MARY MACARTHY WWW.MARY-MACCARTHY.CO.UK
THIS WEEK
EDITORIALS
PRIMARY CARE
WHODUNIT
1279 Self experimentation and the Nuremberg Code
1298 A modest proposal
1319 The rise and fall of celebrity pathology
1300 NHS acronyms and abbreviations
1322 Dr Watson: a regular BMJ reader
1280 The private finance initiative: the gift that goes on taking
1301 Are there too many referral forms?
1324 Agatha Christie’s doctors
1281 Strategies for coping with information overload
RESEARCH 1284 Effect on gastric function and symptoms of drinking wine, black tea, or schnapps with a Swiss cheese fondue: randomised controlled crossover trial 1286 Testing the validity of the Danish urban myth that alcohol can be absorbed through feet: open labelled self experimental study 1287 Beauty sleep: experimental study on the perceived health and attractiveness of sleep deprived people 1289 Can he fix it? Yes, he can!
THE LIVES OF DOCTORS 1290 Junior doctors’ urine output on an intensive care unit: case-control study 1292 Phantom vibration syndrome among medical staff 1294 The barrier method as a new tool to assist in career selection: covert observational study 1296 Bicycle weight and commuting time: randomised trial
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1302 Reflections of Father Christmas’s GP
HISTORY
SURGERY
1326 Medical identification of Henri IV
1304 Red for danger? The effects of red hair in surgical practice
1328 Mozart’s 140 causes of death and 27 mental disorders
1306 Middle ear instrument nomenclature
1330 A shopping list of doctors
1308 The IKEA pencil: a surprising find in the NHS
1332 Short and stout physicians’ friends 1334 Acting on evidence 1336 “In consequence of enemy action”
READING BETWEEN THE LINES 1309 How the growth of denialism undermines public health 1312 Integrative medicine and the point of credulity 1314 On the impossibility of being expert 1316 A dose by any other name would not sell as sweet 1317 A Christmas tree cataract 1318 Pie sharing in complex clinical collaborations
1338 New Zealand’s medical first XV
EDITOR’S CHOICE
Welcome to our feast of fools
M
“For most of the year it preached solemnity, order, restraint, fellowship, earnestness, a love of God, and sexual decorum—and then, at New Year’s, it unleashed the festum fatuorum, the feast of fools, and for several days the world was upside down. Clergy played dice on the altar, brayed like donkeys instead of saying ‘Amen,’ had drinking competitions in the nave, farted to the Ave Maria, and delivered spoof sermons based on parodies of the Gospels .... After drinking tankards of ale, they held their holy books upside down, burned excrement instead of incense, and urinated out of bell towers. They tried to marry donkeys, tied giant woolen penises to their vestments, and held boozy orgies on the altar.”
This sacred parody wasn’t just a joke, argued de Botton, but to ensure that things would be the right way up for the rest of the year. “If you really think that the Christmas issue is an example of festum fatuorum,” commented a colleague, “it’s a pretty tame one.” And yet.
CARNIVALISE
edieval Christianity understood the debt that goodness, faith, and sweetness owe to their opposites, explained Alain de Botton in an article in Harper’s Magazine earlier this year.
Anon captures the feast’s antiauthoritarian tone by liberating the NHS’s abbreviations and acronyms (p 1300). We don’t have priests urinating out of bell towers, but we have intensive care doctors micturating into wide mouthed plastic measuring jugs, unaided by the nursing staff (spoilsports) (p 1290). “A modest proposal” (p 1298) and “Pie sharing in complex clinical collaborations” (p 1318) parody the modern day gospels on the primacy of primary care and the worthiness of multidisciplinary collaborations. John McLachlan’s hoaxing of the scientific committee of an international conference on integrative medicine covers with wonderful economy spoof sermons, farting to the Ave Maria, and burning excrement instead of incense (p 1312). Readers of the article in the
Too much information and not enough time?
masterclasses.bmj.com BMJ | 18-25 DECEMBER 2010 | VOLUME 341
print journal even get a moderately proportioned latex penis (rather than a giant woollen one) thrown in for good measure. And as happens in each year’s Christmas issue, booze is just about everywhere—if not in the nave or on the altar, then on the table (p 1284) and underfoot (p 1286). By contrast there’s nothing remotely foolish about three entries from last year’s competition for the most interesting use of the journal’s online archive. Although they didn’t win, they seemed too good not to share. Learn about the teapot’s occasional, but fascinating, appearances in BMJs over the years (p 1332), how BMJs of a hundred years ago were cannibalised for the plot of Casualty 1909 (p 1334), and how the archives facilitated a meeting between Sherlock Holmes, Dr Watson, and their creator (p 1322). Given the wave of creativity that last year’s competition unleashed, we were tempted to run another one this year. The working title was “How to reorganise the NHS,” and the plan was for entrants to submit their answers on the back of an envelope. From our experience last year, however, it was clear that many entrants would have spent more time drawing up their plans than the coalition
government has. It didn’t seem fair to waste their time. With so much information crying out for our attention (pp 1281, 1314) we have to spend our time wisely. One timesaver is to stop speculating on the nature of the illnesses of the illustrious dead. The fatuity of these efforts is pointed up by Lucien Karhausen’s totting up of Mozart’s suggested causes of death (140) and psychiatric states (27). As he points out, Mozart died only once: “some causes are plausible, only few—maybe one, or maybe none of them—can be true, so most if not all of them are false” (p 1328). His article allows us to draw a line, once and for all, under such speculative contributions. Far better use of your time is to support our charity this year, Save the Children (www. savethechildren.org.uk/bmj), and to nominate worthy contenders (or even yourself) for next year’s BMJ Group Awards (http:// groupawards.bmj.com). The deadline is 24 January—by which time the world should be the right way up again, always excepting the private finance initiative (p 1280). Tony Delamothe, deputy editor, BMJ
[email protected] Cite this as: BMJ 2010;341:c7228
EDITORIALS Self experimentation and the Nuremberg Code Ethics review is needed only when other people are subjects too
RESEARCH, p 1286 THE LIVES OF DOCTORS, pp 1290, 1296
George J Annas professor and chair, Department of Health Law, Bioethics and Human Rights, Boston University School of Public Health, Boston, MA 02118, USA
[email protected] Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2010;341:c7103
doi: 10.1136/bmj.c7103
Editorials represent the opinions of the authors and not necessarily those of the BMJ or BMA For the full versions of these articles see bmj.com
The Nuremberg Code is the cornerstone of human experimentation law and ethics.1 Nonetheless, the suggested exception of self experimentation in its article 5 has never been persuasive: no experiment should be conducted if there is an a priori reason to believe that death or disabling injury will occur, except, perhaps, in experiments where the experimental physicians also serve as subjects. The judges should have stopped at the word “occur.” Why is the exception there, and is it justifiable to put the lives of others at risk because the investigator is willing to risk his or her own life? The answer is that the prosecution at Nuremberg (and apparently the judges as well) thought that this exception was necessary to prevent the Nazi doctors from arguing that previous US government military experiments—most notably the Walter Reed yellow fever experiment—had also knowingly risked the lives of subjects. This explanation is supported by the originally suggested wording of article 5 by each of the two principal doctors who worked for the prosecution at Nuremberg, Leo Alexander and Andrew Ivy. Alexander suggested adding yet another clause: “such as was done in the case of Walter Reed’s yellow fever experiments.”2 Ivy would have replaced the existing clause with: “except in such experiments as those on yellow fever where the experimenters serve as subjects along with non-scientific personnel.”3 As Alexander and Ivy had anticipated, the 1900-1 yellow fever experiments did come up in the cross examination of Andrew Ivy. Ultimately, however, the studies did not play a crucial role because Ivy testified that he could not recall their details. Instead, he made a different point, that unlike the Nazi experiments, these were not performed under government or military orders. Because of the common equation of Walter Reed with self experimentation, it is of interest that Walter Reed himself, unlike his research team, was not a subject in the experiments. Similarly, although the yellow fever experiments made an appearance at Nuremberg, nothing in the testimony suggested that the willingness of an investigator to be a subject could serve as an ethical justification to put other humans at risk of death. Neither of these historical footnotes has much relevance today, not least because few, if any, contemporary researchers are willing to risk their own lives to prove the value or safety of their research.4 In the rare contemporary cases of self experimentation, today’s problem is whether self experimentation (an experiment done by the investigator on himself or herself only) must be reviewed and approved by an ethics committee before it is conducted.4 Three linked articles help clarify the ethics review question.
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Groves studied his bicycle riding and only his bicycle riding, and he has no plans to conduct bicycle riding research. He justifies not having his “n=1” bicycle riding study reviewed because he is the “sole investigator and subject” of the study and that it was “conducted . . . using his normal mode of transport.”5 This misses the central point. Groves was not doing research at all—he was not seeking generalisable knowledge by testing a hypothesis. He was simply trying to decide which of two bicycles to ride to work. The fact that he wrote up his “findings” in the form of a journal article does not make his decision making process a research project. It is a single anecdote that makes interesting reading, but it is much more suited to a cycling magazine or the newspapers than to a medical journal.6 Of course ethics review committees do not and should not review consumer product choice procedures (although someone might caution Groves about the dangers of cycling in the rain and snow). The Danish research team doesn’t say why it didn’t seek ethics committee review for its study on whether alcohol can be absorbed through the feet, although it was probably because all three investigators were physicians in good health, they understood the study, and they reasonably believed that it carried no risk, except perhaps of embarrassment.7 This is responsible. But it is also responsible for an institution (and a medical journal) to require that the “no risk” determination be made by an ethics committee. As the Danish team acknowledges, a slight modification to the protocol, such as including “eyeball drinking,” could radically alter the risks of the research.7 The PARCHED investigators did seek and obtain ethics committee approval for their investigator subject study. This is appropriate because their group contained more than one investigator subject (no plural exists for self experimentation), and because they recognised the risk of death posed by compromises to renal function.8 The ethics committee was overly cautious in its requirement of a data monitoring committee, but it curiously did not require documentation of fluid intake by the subjects, suggesting a cursory review at best. The investigators properly note this failure as a limitation of their study, but this simply makes their recommendation to drink more water while on shift all the more puzzling. Where does this leave us? The reasonable conclusion is that, contrary to article 5 of the Nuremberg Code, for life threatening research the participation of the researcher as a subject adds nothing to the ethical analysis of whether the research can be justified at all. The Walter Reed studies should have been characterised as unethical at Nuremberg (because they predictably would cause the 1279
EDITORIALS
deaths of non-investigator subjects), rather than weakly defended, and they certainly provide no ethical basis for their repetition today. Informed consent is a necessary, but not sufficient, condition of ethical experimentation. Self experimentation is neither necessary nor sufficient. Even where risks are minimal, prior ethics committee review of research in which investigators are subjects should be sought, if only to confirm the reasonableness of the risk assessment. If, on the other hand, an investigator proposes to experiment only on him or herself, that activity is not properly categorised as research at all, but as self indulgence (or, some may say, self abuse). Nuremburg continues to teach us serious ethical lessons. Trivial interventions masquerading as research studies are primarily a source of amusement.
