemaadmissions, $9.5 billion in box officereceipts, 473 films released, and homeentertainment sales to dealers of 1.1billion DVDs and 294 million videocassettes.3

Movies have a powerful influence onpopular culture, due to their interna-tional popularity, easy accessibility,and profitability as an industry.Cinematic depictions of doctors thushave the potential to affect publicexpectations and the doctor-patientrelationship. In a 2002 paper, I con-ducted an in-depth analysis of theportrayal of doctors in the movies,reviewing 131 films from nine countriesspanning eight decades.4 Key findingsfrom this research included: (1) com-passion and idealism were commonin early doctor movie portrayals buthave become increasingly scarce inrecent decades; (2) since the 1960s,positive doctor portrayals declinedwhile negative portrayals increased;(3) doctors frequently are depicted asgreedy, egotistical, uncaring, andunethical, especially in recent films;(4) a recurrent theme is the ‘‘madscientist’’, the doctor-researcher whovalues research more than patients’welfare; (5) because negative portrayalsof doctors are on the rise, patients’expectation and the doctor-patient rela-tionship may be adversely affected; and(6) films about doctors can serve asuseful gauges of public opinion andtools for medical education. The aim ofthis paper is to use this extensivedatabase, supplemented by several morerecent films, to explore selected keythemes about the portrayal of doctorsin the movies. In contrast to the priorpaper, however, this paper will alsofocus on humour in doctor films (bothintentional and unintentional), andexamine the few movies that haveportrayed paediatricians.

MAJOR THEMES IN DOCTORMOVIESMoney and materialismMaterialism and a love of money havepervaded cinematic portrayals of doctorsdating back to the 1920s, and continueto be prominent in recent movies. InDoctor at Sea (1956), Dr Simon Sparrow(Dirk Bogarde) states, ‘‘A Rolls Royce isthe ambition of almost every newlyqualified doctor. And preferably aHarley Street address to go with it.’’ InCarry on Again Doctor (1969), Dr JimNookey (Kenneth Williams) confides toa colleague: ‘‘Specialise, that’s what I’dlike to do! The whole Harley Street bitwith bags of lovely filthy rich womenpatients.’’ In Doctor at Large (1957), thedoctor in charge of a Harley Streetpractice advises Dr Sparrow, ‘‘Youknow, it’s a chastening thought, butgood clothes are more important to a GPthan a good stethoscope.’’Indeed, it shocks and bewilders other

characters when movie doctors do notdisplay adequate wealth. In Playing God(1996), an FBI agent visits the home ofthe surgeon Dr Eugene Sands (DavidDuchovny) to arrest him for the death of

a patient due to operating whileaddicted to drugs, and the agent says,‘‘This is not how a doctor lives. No, thisis squalor. I mean, you did go to medicalschool, right?’’ Dr Sands replies, ‘‘What,are you going to arrest me for failing tolive up to my potential?’’.Money is not infrequently portrayed as

the prime motivation for becoming adoctor and choosing a medical specialty.In Not As a Stranger (1955), medical schoolclassmates discuss their career options:

‘‘Personally, I’m for surgery. I justgot a look at Dr Dietrich’s car. Youknow what he drives? A Bentley.$17,000 bucks.’’‘‘That guy doesn’t take out a splinterfor less than $1000.’’‘‘I’ll still take ear, nose, and throat.The common cold is still the doctor’sbest friend.’’‘‘Call it a virus. You make moredough that way.’’‘‘Look, if you kiddies are all through,your old man here will really wiseyou up. It’s not what you practice,it’s where.’’‘‘What do you mean?’’‘‘I’ve done a little research on thisproblem. The average doctor’sincome is 11 Gs. In the southwest,west, and more...’’‘‘Pebble Beach, Colorado Springs,Beverly Hills, that’s where the richare crackin’ up fast.’’

Movie doctors even base treatmentdecisions on patients’ ability to pay. InCritical Care (1997), Dr Werner Ernst

Figure 1 Paediatrician Dr Larry Quinada (James Mason) in Caught (1949). Reproduced courtesyof the Academy of Motion Picture Arts and Sciences.

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(James Spader), in the intensive careunit (ICU), asks ‘‘ICU ChairmanEmeritus’’ Dr Butz (Albert Brooks)why a comatose patient with a poorprognosis needs a procedure:

‘‘If there’s no reasonable prospect ofcure, why should we proceed?’’‘‘Where have you been all your life:It’s called revenue! He’s got cata-strophic health insurance. Long termhealth care. The works!’’‘‘What difference does his insurancemake?’’‘‘What? It’s cash money. Not one ofthose ‘try and collect from the estate’deals. And you want to yank histubes!’’

PaediatriciansThe medical specialty of movie doctorsmost often is surgery (33%), psychiatry(26%), or family/general practice (18%),with paediatrics accounting for only2%.4 It is informative to examine movieswith a paediatrician as the main char-acter. Every Girl Should be Married (1948)was released with fanfare as RKO’s bigChristmas offering, and was a financialsuccess.5 Anabel Sims (Betsy Drake), aromantic woman determined to findthe perfect husband, meets and falls inlove with handsome paediatrician DrMadison Brown (Cary Grant) whenthey both reach for a copy of ‘‘BetterBabies’’ at a luncheonette. He resists herobvious advances, and she uses everytrick and trap, including a fake romancewith her department store boss, tofinally land Dr Brown. In real life,Drake and Grant met in 1947 aboardthe luxury liner Queen Mary travellingfrom England to the USA, and were

married one year after the film’s release(Drake was Grant’s third wife and themarriage lasted almost 13 years, thelongest of Grant’s five marriages).5

Dr Brown is portrayed as a compas-sionate, dedicated paediatrician whosometimes does not even charge forpatient visits. Brown playfully scolds amother of three who happily departsafter a clinic visit:

‘‘Now before you bring theseyoungsters of yours in here again,

Norma, make sure there’s some-thing the matter with them so that Ican send you a bill.’’‘‘You probably will anyway.’’‘‘Heh, heh.’’‘‘Come along boys, we’ll get nosympathy here.’’

Brown twice comments on the longhours he puts in as a paediatrician. Afterputting in a particularly long day, he saysto his nurse, ‘‘Ohmy, why didn’t I becomea night watchman or a flagpole sitter orsomebody with regular hours instead of ababy doctor.’’ After Brown’s cocktailswith Anabel are interrupted by a callfrom a concerned mother, he says, ‘‘I’msorry, Annabel, but that’s what it’s likebeing a doctor, no time for anything else’’,to which she replies, ‘‘but I think being adoctor is the most wonderful thing in theworld a man can be!’’ Brown delivers alecture to mothers entitled, ‘‘The Parent’sResponsibility to the Child. A Lecture bythe Eminent Pediatrician Madison WBrown, MD’’. His concluding remark isimpressive for revealing an insight privyto the experienced paediatrician: ‘‘How-ever, there is an instinctive wisdom inmost mothers which transcends all thescience of doctors.’’In Caught (1949), Leonora Eames

(Barbara Bel Geddes) fulfils her dreamby marrying millionaire Smith Ohlrig(Robert Ryan), but the marriage is adisaster, so she goes to work in theoffice of paediatrician Larry Quinada(James Mason), who has devoted his

Figure 2 Dr R Wesley McLaren (Steven Seagal) confronts a paramilitary extremist in The Patriot(1998). Reproduced courtesy of the Academy of Motion Picture Arts and Sciences.

Figure 3 Dr John Carpenter (Elvis Presley) speaks to Sister Irene Hawkins (centre, played byBarbara McNair) and Sister Michelle Gallagher (Mary Tyler Moore) in Change of Habit (1969).Reproduced courtesy of the Academy of Motion Picture Arts and Sciences.

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life to serving impoverished children inNew York City (fig 1). They fall in love,but Eames is pregnant with Ohlrig’schild, which she finally miscarries, andthen Eames and Quinada live happilyever after. The portrayal of Dr Quinadais noteworthy for his commitment to theunder-served and lack of interest inmaterialism. Eames’s interview withQuinada proceeds as follows:

‘‘You know what the job is, MissEames?’’‘‘Receptionist.’’‘‘Yes, for Dr Hoffman and me. He’san obstetrician, I’m a paediatri-cian.’’‘‘He brings children into the world, Itry to keep them here.’’‘‘I’m sure you succeed, doctor.’’‘‘Well, I don’t always. It’s easier towrite prescriptions than to pay forthem.’’

Later, when Eames has becomeQuinada’s receptionist and lover, shecomments on his attitude to money:

‘‘That’s because you don’t careabout money.’’‘‘Everyone’s got to care aboutmoney to a certain extent—how elsecan I take you out to dinner when Iwant to. But I care more about otherthings like doing the kind of workthat interests me.’’‘‘Is that why you work on the EastSide?’’‘‘Sure. I can learn more there in oneday than I can learn anywhere elsein one month.’’

