Myotoxicity is a well known side-effect of
on medical errors:3 while the public views open
statins, with a reported incidence of 1–7%.3 No
reporting as a very effective way of reducing errors,
cases of rhabdomyolysis due to monotherapy
physicians prefer confidentiality. We conducted a
with ezetimibe have been described. However,
survey to evaluate the potential contribution of a
disclosure policy to hospital image. Our findings
taking statins has been documented in two
shed additional light on the discordance of opinions
patients.4 Although MD is a known cause of
rhabdomyolysis, the present case strongly suggests
that myotoxicity may be elicited by ezetimibe,
Russian and Arabic) of a representative sample
and poses the question of whether ezetimibe may
of the Israeli public (n ¼ 570) using random-dial
trigger muscular damage by mechanisms that are
software. Respondents were asked to predict the
effects of a transparency policy upon public imageof hospitals and doctors, and also to what extent
Hospital Clinico Universitario ‘‘Lozana Blesa’’
In addition, we conducted 115 face-to-face
interviews of physicians with questions similar
to those of the public survey, in three majorteaching hospitals (two from Israel, one from the
US). They included 53 residents, 54 attending
Hospital Universitario ‘Miguel Servet’
physicians (from internal medicine, surgery and
gynecology), six department heads and two hospital
The majority of the public indicated that an
open disclosure policy would enhance the image
of hospitals (Figure 1). By contrast, a majority of
Hospital Universitario ‘12 de Octubre’
physicians predicted that disclosing mistakes would
damage the image of the hospital (p50.001 vs.
the public). American and Israeli physicians had
Since Israel has a markedly heterogeneous
population, we examined whether ethnic or socialgroups might have different answers. In all sub-
1. Lebo RV, Gorin F, Fletterick RJ, Kao FT, Cheung MC,
groups, including Russians, Arabs, and people with
Bruce BD, et al. High-resolution chromosome sorting
low or high levels of education, the majority
and DNA spot-blot analysis assign McArdle’s syndrome inchromosome 11. Science 1984; 225:57–9.
consistently responded that transparency wouldbenefit hospital image.
2. Bays HE, Moore PB, Drehobl MA, Rosenblatt S, Coth PD,
Dujovne CA, et al. Effectiveness and tolerability of ezetimibe
Both the public and physicians thought that
in patients with primary hypercholesterolemia: pooled analysis
disclosure to patients of individual mistakes by
of two phase studies. Clin Ther 2001; 23:1209–30.
3. Evans M, Rees A. The myotoxicity of statins. Curr Opin Lipidol
4. Fux R, Mo¨rike K, Gundel UF, Hartmann R, Gleiter CH.
Ezetimibe and statin associated myopathy. Ann Intern Med2004; 40:671–2.
Discordant public and professionalperceptions on transparency inhealthcare
Sir,Transparency is becoming a major issue in health-care.1,2 Recent work shows substantial differences
Figure 1. Effect of a disclosure policy upon hospital
between views of physicians and those of the public
image, as perceived by the public and by physicians.
doctors would enhance the doctor’s image. The
5. Australian Council for Safety and Quality in Health Care
public thought that in fact, few or none of the
and Standards Australia International. Open DisclosureStandard: A National Standard for Open Communication in
doctors disclose errors, whereas both Israeli and
Public and Private Hospitals, Following An Adverse Event in
American physicians felt disclosure was common
Health Care. [http://www.health.wa.gov.au/safetyandquality/
(p50.001). The public and the physicians agreed
docs/ACSQHC_Open_Disclosure_Standard.pdf].
that publication of performance data would improve
Our survey suggests that while physicians from
both sides of the Atlantic Ocean share scepticismabout the value of transparency, people from very
diverse backgrounds share convictions regarding
its importance. As discordance between publicand doctors seems to cross cultures, bridging
over mistrust appears to be a global challenge.