1 2 3
4 5 6 7 8
Annas GJ, Grodin MA. The Nazi doctors and the Nuremberg Code: human rights in human experimentation. Oxford University Press, 1992. Schmidt U. Justice at Nuremberg: Leo Alexander and the Nazi doctors’ trial. Palgrave Macmillan, 2004:204. Ivy A. Report on war crimes of a medical nature committed in Germany and elsewhere on German nationals and the national of occupied countries by the Nazi regime during world war II (undated report to the prosecution, 1947). Altman LK. Who goes first? The story of self-experimentation in medicine. University of California Press, 1986. Groves J. Bicycle weight and commuting time: randomised trial. BMJ 2010;341:c6801. Kolata G. Fell off my bike, and vowed never to get back on. New York Times 2010 November 29. www.nytimes.com/2010/11/30/health/ nutrition/30best.html. Hansen CS, Færch LH, Kristensen PL. Testing the validity of the Danish urban myth that alcohol can be absorbed through feet: open labelled self experimental study. BMJ 2010;341:c6812. Solomon AW, Kirwan CJ, Alexander NDE, Nimako K, Jurukov A, Forth RJ, et al; on behalf of the Prospective Analysis of Renal Compensation for Hypohydration in Exhausted Doctors (PARCHED) Investigators. Urine output on an intensive care unit: case-control study. BMJ 2010;341:c6761.
The private finance initiative: the gift that goes on taking Its genius is how it diverts public resources to private interests
Allyson M Pollock professor and director, Centre for International Public Health Policy, University of Edinburgh, Edinburgh EH8 9AG, UK
[email protected] David Price senior research fellow, Institute for Health Sciences, Barts and The London, Queen Mary’s College, University of London, London, UK Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2010;341:c7175
doi: 10.1136/bmj.c7175
bmj.com/archive ЖЖPFI: perfidious financial idiocy. A “free lunch” that could destroy the NHS (BMJ 1999;319:2) 1280
Perfidious financial idiocy was how the BMJ’s editor described the private finance initiative (PFI) in 1999.1 Under the policy, NHS hospitals and land are sold off and new hospitals built using private loans instead of public loans or grants. We argued at the time that this would result in bed closures because hospitals had not been funded to pay the full costs of the loans, which are paid back over the 30-60 year contract period.2 3 And that’s what happened: English NHS hospital capacity fell by 73 882 beds (almost a third) between 1992-3 and 2009-10, and occupancy rates rose to unsafe levels of more than 85% during the period when the PFI system of loan financing was introduced.4 5 In 2000, as controversy grew over PFI related bed reductions, the government’s National Bed Inquiry found that further acute sector closures were unlikely to be safely attainable without more intermediate and community service beds, and it recommended reversal of bed closures.6 The wasteful £4bn (€4.8bn; $6.3bn) independent sector treatment centre programme was introduced as a stop gap,7 and hospital reconfiguration continued. Last week the Public Accounts Committee revealed that PFI is even less affordable.8 Banks lending to PFI projects have increased their interest rates by 20-30% since the financial crisis. But, as Audit Scotland has shown, private finance interest rates were already 2.5-4% above public borrowing rates before the government bail out.9 Higher charges for interest rates mean higher annual repayments by the NHS, as much as £200m a year for every 0.01% to 0.03% increase in lending rate.10 The Public Accounts Committee calculates that the increased bank charges “added £1 billion to the contract price, payable over 30 years, for the 35 projects financed in 2009.”8 But the problem of higher interest rate charges is not confined to new PFI deals. The PFI’s annual charges rise each year because annual payments are linked to the retail price index. This policy requires large injections of taxpayers’ money to support it. The funding freeze and ring fenced PFI debt payments that are index linked provide the ingredients for a perfect economic storm. The scale of the problem for the UK is formidable. By
December 2009, 159 PFI projects, worth £13.2bn in terms of building costs, had been signed to the NHS, and total debt to be repaid had reached £43bn. This year alone (2010-11) all PFI payments across the public sector will reach £8.6bn. The commitment over the next 25 years is projected to be £210bn.8 What stands out is the disparity between the original cost of a building and the final bill—a consequence of higher interest and returns to investors. Is the bill worth it? The government says it is. It argues that we are buying cost efficiency and that contractors have an incentive to be more efficient because it is their own money, not taxpayers’ money, that is at risk. According to the treasury, when “risk transfer” of this kind is taken into account, private finance is no more expensive than public finance.11 The UK parliament has repeatedly questioned the lack of evidence in support of risk transfer and value for money claims. In July 2010, a National Audit Office paper to a House of Lords committee described value for money as “subjective judgements of risk, which can easily be adjusted to show private finance as cheaper.”12 The chairman of the Public Accounts Committee described PFI as “probably the most secure projects to which the banks could lend.”12 The committee previously expressed concern over high interest rates, returns that contractors earn from PFI projects, and the risks they actually bear.13 To restore confidence in the financial markets and to free up lending, the UK government increased public borrowing to support the banking sector. It is this increased borrowing that lies behind the austerity drive across the public sector. In 2008-9, the government recapitalised the Royal Bank of Scotland Group (RBS) and the Lloyds Banking Group at a total cost of £37bn to become the major shareholder in both banks, holding 70% of RBS shares and 43.5% of Lloyds shares.14 The government also agreed to protect RBS from losses on risky assets up to £282bn.15 The effect of government rescue is to transfer the risks, completely or in part, from the private sector back to the taxpayer. These same banks provide loans to and take equity shares BMJ | 18-25 DECEMBER 2010 | VOLUME 341
EDITORIALS
in many PFI schemes; it is ironical that they are currently using high PFI interest rates to rebuild their balance sheet after the financial collapse. In other words, the public sector is making PFI payments to banks it partially owns, at a higher cost of borrowing than traditional public borrowing. This means that investment risks have now been transferred back to the tax paying public, negating the rationale for the policy. The rewards to PFI investors and shareholders are shrouded in secrecy, but an analysis of the financial projections for three hospital projects at the time the contracts were signed has shown that pure equity investors expected to receive £168m for £0.5m of equity invested in the Royal Infirmary of Edinburgh, equity of £100 in Hairmyres PFI hospital was expected to generate £89.14m for investors, and for Hereford hospital equity of £1000 was expected to generate £55.7m.16 These high rewards are contractually protected and underwritten by government. The genius of PFI is the way it diverts public resources from public to private interests, providing guaranteed profits to its backers in a time of austerity. But the shiny “new builds” will be cold comfort for the thousands of NHS staff now being served “at risk of redundancy notices” and millions of patients who face withdrawal of much needed entitlements and public services. A public enquiry and full publication of all contracts are long overdue.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Smith R. PFI: perfidious financial idiocy. A “free lunch” that could destroy the NHS. BMJ 1999;319:2. Gaffney D, Pollock AM, Price D, Shaoul A. The private finance initiative: NHS capital expenditure and the private finance initiative—expansion or contraction? BMJ 1999;319:48. Pollock AM, Dunnigan MG, Gaffney D, Price D, Shaoul J. Planning the “new” NHS: downsizing for the 21st century. BMJ 1999;319:179-84. Department of Health. Hospital activity statistics, 2000-8. www. performance.doh.gov.uk/hospitalactivity/data_requests/beds_open_ overnight.htm. Department of Health. Beds open overnight, 2008-11. www.dh.gov.uk/en/ Publicationsandstatistics/Statistics/Performancedataandstatistics/Beds/ DH_083781. Pollock AM, Dunnigan M. Bed in the NHS. BMJ 2000;320:461. Pollock AM, Kirkwood G. Independent sector treatment centres: learning from a Scottish case study. BMJ 2009;338:1421. House of Commons. Financing PFI projects in the credit crisis and the treasury’s response. Report of the Public Accounts Committee. HMSO, 2010. Audit Scotland/Accounts Commission. Taking the initiative. Audit Scotland, 2002:58. Norman J. Hard times call for a new rebate on PFI deals. Financial Times 2010. www.ft.com/cms/s/0/b5a2d048-a968-11df-a6f2-00144feabdc0. html#axzz17irB8IFt. HM Treasury. PFI: meeting the investment challenge. HMSO, 2003. National Audit Office. Private finance projects. Paper for committee of economic affairs. NAO, 2010. House of Commons. PFI construction performance. Select Committee on Public Accounts. Stationery Office, 2002. HM Treasury. Budget 2009: building Britain’s future. HC 407. Stationery Office, 2009. HM Treasury. Pre-budget report. Securing the recovery: growth and opportunity. Cm 7747. Stationery Office, 2009. Cuthbert J, Cuthbert M. The implications of evidence released through freedom of information in the projected returns from the New Royal Infirmary of Edinburgh and certain other PFI schemes. Papers on the Scottish economy. 2008. www.cuthbert1.pwp.blueyonder.co.uk.
Strategies for coping with information overload You need a machine to help you
READING BETWEEN THE LINES, p 1314
Richard Smith chair, Patients Know Best, Cambridge CB4 0WS, UK
[email protected] Competing interests: The author has completed the Unified Competing Interest form at www. icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; RS is on the board of the Public Library of Science and chair of Patients Know Best, a company that uses technology to enhance patient-clinician relationships; RS was the editor of the BMJ and chief executive of the BMJ publishing Group. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2010;341:c7126
doi: 10.1136/bmj.c7126
bmj.com/archive ЖЖThe knowledge disease (BMJ 1993;307:1578)
Fraser and Dunstan show that even within a narrow specialty it is impossible to keep up with published medical reports.1 Trainees in cardiac imaging reading 40 papers a day five days a week would take over 11 years to bring themselves up to date with the specialty. But by the time they had completed that task, another 82 000 relevant papers would have been published, requiring another eight years’ reading. And this analysis assumes that trainees need to know about cardiac imaging only, whereas they surely need to keep up with other areas of medicine and healthcare. The authors conclude that it is impossible to be an expert. This problem is not new. Dave Sackett, the “father” of evidence based medicine, found some 20 years ago that to keep up to date in internal medicine it was necessary to read 17 articles a day 365 days a year.2 He also found that the median time spent reading by newly graduated doctors was zero, while for senior consultants it was 30 minutes, with 40% reading nothing.2 Some 10 years ago I asked around 100 doctors how much of what they should read to do their job better they actually read. About 80% said less than 50%, and 10% said less than 1%.3 More than half felt guilty about this, and when asked to describe in one word how they felt about their information supply it was mostly negative (impossible, overwhelmed, crushed, despairing, depressed), with just a few answering “challenged.”3 One of the best known responses to information overload was the founding of the Cochrane Collaboration, named after the epidemiologist Archie Cochrane who called for a “critical
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summary . . . adapted periodically, of all relevant randomised controlled trials.”4 He knew that most of the new information was of poor quality, and Brian Haynes showed later that less than 1% of studies in most medical journals reach stringent scientific standards.5 John Ioannidis has argued in the best read paper in PloS Medicine that most research findings are false.6 So it makes no sense for doctors to try and read everything: rather, argued Cochrane, they should rely on critical summaries. But 20 years after the launch of the Cochrane Collaboration a review has found progress to be poor.7 Around 75 clinical trials and 11 systematic reviews are published every day, with no sign of abating. Yet many clinical topics have no Cochrane Library systematic reviews, and perhaps three quarters of interventions lack a firm evidence base. We have what Muir Gray, once director of the National Library for Health, calls an information paradox—we are overwhelmed by new information yet have many unanswered questions. The average 10 minute consultation between a doctor and patient will throw up at least one question that cannot be answered.8 The box lists the possible strategies for dealing with the problem, but the only one that might bring success is to use a machine. Several years ago after conducting a semi-systematic review of the information needs of doctors I tried to identify the characteristics of the machine that would finally solve the seemingly impossible problem of answering all the questions that arise in medicine with the very latest research.8 Here are the characteristics: 1281
W HEATH ROBINSON
EDITORIALS
Strategies for dealing with information overload The ostrich strategy With this strategy doctors simply ignore the torrent of new information. If Sackett’s data are right, many doctors adopt this strategy, especially as they get older.9 The pigeon strategy Perhaps the most common strategy is to hang around with other doctors and pick up titbits of information. You attend grand rounds and the occasional postgraduate meeting, follow some guidelines, and rely on drug company representatives to tell you about new treatments. When you have a tricky question about a patient you consult a colleague—the most common way to get an answer.8 You sometimes flick through journals, but you learn more from the mass media. The most annoying way that you learn new things is from patients who bring newspaper clippings, garbled stories about something on the television, or long printouts from the internet.