After this brief burst of paediatricianmovies, little attention has been paid topaediatricians as main characters. InSunchaser (1996), which does not featurea paediatrician, a 16 year old with aretroperitoneal sarcoma who is impri-soned for murdering his stepfather isreferred to adult oncologist MichaelReynolds (Woody Harrelson), whom helater kidnaps. Angered that a paediatri-cian will not treat the patient becausehe is a murderer, Reynolds says,‘‘Paediatrics can’t just dump their over-load on us. Tell them to cut down on their

lunchtime and tennis. Maybe they’ll havemore time to practice medicine.’’ TheWedding Planner (2001) features Dr SteveEdison (Matthew McConaughey) as apaediatrician who is engaged to anotherwoman but eventually calls off themarriage because he has fallen in lovewith his wedding planner, Mary Fiore(Jennifer Lopez). This maudlin, forgetta-ble film is noteworthy for Edison inex-plicably hospitalising the adult Fiore on apaediatric ward and using a paediatriccervical collar after Fiore suffers a con-cussion and loss of consciousness, and forEdison mentioning that he had to attenda diverticulitis seminar, a conference ofdoubtful utility to a paediatrician.

Bureaucracy and healthcaresystemsMovie doctors frequently face the frus-trations and follies of having to confrontinefficient bureaucracies and healthcaresystems that hinder patient care. InArticle 99 (1991), Dr Sturgiss (RayLiotta) explains to an intern why open-heart surgery is being performed on apatient admitted for prostate surgery:

Figure 4 (A) Dr Constance Peterson (Ingrid Bergman) psychoanalyses a patient in Spellbound (1945). (B) Prison psychiatrist (Sidney Poitier) treats aracist Nazi psychopath prisoner (Bobby Darin) in Pressure Point (1962). (C) Dr Fritz Fassbinder (Peter Sellers) in What’s New, Pussycat (1965) takesnotes on his patient, Michael James (Peter O’Toole). (D) Dr Patch Adams (Robin Williams) plays with paediatric patients in Patch Adams (1998). Allphotographs reproduced courtesy of the Academy of Motion Picture Arts and Sciences.





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Table 1 Annotated ‘‘top-ten’’ lists: doctor movies the author considers the best, most humorous, and most useful in medicaleducation

Best Most humorous (intentionally and unintentionally) Most useful in medical education

1. Red Beard (1965) 1. M*A*S*H (1970) 1. The Doctor (1991)Arrogant young man in 19th century Japandestined to be Shogun’s doctor learns truemeaning of being a doctor from senior mentorwho cares for poor (Toshiro Mifune). Directedby Akira Kurosawa.

Three surgeons in Korean war save lives, goof aroundand engage in sexual antics. Directed by RobertAltman, film won numerous awards and spawnedTV series.

A hotshot surgeon with a detached demeanourlearns about empathy and compassion when hecontracts cancer. Based on autobiographical bookby Ed Rosenbaum.

2. The Hospital (1971) 2. Body Parts (1991) 2. Arrowsmith (1932)Searing examination of chaotic urban hospitaland doctor (played by George C Scott) pushedto the edge. Won American and BritishAcademy Awards for Best Screenplay (PaddyChayefsky).

Unethical surgeon-researcher transplants variousbody parts, with (unintentionally) amusingconsequences. Don’t miss classic line, ‘‘Can’t yousee this arm is killing me!’’

From the Sinclair Lewis novel, film deftly explores adoctor’s motivations and struggles with clinicalversus research career, and thus inspirational andenlightening for medical students. Nominated forfour Academy Awards and Directed by John Ford.

3. Article 99 (1991) 3. High Anxiety (1977). 3. The Citadel (1938)Doctors in Veterans Hospital try to care forpatients despite bureaucracy and stingyadministrator.

Dr Richard Thorndyke (Mel Brooks), new Directorof Psychoneurotic Institute for the Very, VERYNervous, is framed for murder in this parody ofHitchcock movies.

Young, idealistic doctor (Robert Donat) becomesdisillusioned after practicing in Welsh miningtown, is corrupted by lucrative practice for Londonhypochondriacs, and needs major shock toappreciate true meaning of being a good doctor.From AJ Cronin novel; nominated for fourAcademy Awards.

4. State of Emergency (1993) 4. The Patriot (1999) 4. Not As a Stranger (1955)Jaded emergency room doctor (Joe Mantegna)struggles to care for patients as he battlesbudget cutbacks, overcrowding, and takeoverby an HMO.

Steven Seagal plays an MD-PhD family practitioner/holistic healer who is also a single father, NativeAmerican cowboy, and martial arts expert. Hesingle handedly conquers extremist paramilitariesand the most lethal viral outbreak ever.

Follows lives of several medical students,examining such issues as career choices, greed,and racism. Star studded cast includes RobertMitchum, Frank Sinatra, and Lee Marvin asdoctors.

5. Miss Evers’ Boys (1997) 5. What About Bob (1977) 5. Pressure Point (1962)Compelling drama about infamous TuskeegeeStudy of untreated syphilis in African-Americans. Made-for-TV movie won fiveEmmys and nominated for another seven.

Multi-phobic patient (Bill Murray) followsnationally renowned psychiatrist (Richard Dreyfus)on vacation, turning his life upside-down.

Excellent examination of racial issues in whichSidney Poitier plays a prison psychiatrist forced totreat a racist Nazi prisoner (Bobby Darin).

6. The Elephant Man (1980) 6. Carry on Doctor (1968) 6. Whose Life Is It Anyway (1981)Biography of John Merrick (John Hurt) and hiscompassionate physician (Anthony Hopkins).Directed by David Lynch, Hurt won BritishAcademy Award for Best Actor.

Among the most famous in the ‘‘Carry On’’ series,filled with many gags (but not much of a plot).

Superb vehicle for exploring medical ethics issuesin this film about an artist (Richard Dreyfus)paralysed in an auto accident who wants hospitalto let him die.

7. Panic in the Streets (1950) 7. Doctor at Sea (1956). 7. Miss Evers’ Boys (1997).Dr Clint Reed (Richard Widmark), a PublicHealth Service doctor, determines an immigrantkilled by hoodlums had pneumonic plague, andto prevent a catastrophic epidemic, must trackdown killers aided by reluctant police chief.Won Academy Award for Best Story.

To escape romantic entanglement, Dr Sparrow(Dirk Bogarde) becomes ship’s doctor, gettinginvolved with passenger (Brigitte Bardot) andmadcap shore adventures. British Academy AwardNominee: Best British Screenplay.

Film about infamous Tuskeegee Study isoutstanding means for exploring informedconsent, research ethics, and racism.

8. Spellbound (1945) 8. What’s New, Pussycat (1965) 8. The Interns (1962).Hitchcock classic about psychiatrist (IngridBergman) who helps amnesiac accused ofmurder (Gregory Peck) uncover his past.

Engaged philanderer (Peter O’Toole) seeks aid ofpsychiatrist (Peter Sellers) who has problems of hisown. Woody Allen’s first film as both actor anddirector; features Oscar nominated song of same name.

Nice exploration of residency, sexism, racism,ethics, and greed. Look for Telly Savalas andBuddy Ebsen as doctors.

9. Death and the Maiden (1994) 9. Torture Ship (1939) 9. Critical Care (1997)Torture/rape victim (Sigourney Weaver)confronts her doctor torturer (Ben Kingsley) inthis adaptation of a play directed by RomanPolanski.

Research doctor who believes he has isolated‘‘endocrine glands for criminality’’ recruits sixhomicidal criminals to be research subjects onboard ship in exchange for passage to newcountry. Based on a Jack London short story,most humorous moments feature horriblycoercive ‘‘informed consent’’ for research.

Great mechanism for considering key end-of-lifeissues, this film portrays travails of resident (JamesSpader) entangled in siblings’ dispute over theirterminally-ill, comatose father.

10. Guess Who’s Coming to Dinner (1967) 10. Malice (1993) 10. And the Band Played On (1997)African-American tropical medicine specialist(Poitier) brought home by fiancee (KatharineHoughton) to meet her parents (Spencer Tracyand Katharine Hepburn) shock and test parentswith their interracial romance. Academy Awardsfor Best Actress and Screenplay and BritishAcademy Awards for Best Actor and Actress.

Otherwise predictable thriller with nice plot twist,noteworthy for amusing soliloquy by surgeon Jed Hill(Alec Baldwin) featuring, ‘‘You ask me if I have a Godcomplex? Let me tell you something: I am God.’’

Provocative examination of history of HIV/AIDS inUSA that also considers intersection of politics andscience.





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‘‘Here’s the problem: this patient needsopen-heart surgery. The administrationof this hospital will only authorise aprostate procedure. Now what good isfixing his prostate if he has a heartattack every time he tries to use it?’’ InExtreme Measures (1996), a hospitaladministrator confronts resident DrGuy Luthan (Hugh Grant) about thecosts of multiple lab tests on a patientwho died mysteriously:

‘‘Who the hell is Claude Menkins?’’‘‘It’s ‘was.’ I’m afraid he died.’’‘‘Tell me he had insurance.’’‘‘No. That’s not at all likely.’’‘‘This is $2600 worth of lab work.’’‘‘Right. Could I…’’ [Reaches forprintout].[Snatches back printout]. ‘‘I had twopeople tied up for eight hours.’’‘‘Well, you know, Gene, what youdo in the privacy of your own homeis really your business.’’‘‘O.K. Let’s get it into your head.This is not England. This is not theNational Royal Shakespeare tax-payers pick up the tab health caresystem. O.K. Somebody has to payfor this s---!’’