Hyponatraemia following traumatic brain injury
It seems that both the public and physicians know
(TBI) is a common complication, occurring in 13%
physicians make mistakes, but physicians may
of cases.1 The commonest cause of hyponatraemia
not yet fully appreciate the extent of this public
is the syndrome of inappropriate antidiuretic hor-
mone secretion (SIADH), which is responsible for
Transparency in itself appears to become, in public
over 90% of cases,1 whereas cerebral salt wasting,
eyes, an indicator of quality. ’Tell the truth and tell
medications and injudicious use of intravenous
it fast’4 should become standard in healthcare,
fluids may also cause hyponatraemia following TBI.
as recently adopted in Australia,5 but this cultural
As glucocorticoid deficiency can present with
shift may be a tough professional challenge.
hyponatraemia similar to that found in SIADH, it
This work was presented at the annual meeting
is essential to exclude adrenal insufficiency before
of the American Public Health Association in
making a diagnosis of SIADH.2 This may be of
particular importance in the case of TBI, as recent
data have indicated a high frequency of undiag-
nosed hypopituitarism among long-term survivors.3
In addition, 16% of acute head injury patientsshow biochemical evidence of adrenocorticotrophin
(ACTH) deficiency.4 Acute hypopituitarism with
ACTH deficiency may therefore be a potentially
important, cause of hyponatraemia in patients with
acute TBI, which is misdiagnosed as SIADH.
To illustrate this potential pitfall in diagnosing
recent experience of three cases where acute TBI
was complicated by hyponatraemia of between
125–130 mmol/l (normal 135–145 mmol/l) with
all the biochemical features of SIADH (clinical
euvolaemia, inappropriately concentrated urine
and a natriuresis).2 All three patients had significanthead trauma. Patient A had a penetrating skullinjury after falling from a ladder (Figure 1), patient B
had diffuse axonal injury after a road traffic accident
1. Smith R. Transparency: a modern essential. Br Med J 2004;
and patient C had intracerebral haematoma fol-
lowing a fall. At presentation, patients A and
2. Mazor KM, Simon SR, Yood RA, et al. Health Plan Members’
B were also hypotensive (blood pressures of 80/30
Views about Disclosure of Medical Errors. Ann Intern Med
and 70/40 mmHg, respectively) and hypoglycaemic
(plasma glucoses of 0.9 and 2.5 mmol/l, respec-
3. Blendon RJ, DesRoches CM, Brodie M, et al. Views
tively) and required vasopressor support and
of Practicing Physicians and the Public on Medical Errors.
continuous intravenous dextrose infusion. Patient
C had normal blood pressure and plasma glucose.
4. Augustine N. Managing the crisis you tried to prevent.
The diagnosis of post-traumatic hypopituitarism
Harvard business review on crisis management. The Harvardbusiness review paperback series. Boston, Harvard Business
with ACTH deficiency was suspected in cases
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Myotoxicity is a well known side-effect of
on medical errors:3 while the public views open
statins, with a reported incidence of 1–7%.3 No
reporting as a very effective way of reducing errors,
cases of rhabdomyolysis due to monotherapy
physicians prefer confidentiality. We conducted a
with ezetimibe have been described. However,
survey to evaluate the potential contribution of a
disclosure policy to hospital image. Our findings
taking statins has been documented in two
shed additional light on the discordance of opinions
patients.4 Although MD is a known cause of
rhabdomyolysis, the present case strongly suggests
that myotoxicity may be elicited by ezetimibe,
Russian and Arabic) of a representative sample
and poses the question of whether ezetimibe may
of the Israeli public (n ¼ 570) using random-dial
trigger muscular damage by mechanisms that are
software. Respondents were asked to predict the
effects of a transparency policy upon public imageof hospitals and doctors, and also to what extent
Hospital Clinico Universitario ‘‘Lozana Blesa’’
In addition, we conducted 115 face-to-face
interviews of physicians with questions similar
to those of the public survey, in three majorteaching hospitals (two from Israel, one from the
US). They included 53 residents, 54 attending
Hospital Universitario ‘Miguel Servet’
physicians (from internal medicine, surgery and
gynecology), six department heads and two hospital
The majority of the public indicated that an
open disclosure policy would enhance the image
of hospitals (Figure 1). By contrast, a majority of
Hospital Universitario ‘12 de Octubre’
physicians predicted that disclosing mistakes would
damage the image of the hospital (p50.001 vs.