The owl strategy Probably the rarest strategy is that proposed by the originators of evidence based medicine. You build your knowledge patient by patient by identifying questions that arise during interactions. You refine the questions to one that can be answered, search for all relevant evidence, and systematically analyse it, abandoning the large amount that is of poor quality and combining, preferably numerically, that of high quality. The advantage of this strategy is that your information relates directly to your patients. Unfortunately, almost nobody has the time and very few the skills to pursue such a strategy. The Jackdaw strategy Doctors who pursue this strategy follow the pigeon strategy but also regularly search for highly refined evidence— from perhaps the Cochrane Library, Clinical Evidence, guidelines, or other
• Part of the information system that doctors use as they see patients • Able to answer highly complex questions • Connected to a large valid database • Electronic • Fast (answers within five seconds) • Easy to use (as easy as a car) • Portable • Prompts doctors in a way that is helpful not demeaning • Connected to the patient record • Gives evidence related to individual patients • A servant of patients as well as doctors • Provides psychological support. Some of these characteristics may never be achieved. For example, it is impossible to give evidence related to individual patients because evidence is gathered on populations. It would also be hard for machines to provide psychological support, but many of the questions that doctors ask themselves, such as, “Did I do the right thing by that young woman who died of breast cancer last week?”, are really a request for psychological support.8 And will doctors be willing to use such machines? De Dombal showed that computers are better at diagnosing acute abdominal pain than doctors, but his strategies were never widely adopted.11 My father resented my mother buying a dishwasher because he feared it would replace his role, and 1282
sources of evidence based reviews. Unfortunately these sources are full of holes (because the evidence simply doesn’t exist), and the evidence is not useful—and may even be harmful—for patients with comorbidity (who now constitute most patients).10 The inhuman strategy John Fox, once director of the Advanced Computing Laboratory, said that practising medicine is an inhuman activity, meaning that it’s absurd for doctors to practise without the help of machines. Individual doctors have no chance of keeping up with new research, but teams of people can process new information and feed it into machines that doctors (and patients) can use. The most popular of these machines is UptoDate, which has 400 000 users, but there is also BMJ Point of Care, the Map of Medicine, and more.
perhaps doctors are worried that machines might precipitate the reformation, described so beautifully by Joanne Shaw, where priestly doctors with their Latin bibles will have to give way to plebeians speaking the vernacular.12 “Will we ever solve the problem of information overload?” I imagine myself asking God as I arrive in heaven. “Sure,” he’ll answer, “but not in my lifetime.” 1
Fraser AG, Dunstan FD. On the impossibility of being an expert. BMJ 2010;341:c6815. Sackett D. The need for EBM talk. www.cebm.net/index.aspx?o=1083. Smith R. Meeting health care challenges: what are the challenges and what is the role of e-health? http://learn.patientsknowbest.com/WikiEditor. im?doc=2010-12-25-Meeting-healthcare-challenges-what-are-thechallenges-and-what-is-the-role-of-e-health&pid=0. 4 Cochrane AL. 1931-1971: a critical review, with particular reference to the medical profession. In: Medicines for the year 2000. Office of Health Economics, 1979:1-11. 5 Haynes RB. Where’s the meat in clinical journals? ACP J Club 1993;119:A23-4. 6 Ioannidis JPA. Why most published research findings are false. PLoS Med 2005;2:e124. 7 Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Med 2010;9:e1000326. 8 Smith R. What clinical information do doctors need? BMJ 1996;313:1062-8. 9 Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Norcini JJ, et al. Changes over time in the knowledge base of practising internists. JAMA 1991;266:1103-7. 10 Tinetti ME, Bogardus ST, Agostini JV. Potential pitfalls of diseasespecific guidelines for patients with multiple conditions. N Engl J Med 2004;351:2870-4. 11 De Dombal T. Medical informatics: the essentials. Oxford University Press, 1993. 12 Shaw J. A reformation for our times. BMJ 2009;338:b1080. 2 3
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RESEARCH THIS WEEK’S RESEARCH QUESTIONS 1284 What should you drink with a cheese fondue—white wine or black tea, and is a shot of schnapps good for the digestion? 1286 Is the Danish belief that submerging your feet in alcohol can make you drunk merely an urban myth—or is there some truth in it? 1287 Can you tell just by looking at someone that they’re sleep deprived?
DUNCAN SMITH
1289 Which popular children’s toy provides symptomatic relief for ocular neuromyotonia, and why?
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1283
RESEARCH
Effect on gastric function and symptoms of drinking wine, black tea, or schnapps with a Swiss cheese fondue: randomised controlled crossover trial Henriette Heinrich,1 Oliver Goetze,1 Dieter Menne,2 Peter X Iten,3 Heiko Fruehauf,1 Stephan R Vavricka,1 Werner Schwizer,1 4 Michael Fried,1 4 Mark Fox1 4 EDITORIAL by Annas 1
Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland 2 Menne Biomed, Tuebingen, Germany 3 Division of Legal Medicine, University Zurich, Switzerland 4 Zurich Integrative Human Physiology Group, University of Zurich Correspondence to: M Fox, NIHR Biomedical Research Unit, Nottingham Digestive Diseases Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
[email protected] Cite this as: BMJ 2010;341:c6731 doi: 10.1136/bmj.c6731 This is a summary of a paper that was published on bmj.com as BMJ 2010;341:c6731
OBJECTIVE To compare the effects of drinking white wine or black tea with Swiss cheese fondue followed by a shot of cherry schnapps on gastric emptying, appetite, and abdominal symptoms. DESIGN Randomised controlled crossover study. PARTICIPANTS 20 healthy adults (14 men) aged 23-58. INTERVENTIONS Cheese fondue (3260 kJ, 32% fat) labelled with 150 mg sodium 13Carbon-octanoate was consumed with 300 ml of white wine (13%, 40 g alcohol) or black tea in randomised order, followed by 20 ml cherry schnapps (40%, 8 g alcohol) or water in randomised order. MAIN OUTCOME MEASURES Cumulative percentage dose of 13C substrate recovered over four hours (higher values indicate faster gastric emptying), and appetite and dyspeptic symptoms (visual analogue scales). RESULTS Gastric emptying was significantly faster when fondue was consumed with tea or water than with wine or schnapps (cumulative percentage dose of 13C recovered 18.1%, 95% confidence interval 15.2% to 20.9% v 7.4%, 4.6% to 10.3%; P<0.001). An inverse dose-response relation between alcohol intake and gastric emptying was evident. Appetite was similar with consumption of wine or tea, but reduced if both wine and schnapps were consumed (difference −0.40, 95% confidence interval −0.01 to −0.79; P<0.046). No difference in dyspeptic symptoms was present. CONCLUSIONS Gastric emptying after a Swiss cheese fondue is noticeably slower and appetite suppressed if consumed with higher doses of alcohol. This effect was not associated with dyspeptic symptoms. TRIAL REGISTRATION ClinicalTrials.gov NCT00943696
Introduction The benefits of drinking alcohol with food, especially high fat and high energy meals such as cheese fondue, are conflicting. In Switzerland, some traditionalists demand that white wine is drunk with this classic dish, whereas others insist on only black tea. The debate after dinner turns to whether a shot of “spirits” will promote digestive comfort. In studies using a variety of meals and drinks the evidence for the effects of alcohol on gastric emptying were inconsist ent.1‑5 Similarly, alcohol has complex effects on appetite and the likelihood of abdominal discomfort after a meal.6 Critically, only one study has assessed both gastric function and symp toms after alcohol ingestion4 and none considered the effects of alcohol consumed with a high energy, high fat meal. We com pared the effects of white wine, black tea, and cherry schnapps on gastric emptying and abdominal symptoms after ingestion of a Swiss cheese fondue in healthy volunteers. Methods We tested 20 healthy volunteers (14 men, aged 23 to 58) on two days, at least one week apart. None had a history of 1284
alcohol misuse or gastrointestinal disease. None was taking prescription drugs. After fasting for at least six hours, the participants ingested 200 g of Swiss cheese fondue (3260 kJ, 64 g fat, 2 g carbo hydrate, 52 g protein); 50% Gruyere, 50% Fribourgeois (Moite-Moite Fondue, Coop, Basel, Switzerland) labelled with 150 mg sodium 13C-octanoate. The cheese, heated using individual rechauds, was consumed with 100 g of bread (418 kJ). During the meal the participants drank 300 ml of either white wine (Fendant de Valais (Coop, Basel), 40 g of alcohol, 13% by volume) or black tea according to randomisation. At 90 minutes according to a second randomisation the partici pants drank 20 ml of either cherry schnapps (Etter Kirsch, Zug, Switzerland, 8 g of alcohol, 40% by volume) or water. Before the meal and every 10-15 minutes for four hours we collected samples for breath testing. We measured the ratio of 13 C to 12C in the samples using a spectroscopic method (see bmj. com). The proportion of substrate metabolised and exhaled was expressed as the maximal percentage dose of 13C recov ered per hour and the cumulative percentage dose recovered for each time interval.7 8 Additionally, we used the reversed retention curve to estimate the half times for gastric emptying.7 Alcohol in breath was assessed before the meal and every 15 minutes for four hours using a standard breath test device (Draeger, Luebeck, Germany). We used a 100 mm visual analogue scale to assess appetite (hunger, satiety, desire to eat, quantity to eat) before the meal and every 15 minutes for four hours. Similarly, we used a visual analogue scale to assess dyspeptic symptoms, nausea, bloating, and abdominal discomfort.