Humour: intended and unintendedIn Body Parts (1991), psychologist BillChrushank (Jeff Fahey) loses his arm ina car accident, but receives an ‘‘armtransplant’’ by Dr Agatha Webb(Lindsay Duncan), who is transplantingbody parts harvested from convictedkillers. After Chrushank recovers, hefinds that his ‘‘killer’s arm’’ has a lifeof its own, forcing him to strike his wifeand murder the surgeon and anaesthe-siologist who performed his operation.Chrushank sets out to discover otherrecipients of transplants from the donor,who it turns out was a serial killer. Theserial killer’s head is transplanted ontosomeone else’s body, and the killerstarts slaughtering each transplant reci-pient to get back his body parts.Chrushank eventually kills the resur-rected serial killer. Perhaps the mosthumorous segment of the film is whenChrushank asks Dr Webb to detach hisrogue arm transplant:

‘‘Do you realise what I and my teamhave accomplished with that arm ofyours? Don’t you realise that if agun were put to my head I wouldn’tjeopardise the accomplishments thatyour surgery represents?’’‘‘Can’t you see this arm is killingme!’’‘‘I’m sorry to put this so bluntly, Bill,but the pain you’re in just isn’t thatimportant when I balance it againstthe significance of the experiment.’’

‘‘You won’t perform the operation toremove the arm?’’‘‘No. And I’ll see you put in a mentalinstitution before I let you undo whatI’ve done.’’

When you need a doctor who ‘‘reallykicks butt’’, R Wesley McLaren, PhD,MD (Steven Seagal) is your man (fig 2).In The Patriot (1998), McLaren heads upthe Montana Wellness Center, specialis-ing in family practice and holistictherapy. In addition, he is a NativeAmerican cowboy, single father, andformer world famous governmentimmunologist. When a paramilitaryextremist releases a ‘‘highly contagiousviral agent’’ called NAM 37 that has ‘‘10times the potency of anthrax’’, McLarenmust develop a ‘‘cure’’ and fight extre-mists in hand-to-hand combat and withfirearms. Among the more unintention-ally humorous segments are McLarendiagnosing a patient with ‘‘severeoedema of the abdomen and liver’’ beforepalpating the patient’s abdomen, usinga light microscope to examine the virus,developing a treatment for the virusin an evening’s work which almostinstantly cures patients, and McLarenkilling the paramilitary chief with thestem of a wineglass, then doing a flipthrough a plate glass window, holdinghis rescued daughter wrapped in ablanket. The ‘‘cure’’ is derived from atraditional Native American herbal ther-apy, and consists of a tea or injection ofa red flower distillate. A whole armytroop is shown collecting red flowers inbiohazard gear, and the entire commu-nity is saved when US Army helicoptersshower the town with red flower petals,which inhabitants are instructed to useto treat themselves with cups of tea.In Change of Habit (1969), Elvis Presley

plays Dr John Carpenter, a musicallytalented general practitioner who runs afree clinic in a tough section of NewYork City (fig 3). Dr Carpenter is in themiddle of a jam session with communityyouths when he is called away:

‘‘Hey Doc! You left us hanging in themiddle of our thing, man.’’‘‘Just fake it for about 32 bars. I’ll beright back.’’‘‘You’re the doctor?’’‘‘You don’t look like a doctor.’’‘‘Well, man doesn’t live by breadalone. Especially the kind of breadyou make working at the free clinic.John Carpenter, MD. Just like thesign says.’’

Three nuns who also are healthcareprofessionals covertly are assigned aslaypersons to Carpenter’s clinic on areligious mission, including Sister

Michelle (Mary Tyler Moore), a socialworker and speech therapist. Michellefalls in love with Carpenter, but does notallow the relationship to start, andreturns to her convent conflicted. Sheattends a community church whereCarpenter is leading a musical mass,and the movie ends with Michelle tryingto decide between God and the god-likemusician-doctor Elvis Presley, a difficultchoice indeed.

COMMENTDoctor movies continue to fascinatebecause they can be humorous, thoughtprovoking, informative of the public’sperception of doctors, and they nevercease to entertain. Movie doctors pro-vide insightful and realistic portraits ofthe challenges, rewards, and excitementof being a doctor, whether it’s IngridBergman playing a psychiatrist in AlfredHitchcock’s Spellbound (1945), SidneyPoitier as a prison psychiatrist forcedto treat a racist psychopath in PressurePoint (1962), Peter Sellers as the wackypsychiatrist in What’s New Pussycat(1965), or Robin Williams as the physi-cian-clown Patch Adams (1998) (fig 4).For the aficionado, I provide a series ofannotated ‘‘top-ten lists’’ of doctormovies I consider to be the best, mosthumorous, and most useful in medicaleducation (table 1).

ACKNOWLEDGEMENTSI am very grateful to the Academy of MotionPicture Arts and Sciences for providing theoutstanding movie stills, to Sarah Hallbauerfor her assistance in preparing the manu-script, and to Alisa Flores for insights on themovies and manuscript.

Arch Dis Child 2004;89:1084–1088.doi: 10.1136/adc.2003.048843

Correspondence to: Dr G Flores, Center for theAdvancement of Urban Children, Departmentof Pediatrics, Medical College of Wisconsin,8701 Watertown Plank Rd, Milwaukee, WI53226, USA; [email protected]

Supported in part by grants from the RobertWood Johnson Foundation

All figures provided courtesy of the Academy ofMotion Picture Arts and Sciences

REFERENCES1 Motion Picture Association Worldwide Market

Research. MPA snapshot report: 2003international theatrical market. Encino, CA: MPAWorldwide Market Research, 2004.

2 UK Film Council. Film in the UK 2002. Statisticalyearbook. London: UK Film Council, 2003.

3 Motion Picture Association Worldwide MarketResearch. U.S. entertainment industry: 2003 MPAmarket statistics. Encino, CA: MPA WorldwideMarket Research, 2004.

4 Flores G. Mad scientists, compassionate healers,and greedy egotists: the portrayal of physicians inthe movies. J Nat Med Assoc 2002;94:635–58.

5 Turner Classic Movies. Every girl should bemarried. http://www.turnerclassicmovies.com/ThisMonth/Article/0,,76183%7C76184%7C76189,00.html.





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Specialist registrar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How to assess your specialist registrarH Davies, R Howells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Performance assessment requires careful thought and planning

This paper outlines the principles ofgood assessment, including theimportance of defining the purpose

of assessment as well as what shouldbe assessed. It then considers how SpRassessment should be undertaken,including possible tools for assessmentsuch as peer ratings, patient assessmentmini-CEX, and portfolios. It concludeswith a brief discussion of how to drawtogether the various aspects discussedand some advice on remediation.There is a requirement for annual

assessment of all specialist registrars(SpRs).1 However, this is undertaken onan ad hoc basis with wide variation inpractice both between and within special-ties. Little of the assessment undertakento date has been sufficiently robust towithstand legal challenge. Annual assess-ment for SpRs is soon to be extended toSHOs through Modernising MedicalCareers (MMC) and public, political, andprofessional pressure to show that ade-quate self regulation has been importantin driving revalidation forward. A priorityfor the newly established PostgraduateEducation Training and Standards Board(PMETB) has been to provide a principlesand standards framework for assess-ment within postgraduate medical train-ing2 (box 1). Annual assessment fortrainees will be used to show continu-ing fitness to practice within the revalida-tion framework. Assessment thereforeis increasingly recognised as a priority;what remains unclear is how thisshould be done—how will we measuresuccess?The authors are part of a team

responsible for implementing perfor-mance assessment for paediatricians intraining on behalf of the RCPCH. Thisarticle provides guidance on good prac-tice in relation to postgraduate assess-ment with particular reference to SpRsin paediatrics, although the principlesdiscussed are generic in nature. Con-sensus and clarity regarding the purposeof assessment (why), the content ofassessment (what), and the method ofassessment (how) is essential. There isalso a need for a clear framework toaddress problems for the minority ofdoctors whose assessment raises con-cerns about their ability to practiceeffectively.

PRINCIPLES OF GOODASSESSMENTKey characteristics of assessment toolsinclude reliability, validity, educationalimpact, feasibility, and cost effective-ness. The relative importance of thesecharacteristics varies according to thepurpose of the assessment.

