To the Editor: The personal perspective on continuous improvement outlined by Kilham succinctly documents the concerns surrounding the application of management tools to the practice of medicine.1 As Kilham says, continuous improvement has been around for a long time and “flowed from a particular attitude . . . [that of] a mind open enough to recognise better ways of doing things, or ways of doing better things”.1

However, I would argue that even history-taking does need to continually improve to include various communication skills appropriate to individual patients. Continuous improvement in history-taking skills, to enable each patient to express their major concerns and to feel more in control of the consultation, has significantly reduced my feelings of frustration provoked by previous patients. Adherence to the strict script of history-taking taught to me in my undergraduate training seemed to provoke a rejection of the expert advice I was giving them.

Management does need to understand the importance of recognising good work already done and the current high achievements of medical practitioners. On the other hand, even the busiest of clinicians should understand the professional advantage of participation in a project to further improve or develop new ways of solving their patients’ problems. There are multiple strategies needed for the effective “change from the existing entrenched structure and culture of patient care to one based on patient- centred, evidence-based care”.2 However, management certainly needs to support the busy clinicians during the project. It is also better to avoid jargon and the constant renaming of programs. I would argue that the learning principle underlying the range of continuous improvement programs is the same. That principle is to question, accept challenges, explain, justify and seek further information as a continuous process.3

One essential feature of continuous improvement (whatever it is called) is that the practitioner needs to participate in the selection of the project for continuous improvement and the objective outcome measures that will prove the change to be advantageous or not advantageous. It is also important to recognise that successful continuous improvement programs in one context do not necessarily translate to another context.

I agree that management must accept the same standards and accountability demanded of clinicians. In addition, all clinicians should participate in continuous improvement projects as well as being assured that we currently practise medicine at a high standard.