Statistical analysis Gastric emptying was evaluated by the cumulative percentage dose of 13C recovered after each time interval.7 To normalise the scores for appetite we subtracted the group mean score and then divided by the group standard deviations. A correc tion was applied for multiple pairwise comparisons. Results From early during the meal and throughout the study the recovery curves for 13C were lower for wine than for tea, indi cating slower gastric emptying. In addition, the recovery rate decreased immediately after ingestion of schnapps, which was most evident in association with tea (figure). Gastric emptying was significantly faster when fondue was consumed with tea or water than with wine or schnapps (18.1%, 95% confidence interval 15.2% to 20.9% v 7.4%, 4.6% to 10.3%; P<0.001); gastric emptying half times 361 minutes (95% confidence interval 314 to 408 minutes) and 560 minutes (514 to 607 minutes), respectively. Gastric emptying was faster if fondue was consumed with tea rather than with wine, whether schnapps was consumed (increased cumulative recovery 95% confidence interval 2.9% to 11.0%; BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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P<0.002) or not (4.1% to 12.2%; P<0.001). Schnapps also tended to slow gastric emptying, especially when consumed after tea (decreased cumulative recovery −3.6%, 0.4% to −7.7%; P<0.075), equivalent to an increased gastric emptying half time of 80 minutes (95% confidence interval 15 to 145 minutes). An inverse dose-response relation between alcohol intake and gastric emptying was evident (see bmj.com). Ingestion of fondue increased fullness and decreased the appetite score by 0.33 (95% confidence interval 0.03 to 0.63; P<0.032). There was no correlation between appetite score and rate of gastric emptying. Five participants reported moderate (visual analogue scale score >3) dyspeptic symptoms (nausea, bloating, discomfort). Only one participant reported more severe (score >6) symptoms.
bmj.com/video ЖЖJoin the authors at a fondue party as they explain their research at bmj.com/video
Discussion The debate about what to drink with a cheese fondue is one about which everyone at the Swiss dinner table has an opin ion. Our results show that drinking white wine with this high fat, high energy meal decreases the rate of gastric emptying compared with black tea. Taking a shot of spirits after the meal has additional gastrointestinal effects. At the highest doses studied, alcohol seemed to suppress appetite after the meal; irrespective of beverage, dyspeptic symptoms were reported only occasionally. We observed an important decrease in gastric emptying rate when a moderate amount of white wine (300 ml; 14% alcohol) was consumed with a Swiss cheese fondue compared with the same volume of black tea. The decrease was rapid and prolonged, with the recovery of 13C reduced from the first breath sample and never attaining the level of the control arm (figure). This finding is consistent with reports that ethanol and a variety of alcoholic beverages slow gastric emptying when taken before a meal3 5; although, this effect was not always observed if the total energy content of food and drink consumed during the meal was controlled.1 2 A shot of schnapps (20 ml; 40%) also reduced the rate of gastric emptying. The effect was rapid, with an immediate decrease in 13C recovery after intake (figure). It is inconceiv able that a small volume of spirits could “bypass” the meal in the distal stomach quickly enough to exert such rapid effects through feedback from nutrient receptors in the small bowel. Although a trend relating alcohol concentration and gastric
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emptying rate was evident (see bmj.com), we found no cor relation between the concentration of alcohol in the breath and the effects on gastric emptying. Together these findings indicate that alcohol has direct, rather than indirect or sys temic effects, on stomach function. The effects of alcohol on appetite and abdominal symp toms are complex, depending on the timing, quantity, and other characteristics of the drink and the meal.6 9‑ 11 In this study alcohol suppressed appetite, but this was apparent only at the highest concentration (48 g alcohol consumed as wine and schnapps). Although the energy density of alcohol is second only to that of fat, its effect on satiation seems to be less than that of other macronutrients.6 We found no association between beverage consumed during the meal and dyspepsia after the meal. Alcohol pro motes gastric relaxation but delays gastric emptying. As a consequence, drinking white wine and schnapps with a Swiss cheese fondue may provide short term relief of postprandial dyspepsia; however, this may come at the cost of more pro longed fullness and reflux. Connoisseurs might point out that wine or schnapps is often added to fondue; this would not confound the results because, as noted by a cookbook writer, alcohol boiled at 78°C will have evaporated after 20-30 seconds.12 Healthy readers should be reassured that they can continue to enjoy fondue with the beverage of their choice without concerns about postprandial digestive comfort. We thank Brigitte Gabathuler and Diana Jovanovic in the gastrointestinal physiology laboratory, University Hospital Zurich, for their assistance. Contributors and competing interests: See bmj.com. Funding: This study was supported by a donation of cash from Coop Foods (Basel, Switzerland), and study materials from Landert Keramik (Embrach, Switzerland) and Etter Kirsch (Zug, Switzerland). All donations were less than $1000 and were provided as an unlimited grant for research. The funders had no contribution to the study design; collection, analysis, or interpretation of data; writing of the report; or the decision to submit the article for publication. Ethical approval: This study was approved by the Zurich University Hospital research ethics committee. Data sharing: Full study data including statistical analysis and technical appendix are available from the corresponding author at
[email protected]. 1
Kaufman SE, Kaye MD. Effect of ethanol upon gastric emptying. Gut 1979;20:688-92. 2 Moore JG, Christian PE, Datz FL, Coleman RE. Effect of wine on gastric emptying in humans. Gastroenterology 1981;81:1072-5. 3 Franke A, Nakchbandi IA, Schneider A, Harder H, Singer MV. The effect of ethanol and alcoholic beverages on gastric emptying of solid meals in humans. Alcohol Alcohol 2005;40:187-93. 4 Franke A, Harder H, Orth AK, Zitzmann S, Singer MV. Postprandial walking but not consumption of alcoholic digestifs or espresso accelerates gastric emptying in healthy volunteers. J Gastrointestin Liver Dis 2008;17:27-31. 5 Inamori M, Iida H, Endo H, Hosono K, Akiyama T, Yoneda K, et al. Aperitif effects on gastric emptying: a crossover study using continuous realtime 13C breath test (BreathID System). Dig Dis Sci 2009;54:816-8. 6 Yeomans MR, Caton S, Hetherington MM. Alcohol and food intake. Curr Opin Clin Nutr Metab Care 2003;6:639-44. 7 Ghoos YF, Maes BD, Geypens BJ, Mys G, Hiele MI, Rutgeerts PJ, et al. Measurement of gastric emptying rate of solids by means of a carbonlabeled octanoic acid breath test. Gastroenterology 1993;104:1640-7. 8 Goetze O, Fox M, Kwiatek MA, Treier R, Schwizer W, Thumshirn M, et al. Effects of postgastric 13C-acetate processing on measurement of gastric emptying: a systematic investigation in health. Neurogastroenterol Motil 2009;21:1047-e85. 9 Caton SJ, Marks JE, Hetherington MM. Pleasure and alcohol: manipulating pleasantness and the acute effects of alcohol on food intake. Physiol Behav 2005;84:371-7. 10 Caton SJ, Ball M, Ahern A, Hetherington MM. Dose-dependent effects of alcohol on appetite and food intake. Physiol Behav 2004;81:51-8. 11 Caton SJ, Bate L, Hetherington MM. Acute effects of an alcoholic drink on food intake: aperitif versus co-ingestion. Physiol Behav 2007;90:368-75. 12 Petersen J. Sauces: classical and contemporary sauce making. 2nd ed. Wiley, 1998.
Accepted: 19 November 2010 1285
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Testing the validity of the Danish urban myth that alcohol can be absorbed through feet: open labelled self experimental study Christian Stevns Hansen, Louise Holmsgaard Færch, Peter Lommer Kristensen
Endocrinology Section, Department of Cardiology and Endocrinology, Hillerød Hospital, Dyrehavevej 29, DK-3400 Hillerød, Denmark Correspondence to: P L Kristensen
[email protected] Cite this as: BMJ 2010;341:c6812 doi: 10.1136/bmj.c6812 This is a summary of a paper that was published on bmj.com as BMJ 2010;341:c6812
OBJECTIVE To determine the validity of the Danish urban myth that it is possible to get drunk by submerging feet in alcohol.
ues of plasma ethanol concentrations and intoxication related symptoms. The level of significance was 5%, two sided.
DESIGN Open labelled, self experimental study.
Results Plasma ethanol concentrations were below the detection limit of 2.2 mmol/L (10 mg/100 mL). The figure presents the intoxi cation related symptoms. Changes were not significant.
SETTING Office of a Danish hospital. PARTICIPANTS Three adults, median age 32 (range 31-35). MAIN OUTCOME MEASURES Primary end point was concentration of plasma ethanol (detection limit 2.2 mmol/L (10 mg/100 mL)), measured every 30 minutes for three hours with feet submerged in 2100 mL of vodka. The secondary outcome was self assessment of intoxication related symptoms: self confidence, urge to speak, and number of spontaneous hugs. RESULTS Plasma ethanol concentrations were below the detection limit of 2.2 mmol/L (10 mg/100 mL). No significant changes were observed in intoxication related symptoms, although self confidence and urge to speak increased slightly at the start of the study. CONCLUSION Our results suggest that feet are impenetrable to the alcohol component of vodka. We therefore conclude that the Danish urban myth of being able to get drunk by submerging feet in alcoholic beverages is just that; a myth.
Introduction According to Danish urban folklore, it is possible to get drunk by submerging feet in alcoholic beverages. We deter mined whether alcohol can be detected in the circulation after submersion of feet in vodka. Methods The study was open labelled and self experimental. It evalu ated the effect of submerging feet in 2100 mL of vodka on plasma ethanol concentration. Secondary end points were intoxication related symptoms. Three adults (CSH, LHF, and PLK) agreed to participate (see characteristics on bmj.com). None had any skin or liver disease or was dependent on alcohol or psychoactive drugs, or had been implicated in serious incidents or socially embar rassing alcohol related events in the week before the experi ment. The participants abstained from alcohol 24 hours before the experiment. The evening before the experiment they exfoliated their feet with a loofah. On the day of the experi ment, a baseline blood sample was taken. The participants then submerged their feet in three 700 mL bottles’ worth of vodka (Karloff vodka; M R Štefánika, Cífer, Slovakia, 37.5% by volume). Plasma ethanol concentrations were determined every 30 minutes for three hours using a photometric method, with a detection limit of 2.2 mmol/L (10 mg/100 mL, 0.010% weight/volume). Participants recorded intoxication related symptoms (self confidence, urge to speak, and number of spontaneous hugs) on a scale from 0 to 10. The main results are presented as medians (ranges). We planned a paired t test to compare baseline and maximum val 1286
Discussion Our results suggest that the transcutaneous uptake of alcohol (vodka, 37.5% by volume) through feet is not possible. We therefore conclude that the Danish urban myth about being able to get drunk by submerging feet in alcohol is just that; a myth. The limited number of participants is a weakness of this study. However, the frequent measurements of alcohol concen trations, a three hour study period (corresponding to a medium length visit to the pub), and clear data make the results cred ible. Moreover, the results are in accordance with a study in which no transcutaneous absorption of alcohol was observed after multiple use of an ethanol based hand sanitiser.2 As the implications of the study are many, we will men tion a few. Driving with boots full of vodka seems to be safe. Brewery workers cannot become intoxicated by “falling” into a vat. Importantly, students experimenting with transcuta neous alcohol absorption should move on to more relevant activities. Many questions are still to be answered in the research specialty of alcohol transport across non-gastrointestinal barriers. This study has shown that feet are impenetrable to the alcohol component of Karloff vodka. Other stronger beverages, beetroot juice, or combinations of juices and alcoholic bever ages may, however, cross the epithelial barrier of the skin. More over, new pastimes, such as “eyeball drinking,” have emerged. The significance of this activity is unknown. Rumour has it that it makes you drunk quickly . . . and may damage your eyes. Points (median, range)
EDITORIAL by Annas
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Self assessed (arbitrary scale 0-10) intoxication related symptoms (self confidence, urge to speak, and spontaneous hugs) in three healthy volunteers (two men and one woman) while their feet were submerged in 2100 mL of vodka (37.5% by volume) for three hours BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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Contributors: See bmj.com. Funding: The measurement of ethanol concentrations was funded by the Department of Clinical Biochemistry, Hillerød Hospital. Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any company for the submitted work; no financial relationships with any companies that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. Ethical approval: Approval of the study at the local ethics committee was not attempted as this was self experimentation; all the participants were also authors.
Data sharing: No additional data available. 1 2
3
Yu CY, Tu HH. Foot surface area database and estimation formula. Appl Ergon 2009;40:767-74. Miller MA, Rosin A, Levsky ME, Patel MM, Gregory TJ, Crystal CS. Does the clinical use of ethanol-based hand sanitizer elevate blood alcohol levels? A prospective study. Am J Emerg Med 2006;24:815-7. Saghir SA, Bartels MJ, Snellings WM. Dermal penetration of ethylene glycol through human skin in vitro. Int J Toxicol 2010;29:268-76.