ReliabilityReliability is a measure of reproducibil-ity—would you get the same results ifyou administered the assessment again?Possible influences on reliability includedifferences between observers (inter-observer reliability), variation withinobservers (intra-observer reliability),the nature of the test itself (test-retestreliability), and the nature of the pro-blem itself (case specificity). Case spe-cificity is a particular problem forclinical assessment of all types. It isimportant to realise that subjectivityand reliability are not incompatible.Subjective judgements, while not reli-able on an individual basis may bereliable if sufficiently widely sampled.Within medical education, reliability isincreasingly being evaluated using atechnique based on analysis of variance;generalisability theory.3 By analysingcomponents of variance it makes useof all the data to quantify knownsources of error without multiple experi-ments. Identification of the sources oferror is important as it allows sampling

to take place across the sources of error.It is also possible to mathematicallymodel the circumstances that would berequired (in terms of number of obser-vations and numbers of independentobservers) to achieve a given reliability.This means that it is possible to planassessment in a way that ensuresadequate reliability will be achieved.Conventionally a reliability coefficientof 0.8 is desirable for high stakesassessments such as certification proce-dures, although a lower reliability maybe acceptable for widespread screeningassessments.

ValidityValidity is a measure of how completelyan assessment tool measures what itpurports to. There are a number of dif-ferent types of validity including con-struct, content, and criterion validity.4

Reliability is essential to the defensibil-ity of an assessment—but demonstratedvalidity is also a fundamental require-ment. It doesn’t matter how reliable atest is, if it is not actually assessing thearea of interest it is not worth using.

FeasibilityEvaluation of feasibility is essential.Assessment methods that are highlyfeasible on a small scale may prove verydifficult to implement on a larger scalein a range of different settings. Con-sultants are already hard pressed andthe time they have available to committo assessment limited. Use of peers andpatients for assessment as well as otherhealth professionals is an important partof optimising feasibility.

Educational impactTools used should generate educationalfeedback that informs professional devel-opment planning. Because assessmentdrives learning, robust assessmentwhich is seen to be valid and feasible

Box 1: PMETB assessment principles

1. The assessment system must be fit for a range of purposes2. The content of the assessment (sample of knowledge, skills, and attitudes) will be

based on curricula for postgraduate training which themselves are referencedto all of the areas of Good Medical Practice

3. The methods used within the programme will be selected in the light of thepurpose and content of that component of the assessment framework

4. The methods used to set standards for classification of the trainee’sperformance/competence must be transparent and in the public domain

5. Assessments must provide relevant feedback6. Assessors/examiners will be recruited against criteria for performing the tasks

they undertake7. There will be lay input in the development of assessment8. Documentation will be standardised and accessible nationally9. There will be resources sufficient to support assessment





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is likely to have a greater educationalimpact and be more acceptable than onewhich is not. Tools which have lowfeasibility on a wide scale may be veryuseful in the context of remediation fordoctors about whom there is concern.

PURPOSE OF ASSESSMENTFundamental to the development of anyassessment process is clarifying thepurpose of the assessment process. Fortrainees this means determining readi-ness to progress to the next stage oftheir training. The terms summativeand formative are widely used to des-cribe the difference between assess-ments which concentrate on makingpass-fail judgements (summative) andthose which concentrate on providingfeedback on an individual’s strengthsand weaknesses (formative). Summa-tive assessment may produce feedbackwhich clarifies areas of concern orexcellence for doctors, but it is notintrinsic to the process (as it is for aformative assessment process). Assess-ment is the most powerful stimulus tolearning—we should use this strategi-cally. By assessing the areas of practicethat we consider to be the most impor-tant we will inevitably stimulate learn-ing in these areas.

WHAT SHOULD BE ASSESSED?Guidance on SpR annual assessmentto inform the Record of In-TrainingAssessment (RITA) focuses on theassessment of practice, rather thanknowledge.1 For doctors in practicethere is a trend away from compe-tence assessment towards performanceassessment. Competence assessment isa measure of what a practitioner iscapable of doing (the best he/she cando under controlled circumstances),whereas performance assessment is ameasure of what he or she actually doesin daily practice.5 Competence assess-ment does not necessarily predict per-formance.6 Miller provides a usefulframework for conceptualising the dif-ference between performance (does)and competence (shows how)7 (fig 1).However, there continues to be confu-sion about the use of the terms compe-tence and performance; workplacebased assessment may be a better termas it avoids such confusion. Miller’spyramid also emphasises the fact thatperformance is built on a foundation ofknowledge—without adequate knowl-edge it will not be possible to performsatisfactorily across a range of situa-tions. Workplace based assessment pro-vides an authentic representation of theway in which a doctor functions withina complex environment where there aremany potential influences on theirbehaviour. Establishing assessment pro-

cedures requires careful thought and adetailed and structured plan is neces-sary if this is to be done properly.8 Thereis currently a paucity of adequatelyevaluated performance assessmenttools, and this is acknowledged world-wide.5 Tool development must bemapped to domains of competence,and guidance on these is available.5

Within the UK, Good Medical Practice(GMP) provides the framework fordefining what a doctor is expected tobe able to do.9 Mapping of SpR assess-ment to GMP will ensure that therequirements for revalidation are ful-filled by the process. Details of SpRs’practice profiles in terms of both thedistribution of tasks (emergency versusoutpatient work, for example) andrelative frequency of different clinicalproblems are not, however, currentlyavailable.

HOW SHOULD WE BE DOING SpRASSESSMENT?The principles of how the developmentof a rigorous performance assessment

programme for SpRs could be app-roached as well as illustrative discussionof some specific tools will be covered bydiscussion of how this problem has beenapproached within one, specific, post-graduate setting: annual assessmentfor paediatric SpRs in the UK.Areas on which to focus initial efforts

in relation to tool development havebeen informed by a range of sources(box 2). It is intended that all paediatricSpRs will be assessed using high feasi-bility ‘‘screening’’ tools such as peerratings.10 11 Where a potential problem isidentified, more detailed assessment inthe area of concern can be undertaken(fig 2). This is important both to ensurethat a real problem exists in this areaand to provide a detailed profile of thenature of the problem to inform plan-ning of remediation.Possible sources of evidence for per-

formance assessment can be dividedinto two broad groups: generic andspecific skills. Examples of possible toolsin both groups are discussed.

POTENTIAL TOOLS FORPERFORMANCE (WORKPLACEBASED) ASSESSMENTTools suitable for widespreadscreening (level 1, fig 2)Peer ratingsPeer ratings refer to judgements madeby other health professionals about adoctor’s performance. They are broadlyequivalent to 360 feedback which hasbeen used in industry for many years.They usually consist of a questionnairewith some sort of scale against which

Does

Shows how

Knows how

Knows

Behaviour

Cognition

Figure 1 Miller’s pyramid.7

HIGH STAKESDETAILED TESTINGTO DETERMINEREMEDIATION

REMEDIATIONCarefully planned withclear aims andobjectives andreassessment at aspecified time

MORE DETAILEDTESTING

Most entering thisstage will be OK.Some will needtargetted training

SCREENING FORALL SpRs

Most will pass–somewill require moredetailed testing todetermine if they areOK. FEASIBILITYessential

Possible tools include:Video consultationassessmentMini-CEXDetailed testing oftechnical skillsChart stimulated recallPortfolios

Possible tools include:Peer ratingsPatient assessmentSAIL

Figure 2 High feasibility screening tools are followed by more detailed testing in areas of concernto clarify problems and plan remediation where necessary.





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the doctor is judged in a number ofareas. Peer rating is an attractive meansof assessing a broad range of compe-tencies for doctors in practice. It hashuge potential as a high feasibility toolthat is reliable and is able to assess areasthat are otherwise difficult to assess,such as teamworking. Ramsey studiedthe clinical performance of physiciansusing written questionnaires mailed toprofessional associates of the physicians(both doctors and nurses).10 11 Ramsey’squestionnaire consists of 11 categories,and the rater is asked to score thephysician in each category from 1 to 9(or score UA if they feel unable tocomment in a particular category).Eleven raters are needed to achieve areliability coefficient of 0.7.Other workers have evaluated the use

of peer ratings in different settings,mainly within the USA or Canadianhealthcare system.12–14 In one of thesestudies 71% of surgeons followed upthree months after administration of theinstrument contemplated or initiatedchange on the basis of the multi-sourcefeedback (based on self reporting).14

The GMC and PMETB advocate theuse of peer ratings for work basedassessment, and the RCPCH intends toutilise peer ratings as part of thestandardised SpR assessment process.A peer assessment tool developed andevaluated with paediatric SpRs has beenshown to have good reliability andvalidity in a pilot study. The tool consistsof a 25 point questionnaire (SheffieldPeer Assessment Tool, SPRAT) mapped

to GMP. For SpRs 11 raters across arange of health professionals are neededto achieve a reliability of 0.7 (generali-sability analysis). SPRAT performs par-ticularly well in the areas of teamworking and communication, areaswhich are traditionally difficult toassess. It is feasible and generates feed-back which can be used to inform per-sonal development planning (fig 3).