Accepted: 22 November 2010
Beauty sleep: experimental study on the perceived health and attractiveness of sleep deprived people John Axelsson,1 2 Tina Sundelin,1 Michael Ingre,3 Eus J W Van Someren,4 Andreas Olsson,1 Mats Lekander2 3 OBJECTIVE To investigate whether sleep deprived people are perceived as less healthy, less attractive, and more tired than after a normal night’s sleep. DESIGN Experimental study. SETTING Sleep laboratory in Stockholm, Sweden. PARTICIPANTS 23 healthy, sleep deprived adults (age 18-31) who were photographed and 65 untrained observers (age 18-61) who rated the photographs.
1
Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden 2 Division for Psychology, Department of Clinical Neuroscience, Karolinska Institutet 3 Stress Research Institute, Stockholm University, Stockholm 4 Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, and VU Medical Center, Amsterdam, Netherlands Correspondence to: J Axelsson
[email protected] Cite this as: BMJ 2010;341:c6614 doi: 10.1136/bmj.c6614 This is a summary of a paper that was published on bmj.com as BMJ 2010;341:c6614
bmj.com/podcasts ЖЖListen to a podcast with John Axelsson at bmj.com/podcast
INTERVENTION Participants were photographed after a normal night’s sleep (eight hours) and after sleep deprivation (31 hours of wakefulness after a night of reduced sleep). The photographs were presented in a randomised order and rated by untrained observers. MAIN OUTCOME MEASURES Difference in observer ratings of perceived health, attractiveness, and tiredness between sleep deprived and well rested participants using a visual analogue scale (100 mm). RESULTS Sleep deprived people were rated as less healthy (visual analogue scale scores, mean 63 (SE 2) v 68 (SE 2), P<0.001), more tired (53 (SE 3) v 44 (SE 3), P<0.001), and less attractive (38 (SE 2) v 40 (SE 2), P<0.001) than after a normal night’s sleep. The decrease in rated health was associated with ratings of increased tiredness and decreased attractiveness. CONCLUSION Our findings show that sleep deprived people appear less healthy, less attractive, and more tired compared with when they are well rested. This suggests that humans are sensitive to sleep related facial cues, with potential implications for social and clinical judgments and behaviour. Studies are warranted for understanding how these effects may affect clinical decision making and can add knowledge with direct implications in a medical context.
Introduction Sleep has well established effects on physiological, cognitive, and behavioural functionality1‑4 and long term health,5 but its role in social perception, such as that underlying judgments of attractiveness and health, is only anecdotal. To describe the relation between sleep deprivation and perceived health and attractiveness we asked untrained observers to rate the photographed faces of people after a normal night’s sleep and after sleep deprivation.
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Methods We photographed the faces of 23 adults between 14.00 and 15.00 after a normal night’s sleep (23.00-07.00 and seven hours of wakefulness) and after sleep deprivation (02.0007.00 and 31 hours of wakefulness). Sleep times were confirmed with diaries, and by text mes sages sent at bedtime and on awaking (mean time in bed for the normal sleep condition 8.45 (SE 0.20) hours). The sleep deprivation condition started with a restriction of sleep to five hours in bed; the participants texted the time that they fell asleep and awoke (mean 5.06 (SE 0.04) hours). For the next night of sleep deprivation, the participants arrived at the sleep laboratory at 22.00 (after 15 hours of wakefulness) and stayed awake for a further 16 hours. For the sleep condition, participants came to the laboratory at 12.00 (after five hours of wakefulness). For the photo shoot, participants were asked to look into the camera with a neutral, relaxed expression. A series of five or six photographs were taken (see bmj.com). The photogra pher was not blinded to the sleep conditions, but followed a standardised procedure, including minimal interaction with the participants. A blinded rater chose the most typical pho tograph from each series. A month later the photographs were presented at intervals of six seconds in a randomised order to 65 observers (mean age 30 (range 18-61) years), who were unaware of the study WHAT IS ALREADY KNOWN ON THIS TOPIC • Short or disturbed sleep and fatigue constitute major risk factors for health and safety • Complaints of short or disturbed sleep are common among patients seeking healthcare • The human face is the main source of information for social signalling WHAT THIS STUDY ADDS • The facial cues of sleep deprived people are sufficient for others to judge them as more tired, less healthy, and less attractive, lending the first scientific support to the concept of “beauty sleep” • By affecting doctors’ general perception of apparent health, the sleep history of a patient may affect clinical decisions and diagnostic precision 1287
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conditions. They rated the faces in three sessions, for attractiveness, health, and tiredness on a 100 mm visual analogue scale. To avoid the influence of possible order effects we presented the photographs in a balanced order between conditions for each session and allowed a brief intermission after every 23 photographs, including a work ing memory task for 23 seconds to prevent the faces being memorised.
Statistical analyses Data were analysed using multilevel mixed effects linear regression, with two crossed independent random effects accounting for random variation between observers and participants using xtmixed in Stata 9.2. We also present the effect of condition as the percentage change from base line condition (reference) using the absolute value in mil limetres (rated on the visual analogue scale). Results When sleep deprived, people were rated as less healthy (visual analogue scale scores, mean 63 (SE 2) v 68 (SE 2)), more tired (53 (SE 3) v 44 (SE 3)), and less attractive (38 (SE 2) v 40 (SE 2); P<0.001 for all) than after a normal night’s sleep (see bmj.com). Compared with the normal sleep con dition, perceptions of health and attractiveness in the sleep deprived condition decreased on average by 6% and 4% and tiredness increased by 19%.
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Discussion Sleep deprived people are perceived as less attractive, less healthy, and more tired compared with when they are well rested. Apparent tiredness was strongly related to looking less healthy and less attractive. That the untrained observ ers detected the effects of sleep loss in others provides evi dence for a perceptual ability not previously subjected to experimental control, and supports the notion that sleep history gives rise to socially relevant signals that provide information about the bearer. The results are related to photographs taken in an arti ficial setting and presented to the observers for only six seconds. It is likely that the effects reported here would be larger in real life situations, when overt behaviour and interactions add further information. Blink interval and blink duration are known to be indicators of sleepiness,6 and trained observers are able to evaluate reliably the drowsiness of drivers by watching their videotaped faces.7 In addition, a few of the people were perceived as healthier, less tired, and more attractive in the sleep deprived condi tion. Our findings suggest a prominent role of sleep history in several domains of interpersonal perception and judg ment, such as clinical judgment. In addition, because attractiveness motivates sexual behaviour, collabora tion, and superior treatment,8 sleep loss may have conse quences in other social contexts. That good sleep supports a healthy look and poor sleep the reverse may be of par ticular relevance in the medical setting, where estimates of health are essential. It is possible that people with sleep disturbances, clinical or otherwise, would be judged as more unhealthy, whereas those who have had an unusu ally good night’s sleep may be perceived as rather healthy. BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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Conclusions People are capable of detecting sleep loss related facial cues, and these modify judgments of another’s health and attrac tiveness. These conclusions agree well with existing models describing a link between sleep and good health,9 10 and attractiveness and health.8 We thank B Karshikoff for support with data acquisition and M Ingvar for comments on an earlier draft of the manuscript, both without compensation and working at the Department of Clinical Neuroscience, Karolinska Institutet, Sweden. Contributors: See bmj.com. Funding: This study was funded by the Swedish Society for Medical Research, Rut and Arvid Wolff’s Memory Fund, and the Osher Center for Integrative Medicine. Competing interests: None declared. Ethical approval: This study was approved by the Karolinska Institutet’s ethical committee. Participants were compensated for their participation. Participant consent: Participant’s consent obtained. Data sharing: Statistical code and dataset of ratings are available from the corresponding author at
[email protected].
1
Drummond SPA, Brown GG, Gillin JC, Stricker JL, Wong EC, Buxton RB. Altered brain response to verbal learning following sleep deprivation. Nature 2000;403:655-7. 2 Harrison Y, Horne JA. The impact of sleep deprivation on decision making: a review. J Exp Psychol Appl 2000;6:236-49. 3 Huber R, Ghilardi MF, Massimini M, Tononi G. Local sleep and learning. Nature 2004;430:78-81. 4 Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet 1999;354:1435-9. 5 Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mortality associated with sleep duration and insomnia. Arch Gen Psychiatry 2002;59:131-6. 6 Schleicher R, Galley N, Briest S, Galley L. Blinks and saccades as indicators of fatigue in sleepiness warnings: looking tired? Ergonomics 2008;51:982-1010. 7 Wierwille WW, Ellsworth LA. Evaluation of driver drowsiness by trained raters. Accid Anal Prev 1994;26:571-81. 8 Rhodes G. The evolutionary psychology of facial beauty. Annu Rev Psychol 2006;57:199-226. 9 Cirelli C. Cellular consequences of sleep deprivation in the brain. Sleep Med Rev 2006;10:307-21. 10 Horne J. Why we sleep—the functions of sleep in humans and other mammals. Oxford University Press, 1988.
Accepted: 22 October 2010
Can he fix it? Yes, he can! We present a case in which a novel treatment was instigated by the patient to control symptoms of ocular neuromyotonia Case report A 68 year old woman presented with intermittent diplopia lasting a few minutes precipitated by left gaze. Best corrected visual acuities were 6/9 right and 6/36 left. Initial examination showed only a dense left cataract, which was removed, improving vision to 6/9. Unfortunately her symptoms continued. Her diplopia was elicited during orthoptic review, showing a left exotropia, with updrift, measuring 40 prism dioptres. There was limitation of adduction and depression of the left eye. Imaging showed no structural lesion. The episodes increased in frequency to 50-100 times per day. However, she found one day, while playing with her grandson, that wearing a pair of his tight “Bob the Builder” goggles prevented the episodes from occurring (figure). As a result she took to wearing the goggles daily around the house, particularly to watch the television. She also tried other types of goggles, including swimming goggles, but these were not as effective. She was diagnosed with idiopathic ocular neuromyotonia affecting left lateral rectus and left superior rectus muscles. Symptom control was achieved with carbamazepine after a trial of gabapentin failed.
Discussion Ocular neuromyotonia, first described in 1970,1 is characterised by transient diplopia and strabismus that occurs spontaneously or with maintenance of eccentric gaze, resulting in tonic contraction or spasm of ocular muscles.2 It is a rare paroxysmal involuntary contraction that may affect one or more of the ocular motor muscles. Sixth nerve myotonia is triggered by sustained action of the lateral rectus muscle, leading to intermittent exotropia with restriction of adduction.
In our patient the episodes of involuntary strabismus were triggered by lateral gaze. By wearing restricted field goggles that eliminated the stimulus for lateral gaze, the patient prevented these episodes Ocular neuromyotonia is thought to result from spontaneous neural firing from a single neurone or group of neurones, with interneural transmission resulting in a self perpetuating circuit.1 2 Eliminating this mechanism with membrane stabilising agents can lead to resolution of symptoms.2 Our patient has identified a new mechanism for preventing episodes of ocular neuromyotonia, but carbamazepine has now stabilised her condition. Contributors: All authors were involved with writing and editing this case and giving approval for publication. SR and KW act as guarantors, accepting full responsibility for the work, having had access to the data, and controlled the decision to publish.
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Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure. pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Provenance and peer review: Not commissioned, not externally peer reviewed. Patient consent obtained. Kelly Weston OST2, Royal Hampshire County Hospital, Winchester SO22 5DG, UK
[email protected] Kate Bush OST4, Royal Bournemouth Hospital, Bournemouth, UK Farid Afshar specialist registrar, Moorfields Eye Hospital, London, UK Steven Rowley consultant ophthalmologist, Royal Bournemouth Hospital, Bournemouth, UK References are in the version on bmj.com. Cite this as: BMJ 2010;341:c6645
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THE LIVES OF DOCTORS Junior doctors’ urine output on an intensive care unit: case-control study Anthony W Solomon,1 2 3 Christopher J Kirwan,1 4 Neal D E Alexander,5 Kofi Nimako,1 6 Angela Jurukov,1 Rebecca J Forth,7 Tony M Rahman,1 8 on behalf of the Prospective Analysis of Renal Compensation for Hypohydration in Exhausted Doctors (PARCHED) Investigators EDITORIAL by Annas 1
General Intensive Care Unit, St George’s Hospital, London, UK 2 Clinical Infection Unit, St George’s Hospital, London 3 Clinical Research Department, London School of Hygiene and Tropical Medicine, London 4 Department of Renal Medicine, St George’s Hospital, London 5 Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London 6 Department of Chest Medicine, St George’s Hospital, London 7 Portex Anaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health, London 8 Department of Gastroenterology and Hepatology, St George’s Hospital, London Correspondence to: A W Solomon, Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT
[email protected] Cite this as: BMJ 2010;341:c6761 doi: 10.1136/bmj.c6761 This is a summary of a paper that was published on bmj.com as BMJ 2010;341:c6761
OBJECTIVE To compare urine output between junior doctors in an intensive care unit and the patients for whom they are responsible. DESIGN Case-control study. SETTING General intensive care unit in a tertiary referral hospital. PARTICIPANTS 18 junior doctors responsible for clerking patients on weekday day shifts in the unit from 23 March to 23 April 2009 volunteered as “cases.” Controls were the patients in the unit clerked by those doctors. Exclusion criteria (for both groups) were pregnancy, baseline estimated glomerular filtration rate <15 ml/min/1.73 m2, and renal replacement therapy. MAIN OUTCOME MEASURES Oliguria (defined as mean urine output <0.5 ml/kg/hour over six or more hours of measurement) and urine output (in ml/kg/hour) as a continuous variable. RESULTS Doctors were classed as oliguric and “at risk” of acute kidney injury on 19 (22%) of 87 shifts in which urine output was measured, and oliguric to the point of being “in injury” on one (1%) further shift. Data were available for 208 of 209 controls matched to cases in the data collection period; 13 of these were excluded because the control was receiving renal replacement therapy. Doctors were more likely to be oliguric than their patients (odds ratio 1.99, 95% confidence interval 1.08 to 3.68, P=0.03). For each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was 0.27 (0.12 to 0.58, P=0.001). Mortality among doctors was astonishingly low, at 0% (0% to 17.6%). CONCLUSIONS Managing our own fluid balance is more difficult than managing it in our patients. We should drink more water. Modifications to the criteria for acute kidney injury could be needed for the assessment of junior doctors in an intensive care unit.
Introduction Assessing the intravascular fluid balance in critically ill patients is a crucial role of intensive care physicians. When intrinsic renal function is normal and the urinary tract is unobstructed, urine output is a key indicator of intravascular volume status. Because of pressure of work, doctors working in intensive care sometimes delay their own autologous hydration and might become “dry” (intravascularly deplete). We hypothesised that this should not occur to such an extent as to lower doctors’ urine output below that of the patients in intensive care. In this prospective case-control study we compared the urine output of intensive care doctors and their patients. 1290
Methods The study was performed in a 17 bed general intensive care unit in a tertiary referral hospital in London over 22 consecutive weekdays (23 March to 23 April 2009). All junior doctors working on the unit who took responsibility for the daily clerking of one or more patients on day shifts during the study were fully informed of the objectives and were eligible to volunteer as cases. The weight of each doctor was determined (wearing scrubs but no footwear, seated and still, having divested themselves of stethoscope, pager, and pocket contents). For each case, controls comprised the patients on the unit clerked by the case that day. On any day, a case can have been matched with more than one control. During data collection, patients (controls) were allocated to doctors (cases) by the specialist registrar in charge of the unit (based on multiple factors, including patients’ diagnoses and overall complexity and the interests and experience of the available doctors), as normal. We determined the patients’ weights either by self report, from relatives, from the most recent weight documented in the medical notes or by estimating their weight. Pregnancy, estimated glomerular filtration rate <15 ml/ min/1.73 m2 (chronic kidney disease stage 5), and renal replacement therapy (including renal transplantation) were exclusion criteria for both cases and controls. On each data collection day, participating doctors emptied their bladders on arrival at work, noting the time at which they did so on anonymised charts fixed to the inside of the male and female staff changing rooms. On each subsequent occasion during the course of their working day, they measured the volume of urine voided using a wide mouthed 1l plastic measuring jug and recorded the amount on the appropriate chart. Regardless of whether or not they had the urge to do so, they voided once more at the conclusion of their shift, noting the volume of urine and the time at which it was passed. Hourly urine volume passed by controls was recorded on flow charts, as normal. As day shifts for doctors start at 8 am and are scheduled to finish between noon and 6 pm but occasionally overrun, we included control data for the period 8 am to 8 pm. We included data only for the period in which patients were admitted to the unit. We placed no restrictions on the use by either doctors or controls of fluids (whether oral or intravenous) or diuretics (including loop diuretics, thiazides, and foods and drinks containing caffeine) with the exception of alcohol, which was not used by either group. Each participating doctor was offered a single 300 ml cup of caffeinated coffee at the multidisciplinary team ward round each morning, but he or she was not obliged to drink it: its consumption and any subsequent fluid intake was at the discretion of the individual and not recorded. BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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Statistical analyses The exposure of main interest was oliguria as a binary variable. A commonly accepted definition of oliguria is a urine output <0.5 ml/kg for each of six or more consecutive hours, which is thought to confer “risk” of renal injury; when urine output <0.5 ml/kg persists for 12 or more consecutive hours, the kidneys are designated to be “in injury.”1 Use of this definition of oliguria was only possible for controls not cases (because of lack of routine catheterisation of doctors on shift). We therefore defined oliguria for both cases and controls as a mean urine output <0.5 ml/kg/hour over a period of six or more hours of measurement. (For full details of statistics see bmj.com.) Results Eighteen doctors (12 men, six women) volunteered for the study, contributing a total of 87 case days (range per case 1-13 days, median 5, 74% of eligible case days). Non-participation on any day was invariably attributed to forgetfulness. For case days, mean and median urine outputs were 0.77 ml/kg/hour and 0.68 ml/kg/hour respectively. In 22 (25%) of 87 case days, the mean shift long urine output was <0.5 ml/kg/ hour. Twenty of these shifts lasted more than six hours, including one that lasted for more than 12 hours (mean shift length 9.2 (SD 1.9) hours, range 4.5-12.3 hours). Assuming doctors’ urine output was relatively constant throughout each shift, doctors were “at risk” of acute kidney injury (based on urine output criteria1) on 19 shifts (22%) and “in injury” on one further shift (1%). Ten (six men, four women; 55%) of 18 cases had at least one day (range 1-3 days) “at risk” of renal injury or worse over the course of the study. We analysed data for 195 control days paired to case days in 87 strata; each stratum therefore had an average of 2.2 control days. Controls had mean urine output <0.5 ml/kg/hour on 29 (15%) of these 195 control days. Pooling 20 oliguric case days together with 29 oliguric control days and considering oliguria as a risk factor, the odds ratio for being a case rather than a control (given the presence of oliguria) was 1.99 (95% confidence interval 1.08 to 3.68, P=0.03). With output assessed as a continuous variable, for each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was about one quarter (0.27, 0.12 to 0.58, P=0.001). For both primary and secondary analyses, being a doctor was associated with lower urine output; our data monitoring committee therefore stopped the study early on safety grounds. (Several of us also reached the end of our intensive care unit attachment.) Discussion Doctors were twice as likely as their patients to be oliguric. We hope (and expect, given that most do not work as hard as us) that these results are not generalisable to the whole UK medical workforce. Ethical approval: The study protocol was reviewed by the Wandsworth Research Ethics Committee, who ruled that the study was a survey and that therefore, under NHS research governance arrangements, did not require formal ethical approval (00105.09).
A surprising lack of mortality A previous study of 41 972 admissions to 22 intensive care units determined that 17% of patients were “at risk” of acute kidney injury at some time during their stay in intensive care and 11% had “injury.”2 In that series, patients without acute kidney injury had mortality rates in hospital of 8%, while those with risk of injury had mortalities of 21% and 46%, respectively.2 The cumulative 0% (95% confidence interval 0% to
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17.6%) mortality in our (frequently oliguric) cases seems nothing short of miraculous in comparison and is presumably attributable to the robust constitutions of doctors on our unit. We did not collect mortality data on controls. Urine output might be a “softer” marker of acute kidney injury than changes in serum biochemistry. This could explain why mortality was higher for each stratum of acute kidney injury in the series of intensive care patients outlined above.2 An alternative explanation could be the need for separate acute kidney injury criteria in patients in intensive care units and their doctors. All our controls had urine output monitored on an hourly basis by experienced intensive care nurses, 24 hours a day; such data are not merely recorded but acted on. Similar close monitoring of urine output with consequent appropriate intervention for doctors has been declined by our nursing staff, even after presentation of these results, and despite advice from the Royal College of Nursing that “looking after colleagues . . . helps to build trust and increase feelings of security” in the workplace.3 This might be an important issue to address as our data suggest that auto-fluid balance management is more difficult than auto-appendicectomy, which has been successful in 100% of published attempts in the past five decades.4 An obvious parallel conclusion to be drawn here is that medicine is far more complex than surgery.
Accuracy of methods The common belief that timed urine self collections are inherently inaccurate is, in fact, a misconception: in a recent UK study of dietary sodium intake, of 751 24 hour urine collections by members of the public, 692 (92%) were objectively assessed as complete or near-complete.5 Our urine was self collected by medically trained individuals in a single location to which participants were essentially confined for the duration of their shift; the unit had one male and one female washroom, and notices concerning the study were prominently displayed in both. Reminders of the importance of accurate collection were also given to each participating doctor on a daily basis. Study weaknesses We did not prescribe or record the intake of fluids in cases. We were unable to record an objective measure of each doctor’s stress each day and can therefore not exclude an antidiuretic effect of stress induced vasopressin release. We also cannot rule out a Hawthorne effect. Finally, we did not attempt to ultrasonographically exclude postmicturition urinary retention in our cases at the end of each shift. Implications Oligoanuria is usually acute renal success rather than failure, being a sophisticated response to tubular damage caused by renal hypoperfusion or nephrotoxins, preventing life threatening polyuria when reabsorption of glomerular filtrate is impaired.6 The frequency with which this response was manifest in our doctors could (as suggested by our renal and intensive care physician) be interpreted as a demonstration of the physiological superiority of doctors in intensive care units or merely show (as suggested by the rest of us) that we should try to drink more water while on shift. We need a functioning water fountain in the staff room and the sense to go and drink from it. Full version of article on bmj.com 1291
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Phantom vibration syndrome among medical staff Michael B Rothberg, Ashish Arora, Jodie Hermann, Reva Kleppel, Peter St Marie, Paul Visintainer Division of General Medicine, Baystate Medical Center, Springfield, MA, and Tufts University School of Medicine, Boston, MA, USA Correspondence to: M B Rothberg, Division of General Medicine and Geriatrics, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
[email protected] Cite this as: BMJ 2010;341:c6914 doi: 10.1136/bmj.c6914 This article is an abridged version of a paper that was published on bmj.com. Cite this article as: BMJ 2010;341:c6914
OBJECTIVE To describe the prevalence of and risk factors for experiencing “phantom vibrations,” the sensory hallucination sometimes experienced by people carrying pagers or cell phones when the device is not vibrating. DESIGN Cross sectional survey. SETTING Academic medical centre. PARTICIPANTS 176 medical staff who responded to questionnaire (76% of the 232 people invited). MEASUREMENTS Electronic survey consisting of 17 questions about demographics, device use, phantom vibrations experienced, and attempts to stop them. RESULTS Of the 169 participants who answered the question, 115 (68%, 95% confidence interval 61% to 75%) reported having experienced phantom vibrations. Most (68/112) who experienced phantom vibrations did so after carrying the device for between 1 month and 1 year, and 13% experienced them daily. Four factors were independently associated with phantom vibrations: occupation (resident v attending physician), device location (breast pocket v belt), hours carried, and more frequent use in vibrate mode. Strategies for stopping phantom vibrations included taking the device off vibrate mode, changing the location of the device, and using a different device. CONCLUSIONS Phantom vibration syndrome is common among those who use electronic devices.