Performance assessment based onwritten recordsCorrespondence betweenprofessionalsCorrespondence between health profes-sionals is an important record of ahealthcare event. From April 2004 it willbe mandatory to copy correspondencebetween professionals to patients/carers,and many doctors are already doing this.A validated tool for the assessment ofoutpatient correspondence has beendeveloped (Sheffield Assessment Instru-ment for Letters, SAIL). It has beenshown to have good reliability andfeasibility,15 although further work isneeded to determine how best to utiliseSAIL in the context of widespread SpRassessment. Potentially other SpRs couldbe used as raters, which has highfeasibility and good educational impact.A small pilot study has shown a signifi-cant improvement in letter writing fol-lowing training with SAIL.16

Patient and parent feedbackPatients and/or their carers are ideallyplaced to provide feedback on how well

a doctor communicates with them. Avast number of patient satisfaction toolsare available. However, there has beenalmost no work undertaken whichrobustly evaluates how to use thepatient’s perspective as a defensiblecomponent of a rigorous assessmentprocess, a problem highlighted bySitzia in his review of patient satisfac-tion data.17 The American Board ofInternal Medicine (ABIM) has donework to evaluate a patient assessmenttool.18 A recent study of 351 paediatricconsultations using the SheffieldPatient Assessment Tool (SHEFFPAT)has shown that 25 consultations aresufficient for parents’ feedback to meetthe criteria required for inclusion in aperformance assessment programme(reliability of .0.8 evaluated usinggeneralisability).19 Utilising patients/carers not only meets criteria for perfor-mance assessment, but also fits wellwith the GMC and PMETB require-ments and the concept of the expertpatient.

Tools better suited for moredetailed testing (level 2, fig 2)Performance assessment based onwritten recordsWritten recordsMedical records have huge potential forassessment, but ward based records maynot represent the performance of thedoctor making decisions (for example,an SpR or consultant ward roundrecorded by an SHO).20 Furthermore,assessment of the medical record alonedoes not allow an assessment of deci-sion making/patient management skillsas record keeping is simply too incon-sistent. It may be important to assess anindividual’s ability to keep adequatewritten records, but this does notnecessarily reflect their decision makingskills. A potential way of using medicalrecords to test more complex skills suchas decision making, however, is throughchart stimulated recall.

Chart stimulated recallChart stimulated recall (CSR) consistsof assessment of performance throughstructured interviews, for which a selec-tion of medical records from a physi-cian’s caseload acts as the focus.Assessment may be based on the qualityof data acquisition, patient evaluation,the clinician’s choices about patientmanagement, and knowledge base. TheGMC and College of Physicians andSurgeons of Ontario (CPSO) Canadaincorporate CSR within their proceduresfor evaluating poorly performing doc-tors. Charts are reviewed by two asses-sors, and used as the focus fordiscussions with the physicians.Because case specificity (performance

Box 2: Areas on which to focus initial efforts in relation to tooldevelopment for paediatric SpRs

These have been informed by a range of sources:

N Detailed review of performance assessment literature

N Areas recognised as being central to the practice of most physicians, inparticular the consultation

N Good Medical Practice (GMP)9

N Agreed international domains for performance assessment (which map toGMP)5

N Areas recognised as being common areas of complaint/poor perfor-mance (communication and teamwork in particular)

N Consensus exercise with paediatric tutors identifying key features of aneffective (paediatric) consultation

N Areas identified in GMC pilot for revalidation as being areas wheredoctors found it difficult to provide evidence of adequate performance(implying a deficiency of tools)—in particular, patient feedback andteamwork

N Areas where previous work suggests that performance assessment maybe undertaken in a feasible, reliable way across a range of domains—inparticular, peer ratings10 11

N Areas complementary to work being undertaken by the RCP, to avoidunnecessary duplication of effort





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of an individual which is dependent onthe nature of the medical case aroundwhich the interview is based) is aproblem with this type of assessmenttool, CSR interviews would need to beconducted on several occasions duringtraining, in order to ensure that themethod has adequate sampling validity.Norman and Salvatoori have shown

satisfactory reliability using CSR, andfound it to be feasible.21 22 Data on theuse of CSR in the UK setting forperformance assessment are not avail-able, but CSR has the potential to allowassessment areas which are otherwisevery difficult to assess.

Clinical and technical skil lsAlthough the assessment of communi-cation, teamworking, and other genericskills is clearly essential, it is alsoimportant that core clinical skills areassessed. Possible tools available includemini-CEX.23 Mini-CEX is utilised by theABIM to assess residents in training. Itsaim is to assess residents’ clinical skills,attitudes, and behaviours using a struc-tured rating form completed by a seniormember of faculty while observing aclinical encounter. It takes on average20 minutes per encounter. Scores on themini-CEX are influenced by the diffi-

culty of the clinical case encountered aswell as the nature of the problem. Widesampling is essential and it is a methodthat is relatively time consuming forsenior doctors, potentially limiting itsfeasibility. Work is being undertakenby the Royal College of Physicians toevaluate its measurement characteristicsin a UK training grade setting.24

Assessment of core technical skills isclearly also important. A range ofpotential methodologies for doing thishave been developed within the surgicalspecialties, and these could be modifiedfor a paediatric setting.25 The use ofvideo also has potential for the assess-ment of technical skills.26

Video has also been used for theassessment of consultation skills, mostwidely within a primary care settingwithin the UK, and also in theNetherlands and Australia.27–29 This hastremendous potential for providingstructured feedback that can informpersonal development planning for doc-tors. Pilot work is underway evaluatinga paediatric consultation assessmenttool based around existing models ofthe consultation. It may be appropriate,however, that the use of video forassessment purposes is reserved forthose doctors who appear to have

difficulty in the area of communicationidentified by higher feasibility screeningtools such as patient assessment andpeer rating. All trainees could, however,valuably be exposed to review of videosof their consultations as part of theirtraining.

Other skil lsMany other attributes and skills makeup a doctor’s practice and have not beendiscussed here. These include, for exam-ple, teaching and training, researchskills, and critical appraisal. Portfoliosoffer potential as a means of assessing adoctor’s overall professional profile,including these aspects of practice, aswell as, importantly, an individual’sability to learn from experience. How-ever, while their usefulness as a means ofsupporting professional development iswidely acknowledged, their role in per-formance assessment is controversial.30

Putting it all togetherNone of these individual assessments ontheir own will be sufficient. In order toobtain a representative picture of adoctor’s overall practice, a number ofassessments sampling widely across thedoctor’s practice will be essential. Theseshould be planned well in advance, and

6

5

4

3

2

Doctor's mean

Question 10 asks the assessor to rate the doctor in relation to their ability to deal with stress, an area in which this doctor is performing less well than his/her peers and which could be a focus for development planning.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Group mean

Self

Figure 3 Example of feedback given to an individual doctor on the basis of peer ratings.





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the nature and timing of the assess-ment processes made explicit to thetrainees being assessed as well as tothe assessors.Training for assessors is essential and

is likely to improve the reliability of theprocess. The nature and purpose of theassessments and the criteria againstwhich judgements are being madeshould be made explicit to all partici-pants. Quality assurance processes mustbe built into the process and shouldevaluate reliability and validity as wellas ensuring that the overall assessmentprogramme is in line with the PMETBassessment standards framework.2

Detailed assessment should be under-taken of possible problem areas identi-fied by screening tools such as peerratings.

Remediation: principles andplanning the processRemediation should be offered to alldoctors about whom significant concernin any area of their practice has beenraised, and adequate (or otherwise)remediation confirmed by appropriateassessment processes. Ideally each SpRand SHO programme should have anindividual who is responsible for reme-diation. A written, individualised, fra-mework should be produced in line witha nationally agreed outline frameworkfor remediation. Additionally, it is ofparticular importance that an attempt ismade to measure an individual’s degreeof insight into areas of concern as thismay significantly affect the success of aremediation programme. Tools to assessinsight are not yet well developed, but itis recognised as being a priority area forperformance assessment development.31

CONCLUSIONSAppropriate rigorous assessment of doc-tors is a challenge. Development andimplementation of performance assess-ment requires careful thought andplanning and a considerable investmentof resources, both time and money.However, such investment is essential.Assessment is not only mandatory, it isthe most powerful stimulus to learning.We should ensure that it is undertakenrigorously, but also that we assess notsimply what is easiest, but what is most

important, so that assessment has a realinfluence on doctors’ practice and hencethe quality of care they provide forpatients.

ACKNOWLEDGEMENTSSpecial thanks are extended to Dr VinDiwakar for his thoughtful comments andinput. Thanks also are due to Dr JulianArcher, Dr Jim Crossley, and Miss JudithEllis.


Authors’ affiliations. . . . . . . . . . . . . . . . . . . . . .

H Davies, Sheffield Children’s NHS Trust,RCPCH lead for Performance Assessment,Sheffield, UKR Howells, RCPCH Education Fellow andHonorary Clinical Lecturer, University ofCambridge, Department of Paediatrics,Cambridge, UK

Correspondence to: Dr H Davies, Consultant inLate Effects/Medical Education, SheffieldChildren’s NHS Trust, Western Bank, SheffieldS10 2TH, UK; [email protected]

Accepted 23 December 2003

REFERENCES1 NHSE. A guide to specialist registrar training,

NHSE, 1998.2 Southgate L, Grant J. Principles and standards for

an assessment system for postgraduate medicaltraining, PMETB Subgroup on Assessment,2003.

3 Crossley J, Davies H, Humphris G, et al.Generalisability: a key to unlock professionalassessment. Med Educ 2002;36:972–8.

4 Jolly B. The good assessment guide: a practicalguide to assessment and appraisal. London: JointCentre for Education in Medicine, 1997.

5 Hays RB, Davies HA, Beard JD, et al. Selectingperformance assessment methods for experiencedphysicians. Med Educ 2002;36:910–17.

6 Rethans J, Sturmans F, Drop R, et al. Doescompetence of general practitioners predict theirperformance? Comparison between examinationsetting and actual practice. BMJ1991;303:1377–80.

7 Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65(9suppl):S63–7.

8 Schuwirth LW, Southgate L, Page GG, et al.When enough is enough: a conceptual basis forfair and defensible practice performanceassessment. Med Educ 2002;36:925–30.

9 GMC. Good Medical Practice, GMC, 2001.10 Ramsey PG, Wenrich MD. Peer ratings. An

assessment tool whose time has come. J GenIntern Med 1999;14:581–2.

11 Ramsey PG, Wenrich MD, Carline JD,et al. Use of peer ratings to evaluate

physician performance. JAMA1993;269:1655–60.

12 Rodgers KG, Manifold C. 360-degreefeedback: possibilities for assessment of theACGME core competencies for emergencymedicine residents. Acad Emerg Med2002;9:1300–4.

13 Violato C, Hall WG. Alberta PhysicianAchievement Review. CMAJ 2000;162:1803.

14 Violato C, Lockyer J, Fidler H. Multisourcefeedback: a method of assessing surgicalpractice. BMJ 2003;326:546–8.

15 Crossley GM, Howe A, Newble D, et al. SheffieldAssessment Instrument for Letters (SAIL):performance assessment using outpatient letters.Med Educ 2001;35:1115–24.

16 Fox A, Palmer R, Crossley J, et al. Improving thequality of outpatient clinic letters using theSheffield Assessment Instrument for Letters (SAIL).Med Educ 2004;38:852–8.

17 Sitzia J. How valid and reliable are patientsatisfaction data? An analysis of 195 studies.Int J Qual Health Care 1999;11:319–28.

18 Webster GD. Final report on the PatientSatisfaction Questionnaire Project, AmericanBoard of Internal Medicine, 1989.

19 Crossley J. Assessing the clinical performance ofdoctors. Thesis for Doctorate of Medicine, OxfordUniversity, 2003.

20 Fernando KJ, Siriwardena AK. Standards ofdocumentation of the surgeon-patient consultationin current surgical practice. Br J Surg2001;88:309–12.

21 Norman GR, Davis DA, Lamb S, et al.Competency assessment of primary carephysicians as part of a peer review program.JAMA 1993;270:1046–51.

22 Salvatori P, Baptiste S, Ward M. Development ofa tool to measure clinical competence inoccupational therapy: a pilot study? Can J OccupTher 2000;67:51–60.

23 Norcini JJ, Blank LL, Duffy FD, et al. The mini-CEX: a method for assessing clinical skills. AnnIntern Med 2003;138:476–81.

24 Wragg A, Wade W, Fuller G, et al. Assessing theperformance of specialist registrars. Clin Med2003;3:131–4.

25 Martin JA, Regehr G, Reznick R, et al.Objective structured assessment of technicalskill (OSATS) for surgical residents. Br J Surg1997;84:273–8.

26 Cronin C, Cheang S, Hlynka D, et al.Videoconferencing can be used to assessneonatal resuscitation skills. Med Educ2001;35:1013–23.

27 Campbell LM, Howie JG, Murray TS. Use ofvideotaped consultations in summativeassessment of trainees in general practice.Br J Gen Pract 1995;45:137–41.

28 Ram P, Grol R, Rethans JJ, et al. Assessment ofgeneral practitioners by video observation ofcommunicative and medical performance in dailypractice: issues of validity, reliability andfeasibility. Med Educ 1999;33:447–54.

29 Hays R, Spike N, Sen Gupta T, et al. Aperformance assessment module for experiencedgeneral practitioners. Med Educ2002;36:258–60.

30 Wilkinson TJ, Challis M, Hobma SO, et al. Theuse of portfolios for assessment of the competenceand performance of doctors in practice. MedEduc 2002;36:918–24.

31 Hays RB, Jolly BC, Caldon LJ, et al. Is insightimportant? measuring capacity to changeperformance. Med Educ 2002;36:965–71.





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Obstetrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hindu birth customsA R Gatrad, M Ray, A Sheikh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Marriage, pregnancy, and birth rituals

Many expectant mothers havefears and anxieties about theirpregnancy. For Hindu pregnant

women, these general concerns may becompounded by difficulties in commu-nicating with healthcare professionals.It is our aim in this paper to provideclinicians with a basic understanding ofHindu birth customs in the hope thatsuch appreciation will go some way tofacilitating provision of culturally com-petent and sensitive care.In their excellent paper Webb and

Sergison1 defined cultural competenceas an evolving process that depends onself-reflection, self-awareness, andacceptance of differences. They furtherexplain that such competence is basedon improving understanding as opposedto an increase in cultural knowledge.While fully concurring with their viewswe would argue that knowledge ofcultural context can be helpful inproviding a prototype (as opposed to astereotype) of factors which may beimportant in the provision of patientcentred care.Hinduism—one of the oldest world

religions dating back to around1500BC—originates from around theIndus Valley2 in what is now Pakistan.Scriptures were originally written inSanskrit, a language in which mostHindus of today are no longer literate,and therefore customs over the yearshave tended to be passed on by word ofmouth. Almost 14 centuries ago, manyHindus converted to Islam and 600years ago Sikhism was founded as an‘‘off shoot’’ of Hinduism. It is thereforeunsurprising that not only have originalHindu customs been diluted over theyears but that the practises of otherreligious customs found within SouthAsia have intertwined with remnants ofHindu teachings. However we have notencountered any consanguineous mar-riages among Hindus in the UK, apractice common among Muslims theworld over.3

Hindus believe in a ‘‘transcendent’’God who may be worshipped in avariety of ways through different sym-bolic manifestations (for example, sta-tues). The three supreme Hindu deitiesforming the Hindu Trinity4 are: Brahma(The Creator), Vishnu (The Preserver),

and Shiva (The Destroyer). In Britain,the majority of Hindus are Vishnuvites.5

Many Hindus believe that a person isborn into a caste or acquires it bybehaviour;6 for example, a person of alower caste by being ‘‘pious’’ can gohigher up the caste ladder. Although nolonger officially recognised and lessvisible in modern India than in the past,the caste system still has a strong holdon Hindu families, and the impact ofthis on customs (including birth) alsoextends to those who have migrated.There are broadly four main castes:Brahmins (highest), Ksatriya (rulingcaste), Vaisya (farmers and merchants),and sudras (the untouchables); thislatter group usually work as servantsin India.7

Closely linked with the caste system isthe belief in reincarnation—a belief thatone’s deeds in a former life determinethe caste that one is born into. Thisphilosophy of Karma8 is of fundamentalimportance to Hindus, as, it is ‘‘deeds’’in this world that will decide how thesoul is reborn in the future. It is believedthat this cycle of birth, death and rebirthultimately results in attaining a state ofpurity that allows the liberated soul tobecome ‘‘at one’’ with the Divine pre-sence.

DEMOGRAPHICCONSIDERATIONSThe 2001 (UK) census revealed thatthere are over 559 000 Hindus inBritain,9 the majority (467 000) ofwhom originate from the Indian sub-continent, with a sizable communitycoming from East Africa. This EastAfrican Hindu group is somewhat aty-pical in that it has undergone migrationtwice in a relatively short timeframe—first from India to East Africa and thenon to Britain. In Britain, areas such asHarrow, Leicester, and Brent have sig-nificant Hindu communities making up14–19% of the overall population (Officefor National Statistics, 2003). Althoughgenerally religious, allegiance to reli-gious customs will vary according to theextent of ‘‘acculturation’’ (wherebymigrants take on some of the character-istics of the host community), and alsoon whether the family roots were inurban or rural India.

BIRTH RITUALS AND THEIRPRESENT DAY OBSERVANCEThe origins and performance of Hindurites are not only somewhat complexbut often also differ between castes.Here, we attempt to present somecommon features of these rites in orderto help non-Hindu healthcare profes-sionals to develop a working apprecia-tion of these practices and theirsignificance.Manu, the legendary author of the

Sanskrit Code of Law10 created a num-ber of sacraments or Samskaras—a wordwhich means ‘‘perfection’’. These are‘‘activities that help achieve ‘purity’ as aresult of which the personality of theindividual is developed to the full, fromconception to the grave’’.11 Each sacra-ment involves a prayer and often aritual. Although only some of thesesacraments relate to the present discus-sion of birth customs, for completenessand contextualising the principle, thefirst 10 of these that are relevant to thepaediatric age group are described(table 1).