Introduction Electronic devices, such as pagers and cell phones, have become ubiquitous in the information age. In order to maintain electronic access in quiet areas, users often place such devices on “vibrate” mode. Repeated use of the vibration mode may result in intermittent perception that the device is vibrating when, in fact, it is not. This sensation, sometimes referred to as phantom vibration syndrome, has been described in the lay press,1 but its prevalence has not been established. We conducted a survey of medical professionals who are expected to carry an electronic communication device in order to assess the prevalence of this phenomenon and other factors associated with it.
THOM FERRIER
Methods In May 2010 we conducted a cross sectional survey of medical staff at Baystate Medical Center, western Massachusetts, and at an affiliated health centre. Because this was a hypothesis generating study, we did not perform a sample size calculation. Instead, all internal medicine staff and students who were on the hospital paging system received an email invitation to participate in an online survey about electronic devices such as pagers and cell phones. Members of the mailing list also received two follow-up reminders at roughly one week intervals. The survey contained 17 questions, including potential factors associated with phantom vibrations— 1292
age (in 10 year increments), sex, occupation, the type of device used, whether the device was used in vibration mode, where it was worn, and how frequently it rang—and whether the respondent has experienced phantom vibrations (survey available on request). For those who reported phantom vibrations, we also asked how often they occurred, how bothersome they were, what methods users employed to stop the vibrations, and whether any of these were successful. The survey was pilot tested to assure clarity and coherence and was approved by the institutional review board of Baystate Medical Center.
Statistical analysis We conducted comparisons between the primary outcome (presence or absence of phantom vibrations) and categorical variables using Fisher’s exact test and Cuzick’s non-parametric test for trends.2 Our multivariable analyses used Poisson regression with robust standard errors in order to facilitate interpretation of the prevalence ratios and to produce valid estimates of the confidence intervals for prevalence ratios.3 For univariable analyses, observations with missing data for specific variables were excluded from analyses using those variables (that is, casewise deletion). Multivariable models were based on observations with valid values for all variables included in the final model (that is, listwise deletion) Associations from univariable and multivariable analyses were considered significant at a critical test level of 5%. Results Of the 232 people who received the email invitations, 176 (76%) responded (see bmj.com for details of their characteristics). In all, 115/169 (68%, 95% confidence interval 61% to 75%) reported having experienced phantom vibrations. Phantom vibrations were equally common with pagers and cell phones (99/145 (68%) v 96/139 (69%), P=0.80). Most respondents began experiencing phantom vibrations after carrying the device for between one month and one year (68/112 (61%, 51% to 70%)), but 18 (16%) experienced them after less than a month, and 26 (23%) did not experience them until they had used the device for a year or more (table 1). Most respondents experienced the phantom vibrations either weekly or monthly (97/111 (87%, 80% to 93%)), but 14 (13%, 7% to 20%) experienced them on a daily basis. Secondary analyses In univariate analysis, five factors were associated (defined as P<0.05) with experiencing phantom vibrations: age, occupation, device location, hours worn per day, and how often the device was used in vibrate mode. In multivariable analysis, only occupation (or age), device location, and how often the device was in vibrate mode remained significantly associated with phantom vibrations (table 2 on bmj.com). Because age and occupation were highly co-linear in this sample, it was impossible to estimate their effects on phantom vibrations simultaneously. Both variables had a similar influence on the other variables when modelled separately. BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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TABLE 1 | CHARACTERISTICS OF PHANTOM VIBRATIONS EXPERIENCED BY 115 RESPONDENTS TO SURVEY OF PHANTOM VIBRATION SYNDROME Characteristic
No (%) of respondents*
Ever experienced phantom vibrations Bothersomeness: Not at all A little Bothersome Very bothersome Duration of use of device before phantom vibrations began: <1 month 1–5 months 6–12 months >12 months Frequency of phantom vibrations: Daily Weekly Monthly Succeeded in stopping the phantom vibrations Moving the device Helpful Not helpful Not attempted Stop using in vibrate mode Helpful Not helpful Not attempted Change device Helpful Not helpful Not attempted
115 37/114 (32) 69/114 (61) 6/114 (5) 2/114 (2) 18/112 (16) 46/112 (41) 22/112 (20) 26/112 (23) 14/111 (13) 43/111 (39) 54/111 (49) 43/111 (39) 29/105 (28) 17/105 (16) 59/105 (56) 27/103 (26) 9/103 (9) 67/103 (65) 7/99 (7) 7/99 (7) 85/99 (86)
*Numbers adjusted for those who did not answer the particular question.
Most respondents who experienced phantom vibrations found the sensation to be not at all or only a little bothersome (106/114 (93%, 87% to 97%)). However, 8/114 respondents (7%, 2% to 12%) found the sensation to be bothersome or very bothersome. Finally, of those who experienced phantom vibrations, 43/110 (39%, 30% to 48%) were able to stop them. Strategies for stopping them included taking the device off vibrate mode, changing the location of the device, and using a different device (success rates of 27/36 (75%) v 29/46 (63%) v 7/14 (50%) respectively, P=0.217). Interestingly, 42/108 (39%, 30% to 49%) respondents did not attempt any strategies to stop the phantom vibrations.
bmj.com/video ЖЖWatch Michael Rothberg and colleagues explain why they did the research and what they found at bmj.com/video
Discussion In this cross sectional survey of medical staff, we found that almost 70% had experienced phantom vibrations from an electronic device. The perceptions were most common among students and house staff and were associated with frequency of use. Most respondents found the sensations to be only mildly annoying, but 2% found them very bothersome. As a result, only 61% had tried to stop them, and most of those who tried succeeded in extinguishing the sensation—either by moving the device or refraining from using it in vibrate mode. The cause of phantom vibration syndrome has not been explored, but the extremely high prevalence of phantom vibrations encountered in our sample attests to the fact that normal brain mechanisms are at work. Why some individuals experience it while others do not, why it is more common in younger people (or house staff), and why some body locations seem to be more prone than others to developing phantom vibrations remain unanswered questions. It may be that neural plasticity of younger people makes them more susceptible to imagining vibrations. Alternatively, it may be
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that pages received by medical students and house staff are more likely to require urgent attention than those received by attending physicians. Like new mothers who constantly imagine they hear their baby crying, students and residents check and recheck their pagers. For those who attempted to stop the phantom vibrations, relocating the device was often successful. Also the sensations, which were associated with frequency of use, seemed to disappear if the stimulus was avoided. Refraining from using the device in vibrate mode did not work for everyone, however, and some people felt the device vibrating even when they were not in contact with it.
Comparison with other studies This is the first report of this phenomenon that we are aware of in the medical literature. In a graduate thesis published in 2007 on “Emotional and behavioral aspects of mobile phone use,” David Laramie surveyed 320 adult mobile phone users and found that two thirds had experienced phantom rings,4 similar to the proportion we report. Limitations of the study Our study had several limitations. Firstly, the survey was limited to medical professionals in a single institution. However, our findings are similar to those reported in a graduate thesis studying the general population. Secondly, frequency of use was self reported and may have been overestimated or underestimated. Similarly, efforts to stop the vibrations were also assessed retrospectively without controls. Thirdly, 24% of those invited to participate declined to do so. We tried to hide the exact nature of the survey, but those who took it early may have revealed the content to others and thereby introduced a bias into our sample. Finally, our survey represents a single point in time. Conclusions and implications More than half the people on the planet now carry some sort of cellular phone,5 and many of these will set the device on vibrate mode at least some of the time. If two thirds of these people develop phantom vibrations—even if they are not very bothersome—then the global impact is substantial. If even a small proportion of users experience severe symptoms, then effective treatment will be required. More research is needed to understand why phantom vibration syndrome occurs and how to stop it. The study was conducted with the goodwill of the participants and investigators. Funding: None. Competing interests: None declared. Ethical approval: Consent was not obtained but the presented data are anonymised and risk of identification is low. Data sharing: Complete survey and dataset available from MBR at Michael.
[email protected]. 1 2 3 4 5
Haupt A. Good vibrations? Bad? None at all? USA Today 2007 June 12, 2007. Cuzick J. A Wilcoxon-type test for trend. Stat Med 1985;4:87-90. Barros AJ, Hirakata VN. Alternatives for logistic regression in crosssectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003;3:21. Laramie D. Emotional and behavioral aspects of mobile phone use [PhD thesis]. Alliant International University, 2007. Market Information and Statistics Division TDB, International Telecommunication Union. The world in 2009: ICT facts and figures. International Telecommunications Union, 2009.
Accepted: 24 November 2010 1293
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The barrier method as a new tool to assist in career selection: covert observational study R Scott McCain, Andrew R Harris, Kevin McCallion, W Jeffrey Campbell, Stephen J Kirk
Cite this as: BMJ 2010;341:c6968 doi: 10.1136/bmj.c6968 This is an abridged version of a paper that was published on bmj.com as BMJ 2010;341:c6968
OBJECTIVE To determine if senior doctors’ parking habits and skills are associated with clinical specialty and, if so, whether observation of junior doctors’ parking could provide guidance in choice of specialty. DESIGN Covert observational study. SETTING Pass-card controlled consultants’ car park (parking lot), December 2009. PARTICIPANTS 103 consultants entering the car park on three consecutive mornings. MAIN OUTCOME MEASURES The outcomes were specialty and sex of the consultants, manner of approaching the barrier (pass-card ready or not), and time taken to park, exit the vehicle, and walk to a designated area. RESULTS Approaches to the barrier and parking were recorded for 103 consultants: 28 anaesthetists (22 men, six women), 29 physicians (internists, 18 men, 11 women), 14 radiologists (nine men, five women), and 32 surgeons (30 men, two women). The manner of approaching the barrier (card ready) differed by specialty but not by sex. The total time taken to park (seconds) differed significantly between specialties: surgery (median 68, interquartile range 61-71 seconds), anaesthesia (82, 76-91 seconds), radiology (86, 70-103 seconds), and general medicine (112, 96-136 seconds). The time taken to park was overall longer among women, but this was explained by their specialty (men and women matched by specialty did not differ). CONCLUSIONS The total time taken to park and manner of approaching the barrier to gain entry to the car park differed across specialties. Surgical consultants were fastest, followed by consultant anaesthetists and consultant radiologists, with physicians slowest. Sex was not an influencing factor. If reproducible in studies of a similar nature the “barrier method” could allow for a low cost means of guiding junior doctors in career selection.