MARRIAGE AND PREGNANCYThe Hindu Marriage Act (1955) prohib-ited child marriages in India, stipulatingthat boys could only marry after the ageof 18 years and girls after 15. Previously,early ‘‘child marriages’’ were thought bymany to be a check on immorality andcorruption. The introduction of this Actis believed to have contributed to a fallin maternal and infant mortality, whilesimultaneously improving the chancesof the young to further their educationbefore marriage.12

Garbadhana—the fetus laying cere-mony is performed at the consumma-tion of marriage and involves specialprayers for fulfilling parental duties toperpetuate the human race. In ancienttimes, the bridegroom did not approachthe bride until the fourth night, buttoday this practice is only symbolicallyenacted at the marriage ceremony.Punsavana—the ‘‘male making’’ rite is

performed during the third month ofpregnancy, in the belief that the ‘‘deity’’governing the sex of the fetus isactivated and a male ‘‘issue’’ assured.Sons are preferred because of thecarriage of the family name and thehope that the son will light the funeralpyre of his parents. Manu says: ‘‘A manis perfect when he consists of three:himself, his wife, and his son’’.13 In fact,there is still a belief among many that inthe next world/birth, the happiness of afather depends on having a continuousline of sons.14 Furthermore, birth of agirl, particularly in India, may generateparental anxieties because of the heavyfinancial burden resulting from thegiving of dowries.





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Simmanantannaya—also known asValaiakappu in some parts of Indiainvolves the wearing of red or greenglass bangles from the seventh month ofgestation. The sound of these bangles isbelieved to reach the womb and comfortthe fetus. Traditionally, these areremoved after birth and given to themidwife. Historically it is of interest tonote that in this sacrament the motheris allowed to fulfil her last wishes, suchas any craving for certain foods, as she isnow thought to be entering a hazardousperiod.15 A pregnant mother is thereforenow expected to rest as much aspossible. To this end, some womenreturn to their parental home, even inthe UK, only to return to the maritalhome 40 days after delivery. It may bethat some patients miss their antenataland postnatal appointments, partly as aresult of this custom and the fact thatclinics are often less accessible, withpoor language support.A study by Gatrad et al showed that

there were significant differences inbirth weight between five subgroups ofSouth Asians.16 These groups wereMuslim Pakistanis, Muslim Bang-ladeshis, Muslim Gujaratis, Sikhs, andHindus. Although South Asian babieswere generally lighter than the Euro-pean, Hindus had the lightest babiesat birth. It should be remembered thatmany Hindu women are often strictvegetarians and therefore do not eateggs, fish, or meat which may, inaddition to genetic and other environ-mental factors, partly explain the loweraverage birth weight of babies comparedto other South Asian subgroups.

BIRTHOur experiences suggest that, in com-mon with other South Asian women,many Hindus prefer to be seen byfemale doctors during pregnancy andlabour, on the grounds of modesty.A premature birth in the eighth

month of pregnancy is sometimessuperstitiously attributed to a cathaving entered the mother’s room in a

‘‘former’’ confinement. It is believed bysome that a child born in this monthcould die on the eighth day, in theeighth month, the eighth year, or theeighteenth year! Some Hindus thereforeconsider the number ‘‘eight’’ unlucky.In India, when a male is born a Thali

(a flat bronze utensil akin to a largetray) is beaten with a stick by friendsand relatives. In the case of a girl, a fan,used for winnowing, is beaten.Jatakarma—this ceremony welcomes

the child into the family. The fathertouches and smells the child and whis-pers religious verses (Mantras) into theears of the infant. All this is to promisethe baby a safe and comfortable envir-onment. To ward off evil, a small ‘‘dot’’often in the shape of ‘‘Om’’ (see fig 1) isdrawn behind the baby’s ear using Kajal,a carbon based eye ‘‘make up’’.This symbol may also be seen on a

chain around a baby’s neck or indeed beplaced in a cot. A family member with‘‘virtuous qualities’’ writes, with jaggerydipped in Ghee (a purified form ofbutter), the word ‘‘Om’’ onto the tongueof the neonate in the hope that theperson’s good qualities are passed on tothe infant.Symbolically, female members of the

family wash a nursing mother’s breasts

before breast feeding is commenced. Weare aware of this practice in some Hindufamilies in Britain. The custom of notbreast feeding the baby for the first twodays is still rife in India, but in ourexperience this is not the case in Britain.Certain foods are believed by many

South Asians, including Hindus, to haveeither a ‘‘cooling’’ or a ‘‘heating’’ effecton the functions of various organs of thebody, such as mood, personality, andphysical wellbeing.17 Health profes-sionals would therefore do well to beaware of the concept of ‘‘hot’’ and‘‘cold’’ foods, both during pregnancyand the puerperium. For example, whenthe mother is breast feeding, if a babyhas a cold or a fever, in the former caseshe may avoid ‘‘cold’’ foods and theconverse when the baby has a raisedtemperature. This concept is quitedivorced from the actual temperatureof food or the intensity of taste of spices.High protein, acid, and salty foods areconsidered ‘‘hot’’, whereas ‘‘cold foods’’are often sweet. Lentils, millet, auber-gines, and grapes are examples of ‘‘hot’’foods, and cereals, potatoes, milk, andwhite sugar are examples of ‘‘cold’’foods.Karnavedha—this refers to the ear

piercing ceremony. Although usuallycarried out after the age of 3 years inmost castes, there are some familieswhere a father will not see the baby’sface after birth until certain rituals havebeen performed, including ear piercing.Even the piercing of ears may be in theshape of Om. In India, a goldsmithperforms this ritual for both sexes.Although girls often retain these holes,boys usually lose them in early child-hood.The sixth day after birth is considered

the most auspicious in a person’s life.On this day, a fragile white cottonthread is ceremoniously tied aroundthe wrist, ankle or neck—this willusually spontaneously fall off a fewdays later. It is on the same sixth daythat a pen and a blank piece of paper areplaced in the baby’s cot, as it is believedthat on this day the goddess of learningcharts the baby’s future. The mothermay observe a fast on this day.Namakarana—the name is selected in

such a way as to inspire the child tofollow a righteous path. According toHindu scriptures, a boy’s name shouldhave an ‘‘even’’ number of syllables anda girl’s name an ‘‘odd’’ number. Thiscustom is rarely followed in Britain,although in Indian villages it is stillpractised. There are several ways ofnaming a baby.18 One of the commonest,even in the west, is according to theNakshatra or the sign of the Zodiac at thetime of birth of the baby. It is believedthat certain planets govern certain days,

Table 1 Hindu sacraments (Samskaras) relevant to children

Name Procedure Time when carried out

Grabadhana Sacrament of impregnation Before pregnancyPunsavana Second/third month of pregnancy Second/third month of pregnancySimantonnayana Fifth to eighth month of pregnancy Fifth to eighth month of pregnancyJatakarma At birth At birthNamakarana Naming the baby 10–12 days after birthNisramana First outing of the child Third/fourth monthAnnaprassana Weaning of the child Sixth monthChuda Karma Cutting of hair Occasionally at birth

Usually between first and third yearKarnavedha Piercing of ears Third to fifth yearUpanayana Investiture of sacred thread From eighth year, denoting the beginning

of manhood

Figure 1 Om symbol. The most importantHindu symbol isOm; this has been described as‘‘an Aksara or the ‘Imperishable Symbol’; it isthe Universe, the past, the present and thefuture—all that is and all that will be is Om;likewise all else that exists beyond the bounds oftime—that too is Om’’.25





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for example Mars governs Tuesday. Ifthe Nakshatra for the time of birth isunfavourable, this may be a bad omenfor the family necessitating certainrituals, which may include a specialprayer and the father not seeing thebaby for a few days.19 It is of interest tonote that the documents, containing thehoroscope of the baby, are admissible aslegal papers of ‘‘proof of age’’ in India.20

Furthermore, the horoscope will beespecially important for arranging asuitable marriage later.21

From the Nakshatra the first letter ofthe name is ascertained. For example, ifit is a ‘‘G’’ then the name could beGyatri for a girl. The paternal aunt oftenplays an important part in the choice.Children may have a middle name suchas ‘‘Devi’’ for a girl or ‘‘Lal’’ for a boy; forexample, Gyatri Devi and Babu Lal.There are certain prohibited times fornaming the baby; for example, at thetime of an eclipse or when the signs ofthe Zodiac are changing. Hindu nameshave meanings; for example, Ravi for aboy means sun and Madhu for a girlmeans honey. Some boys are namedafter gods; for example, the namesKrishna or Ram. Some girls may benamed Chandra in the belief that themoon (Chand) will bring them luck andgood fortune. Table 2 lists some com-mon male and female Hindu names.The naming ceremony takes place on

the tenth or twelfth day after birth, atime when the mother is considered‘‘clean’’ in order to carry out normalhousehold chores, such as cooking. Thiscustom is still practised by some Hindufamilies in the West. The nursingmother is now allowed male visitors.Annaprassana—this ceremony takes

place after six months when weaningis believed to be necessary for the babyto become more mobile. A delay inweaning that one occasionally encoun-ters in Britain may be as a result of thisbelief. Although we have no evidencethat Hindu babies in general are weanedat around four months in Britain, it isour experience that this is so.

Chuda Karma—the hair cutting cere-mony (removal of scalp hair) is per-formed at any stage depending onfamily tradition, although according tothe Samskara (table 1) it is performedbetween the first and the third year.

DEATH OF A NEONATE ORINFANTAt death, the baby is believed to leavethe ‘‘earthly’’ realm into an ‘‘intermedi-ate’’ zone in readiness for its journey tothe ‘‘Divine realm’’. Although Hindusoften prefer to die lying on the ground(Mother Earth), this custom is rarelypractised for babies dying in Britain.Quality of palliative care, if indeed suchcare was necessary, has an impact ondeath and bereavement.22 Hindus whohave perceived what they witness as abad death, may be very anxious aboutthe ghost of the deceased.23

As a baby approaches death, thefamily will chant ‘‘Ram Ram’’ or ‘‘Om’’and recite from the Bhagavad Gita—theholy book for Hindus. A thread with areligious significance may be tiedaround the wrist or neck of the baby.Stillborns need the same religious‘‘service’’ as adults. A leaf from a Tulsishrub (basil leaf) is placed in thebaby’s mouth, occasionally with a goldcoin. After a ritual wash, new clothesare put on the baby who is subse-quently wrapped in a white shroud.The body of a baby may be taken fromthe hospital straight to the cemetery.However if the corpse is taken home,candles are lit and holy water fromthe River Ganges sprinkled onto thebody.Babies and young pre-pubertal chil-

dren dying before the Upanayama stageare buried, whereas adults are cremated.Upanayama is the tenth sacrament and isa stage in a child’s life when he/shebegins adulthood after the age of 8years. It is a stage ritualised by wearinga religious thread called Janeo. Childrenwho die before this stage do not needpurification by fire as they are classed asbeing ‘‘without sin’’. As a general rule,

particularly in rural India, a cup ofwater is placed at the head of the graveof a baby. Women are never present atburials, even in Britain.

POSTMORTEM EXAMINATIONSAND ORGAN TRANSPLANTATIONWith any family, from whatever ethnicgroup or creed, whose beliefs and needsat a time of crisis cannot be assumed orinferred, this subject should bebroached with sensitivity; this is parti-cularly so in Hindus whose belief inKarma may result in possible anxietiesabout whether or not all organs will bereturned to the body after a postmortemexamination. Generally there is nospecific prohibition to postmortemexaminations or organ transplants inHindu teachings.24

DISCUSSIONAlthough we appreciate that one cannotbe expected to have detailed knowledgeof every aspect of the multiculturaltapestry of present British society, thereis a significant Hindu community inBritain today and therefore some under-standing of cultural norms and values isimportant. Such knowledge, we believe,is important for health professional torespond to individuals by reflecting ontheir own culture, and recognising andrespecting the difference. Learning topronounce names and a few words,especially a greeting with a smile, iswhat the patient appreciates. We shouldin addition develop a broad understand-ing of the contexts and needs of Hinducommunities such as language difficul-ties, modesty, and gender issues. Theuse of trained interpreters/advocateswould further provide the necessarysupport for a truly culturally competentcare. Achieving effective communica-tion and striving towards improvedaccess for such communities will go along way to breaking down barriers byresponding flexibly to all patients,whatever their need. Health profes-sionals should be confident enough toask their patients: ‘‘Are we doing thisthe right way for you?’’ or ‘‘How wouldyou like us to do this?’’. Professionalsshould be prepared to learn fromfamilies they are supporting as well asprovide advice and information. This is atrue partnership and one path to cultu-rally competent practice.25

CONCLUSIONSThe process of acculturation continues;for example, some Hindu children havewestern names. It does not alwaysfollow that because a patient is classedas belonging to a certain religion that heor she follows that faith. Some peoplemay wish to maintain practices that areimportant to them while others may

Table 2 Examples of common Hindu names

Male Female

Name Meaning Name Meaning

Abhijit A constellation of stars Anjali OfferingAkaash Sky Anuradha Bright starAnand Bliss Priya Loved oneRajiv Lotus flower Priti SatisfactionRohit Red colour Puja PrayerRavi Sun Madhu HoneySameer Breeze Madhur SweetDeepak Lamp Meena Precious stoneMohan Charming Lakshmi Consort of VishnuHarsh Joy Jaya Victory





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only nominally express allegiance andare not concerned with orthodox prac-tice—this being especially true for thoseliving in the West. Furthermore, reli-gions are divided into different sects,resulting in individual adherents havingtheir own particular view and interpre-tation of their faith and culture. Indeed,different generations within the samefamily may have differing views.Nonetheless, there are particular cus-toms and rites, which tend to bindmembers of a religious community,and our experiences suggest that birthcustoms continue to be important tomany Hindu communities, includingthose in Britain.


Authors’ affiliations. . . . . . . . . . . . . . . . . . . . . .

A R Gatrad, Manor Hospital, Walsall, UK;Hon Professor Paediatrics University ofKentucky, USAM Ray, Manor Hospital, Walsall, UKA Sheikh, Division of Community HealthSciences: GP Section, University of Edinburgh,Edinburgh, UK

Correspondence to: Dr A R Gatrad, ManorHospital, Moat Road, Walsall WS2 9PS, UK;[email protected]

REFERENCES1 Webb E, Sergison M. Evaluation of cultural

competences and anti-racism training in childhealth. Arch Dis Child 2003;88:291–4.

2 Flood G. An introduction to Hinduism.Cambridge: Cambridge University Press,1996:21.

3 Dhami S, Sheikh A. The family: predicament andpromise. In: Sheikh A, Gatrad AR, eds. Caring forMuslim patients. Radcliffe, 2000:49.

4 Sharma A. Classical Hindu thought. Oxford:Oxford University Press, 2000:72.

5 Neuberger J. Caring for dying people of differentfaiths, 2nd edn. London: Moseby, 1994:24–9.

6 Lipner J. Voice of tradition caste and narrative. In:Hindu: the religious belief and practice. London:Routledge, 1994:108.

7 Joicey J. A handbook of Hinduism. Newcastleupon Tyne Education Committee, 1980:41.

8 Lipner J. Morality and the person. In: Hindu: thereligious belief and practice. London: Routledge,1994:233.

9 Office of National Statistics. Census 2001.10 Pandey R. Hindu Samskaras. Delhi: MLBD,

1969:17–24.11 Singh C, Nath P. Hindu manners, customs and

ceremonies. Delhi: Crest Publishing House,1999:8.

12 Singh C, Nath P. Hindu manners, customs andceremonies. Delhi: Crest Publishing House,1999:31.


14 Flood G. An introduction to Hinduism.Cambridge: Cambridge University Press,1996:203.

15 Chaudhery NC. Religious control of Hindu life.London: Trinity Press, 1979:210–11.

16 Gatrad A, Birch N, Hughes M. Preschool weightsand heights of Europeans and five subgroups ofAsians in Britain. Arch Dis Child1994;71:207–10.

17 Henley A. Asian patients in hospital and at home.London: Pitman, 1979:129.

18 Stutley M, Stutley J. A dictionary of Hinduism. Itsmythology, folklore and development. London:Routledge, 1977:202.



21 Shattuck C. Hinduism. Religions of the world.London: Routledge, 1999:81.

22 Koffman J, Higginson IJ. Accounts of carer’ssatisfaction with health care at the end of life: acomparison of first generation black Caribbeanand white patients with advanced disease. PalliatMed 2001;15:337–45.

23 Firth S. Religious perspectives on end of life care:a Hindu patients spiritual and cultural valuesduring the end of life period. Lancet. In press.

24 Schott J, Henley A. Culture, religion andchildbearing in a multicultural society,Butterworth-Heinemann, 1996:311.

25 Rathakrishnan S. The Bhagavad Gita. Delhi:Harper Collins, 2000.

ARCHIVIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Teenage pregnancy

The rate of teenage pregnancy is higher in Britain than in other European countries.Professional attitudes towards teenage pregnancy tend to be polarised with someconsidering it undesirable because of increased risks to mother and child while others

have argued that teenagers may be well suited for pregnancy and that much harm comesfrom the stigmatisation of teenage parents. A study in Sweden (Petra Olausson andcolleagues. British Journal of Obstetrics and Gynaecology 2004;111:793–9, see also commentary,ibid: 763–4) has shown that teenage mothers there are more likely to die young.The study included 460 343 women born between 1950 and 1964 and alive in December

1990. All had had a first child before the age of 30. Between 1990 and 1995, 1269 of thesewomen died at ages 30–45 years. Mortality decreased with age at birth of first child from 107deaths per 100 000 person-years among women whose first child was born when they were17 years or younger to 87 per 100 000 person-years (first birth at 18–19 years), 54 (20–24years), and 42 (25–29 years). Overall, early adult mortality in teenage mothers was increasedby 60% after adjustment for socioeconomic background at the time of the first birth and agein 1990. The main causes of premature death were violence, cervical cancer, coronarydisease, lung cancer, suicide, and alcohol. Adjustment for socioeconomic factors operatingafter the birth of the first child reduced, but did not eliminate, the increase in risk.Teenage mothers in Sweden have an increased risk of premature death in later life. Much

of the increased risk is associated with adverse socioeconomic and lifestyle factors. Thewriter of the commentary argues in favour of helping teenagers to avoid pregnancy but alsoof providing adequate support for pregnant teenagers during and after their pregnancies.





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