Introduction In the United Kingdom, interview scores are the main discriminating factor to identify trainee doctors suitable for a specialty, whereas elsewhere references assume more importance.1 Assessments focus on knowledge rather than personality traits, ability, or aptitude needed for a particular specialty. Using covert observation of behaviour we investigated the association between senior doctors’ parking habits and skills and their clinical specialty. On this basis, observation of junior doctors’ parking habits could determine their most appropriate career choice. Methods Entries to a consultants’ car park (by electronic cards) were monitored on three consecutive mornings (07.15-10.30 am) in December 2009. This open, single level car park, entered by a private road, 1294
provides parking for consultants from several specialties. An observer, familiar with the hospital’s consultants and their specialty, wore a hooded coat and stood at a partially concealed point. The manner of approaching the barrier was assessed and recorded as “card ready” if the entry card was ready for use. A stopwatch recorded the time (seconds) to approach and negotiate the barrier, park the vehicle, get out of the vehicle, and walk to a designated point. We categorised the consultants by specialty and sex.
Statistical analysis We present time (seconds) as medians (interquartile ranges). The difference in manner of approaching the barrier was assessed using the χ2 test and Fisher’s exact test. The Kruskal-Wallis one way analysis of variance was used to analyse the difference in times between all groups. When significant differences were identified we used the MannWhitney-Wilcoxon test to carry out further analysis between two groups. We considered P<0.05 to be significant. Results Approaches to the barrier and parking were recorded for 103 consultants (79 men, 24 women): 28 anaesthetists (22 men, six women), 29 physicians (18 men, 11 women), 14 radiologists (nine men, five women), and 32 surgeons (30 men, two women). One physician was excluded as he arrived to work on a motorcycle and entered the car park through a gap in the barrier system and did not use his electronic pass. One anaesthetist, who thought the observer was a member of hospital management, protested vehemently at his presence and was excluded from the study as time had been prolonged artificially. Surgeons were significantly fastest (median 68, 61-71 seconds) followed by anaesthetists (82, 76-91) and radiologists (86, 70-103), with physicians the slowest (112, 96-136; table). Surgeons were fastest for all outcomes. The difference in each timed outcome between all specialties was significant (P<0.001; see bmj.com). Overall time (seconds)
Department of General Surgery, Ulster Hospital, Dundonald, Belfast BT16 1RH, Northern Ireland Correspondence to: R S McCain
[email protected]
200 160
Manner of approach Card ready Card not ready
120 80 40 0
Surgery
Anaesthesia
Radiology
General medicine Specialty
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OVERALL TIME TO PARK AND MANNER OF APPROACH TO CAR PARK, BY SPECIALTY AND SEX Specialty and sex Surgery: Men Women Total Anaesthesia: Men Women Total Radiology: Men Women Total General medicine: Men Women Total
Sample size
Median (interquartile range) overall time (s)
No (%) with card ready at barrier
30 2 32
67 (61-71) 85 (77-93) 68 (61-71)
28 (93) 2 (100) 30 (94)
22 6 28
82 (75-89) 90 (84-91) 82 (76-91)
12 (55) 3 (50) 15 (54)
9 5 14
75 (56-80) 100 (91-121) 86 (70-103)
7 (78) 4 (80) 11 (79)
18 11 29
109 (98-120) 122 (97-144) 112 (96-136)
9 (50) 3 (27) 12 (41)
Overall time to park was significantly longer among women (100, 91-130 v 77, 68-100; P<0.001). Male and female physicians, anaesthetists, and surgeons did not differ. The difference between male (n=9) and female (n=5) radiologists was significant, although the numbers were small (see bmj.com). The manner of approaching the barrier differed by specialty (P<0.001); 54% of anaesthetists (n=15), 41% of physicians (n=12), 79% of radiologists (n=11), and 94% of surgeons (n=30) had their cards ready (see bmj.com). The specialties differed in total time taken regardless of how the barrier was approached (figure). Confounding variables were thought to have no influence on the overall results. One anaesthetist crashed into the ticket machine. One physician approached the barrier with his head out of the driver’s window to check how close he was to the kerb. Another physician was obliged to open her door to use the pass-card. BMJ | 18-25 DECEMBER 2010 | VOLUME 341
Discussion The covert observation of parking skills (COPS) of consultants showed that surgeons park fastest, followed by anaesthetics and radiologists (no significant difference), with physicians slowest. Men and women matched by specialty did not differ significantly. Consistency was maintained by using one observer. Few confounding variables existed. The car park is large and availability of parking was not a concern. Information on bags carried was not formally recorded, but most consultants carried at least one into work. No one carried more than two items. It was more common for surgeons than for consultants from the other specialties to carry two items, with several carrying a large bundle of radiographs in addition to a bag. This did not affect the results, as surgeons were the fastest group overall. Although participants were blinded, the observer was not. Consultants who carried out the study were excluded from analysis. No other consultants in the hospital were aware of the study. The authors are surgeons, and although we accept that this is a potential source of bias, we believe that data were gathered accurately. When interpreting the data we have assumed that consultants in our unit are appropriate for their specialty, but we cannot be sure. It is unclear if personality traits seen in parking influence choice of specialty or if specialty influences personality. Furthermore, it is unclear if trainees’ driving habits are well established early enough to allow for use of COPS as an assessment tool. We would propose that if validated in similar studies, COPS could allow objective assessment of doctors in training and provide them with guidance on specialty choice. Contributors: See bmj.com. Data sharing: Statistical dataset and code available from the corresponding author at
[email protected]. 1
Jefferis T. Selection for specialist training: what can we learn from other countries? BMJ 2007;334:1302-4.
Accepted: 29 November 2010 1295
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Bicycle weight and commuting time: randomised trial J Groves EDITORIAL by Annas Department of Anaesthetics, Chesterfield Royal Hospital, Calow, Chesterfield, UK Correspondence to: J Groves
[email protected] Cite this as: BMJ 2010;341:c6801 doi: 10.1136/bmj.c6801 This is an abridged version of a paper that was published on bmj.com as BMJ 2010;341:c6801
OBJECTIVE To determine whether the author’s 20.9 lb (9.5 kg) carbon frame bicycle reduced commuting time compared with his 29.75 lb (13.5 kg) steel frame bicycle. DESIGN Randomised trial. SETTING Sheffield and Chesterfield, United Kingdom, between mid-January 2010 and mid-July 2010. PARTICIPANTS One consultant in anaesthesia and intensive care. MAIN OUTCOME MEASURE Total time to complete the 27 mile (43.5 kilometre) journey from Sheffield to Chesterfield Royal Hospital and back. RESULTS A total of 30 journeys and 809 miles (1302 km) were travelled on the steel frame bicycle during the study period, compared with 26 journeys and 711 miles (1144 km) on the carbon frame bicycle. The difference in the mean journey time between the steel and carbon bicycles was 00:00:32 (hr:min:sec; 95% CI –00:03:34 to 00:02:30; P=0.72). CONCLUSIONS A lighter bicycle did not lead to a detectable difference in commuting time. Cyclists may find it more cost effective to reduce their own weight rather than to purchase a lighter bicycle.
Introduction Last year I acquired a secondhand steel frame bike for £50, spruced it up, and set off using it for my daily commute to work. I soon got into the swing of cycling the 27 miles (43.5 kilometres) from home in Sheffield, to work in Chesterfield and back, managing it most days when I wasn’t on call and didn’t have commitments off site. After about six months of commuting I began to wonder whether the one way journey time of about 55 minutes could be reduced by a new carbon frame bike. Evidence based cycling is not high on the bicycle salesman’s agenda. No one will tell you how much more efficient one bicycle is over another; they just say it is better. Making a decision on what was perceived to be best and dreaming of extra time in bed, I looked into the UK government’s Cycle to Work scheme. This allows an employee to purchase a bicycle (up to a cost of £1000 (€1180; $1560)) at a significant discount by using tax incentives, provided the bicycle is used for commuting to and from work.1 Doubt has been expressed in the popular press regarding whether the new generation of middle aged men in Fig 1 | The author and the two bicycles used in the study, with the steel frame bike on the left and the carbon frame bike on the right
lycra (MAMILs) are actually using their scheme funded bikes to commute or just to gum up the roads at weekends. I purchased a bike with a carbon frame, lighter wheels, and narrower tyres. All were factors that made me believe that the extra £950 I had spent would get me to work in a trice. My new bike seemed wonderful, if somewhat uncomfortable. I didn’t notice a dramatic decrease in commuting time, nor did the cycle computer I had fitted to it. But, one sunny morning, I got to work in 43 minutes, the fastest I could recall. My steel bike was consigned to a corner of the garage to gather dust—until I had a puncture. The next day I was back on my old steel bike. I fitted the cycle computer, set off . . . and discovered I had got to work in 44 minutes. “Hang on,” I thought, “was that minute worth £950 or was it a fluke?” There was only one answer: a randomised trial. I toyed with the idea of blinding it but, in the interest of self preservation and other road users, decided against it.
Methods This was a single centre, randomised, non-blinded trial; n=1. Both bicycles were of traditional “road” construction with drop handlebars, although the frame of one was made of steel and the second carbon (fig 1; table 1). Identical lights and fittings were used on each bike. Between mid-January 2010 and mid-July 2010, either the steel frame bicycle or the carbon bicycle was randomly allocated for my daily commute according to the toss of a £1 coin. The time the bicycle was moving for the 27 mile (43.5 km) round trip was recorded with a bicycle computer. Clothing worn was determined by the weather conditions on the morning of travel. The journey, predominantly on urban A roads, included 0.62 miles (1 km) of dual carriageway, 1.86 miles (3 km) of country lanes, and 328 feet (100 metres) of farm track. The total ascent for the round trip was 2766 feet (843 metres). The journey times were entered into a spreadsheet and times compared. Results A total of 30 journeys and 809 miles (1302 km) were travelled on the steel frame bicycle during the six month study period, compared with 26 journeys and 711 miles (1144 km) on the carbon frame bicycle (table 2). Two journeys on the steel bike were excluded owing to punctures. One journey on the carbon bike was excluded after an offer of a lift home with a colleague. The slowest journey was on the carbon bike in heavy snow, and the fastest journey on the steel bike as a direct result of chasing one of my fitter cycling colleagues to work. The average journey time on the steel frame bicycle was 1:47:48 and on the carbon frame bicycle was 1:48:21. The difference in the mean journey time was 00:00:32 (95% CI –00:03:34 to 00:02:30; P=0.72). Forces acting against the cyclist Gravity The difference in weight between the two bicycles is 8.85 lb (4 kg), whereas the rider weighs the same at 167.6 lb (76 kg). The energy expended on lifting the steel bike and rider
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THE LIVES OF DOCTORS
TABLE 1 | BICYCLE SPECIFICATION
Frame Wheels Tyres Pedals Weight
Steel frame bicycle
Carbon frame bicycle
Steel 321 Alloy 36 spoke 700C wheel of standard alloy rim construction 32 mm Schwalbe Marathon Non-clip 29.75 lb (13.5 kg)
Carbon monocoque 20 spoke 700C wheel with alloy rim 25 mm Schwalbe Marathon Plus Non-clip 20.9 lb (9.5 kg)
TABLE 2 | SPEED, DISTANCE, AND JOURNEY TIMES
Total number of journeys Total distance Top speed Fastest journey time (hr:min:sec) Slowest journey time (hr:min:sec) Average journey time (hr:min:sec)
Steel frame bicycle
Carbon frame bicycle
30 809 miles (1302 km) 36 mph (58 kph) 1:37:40 1:57:44 1:47:48
26 711 miles (1144 km) 36 mph (58 kph) 1:40:50 2:03:20 1:48:21
through 2766 feet (843 metres) is about 740 kilojoules, compared with about 706 kilojoules for the carbon bike (see web appendix A). The additional energy expended on lifting the steel bike compared with the carbon bike was 34 kilojoules (5% extra). Friction (rolling resistance) The difference in friction (rolling resistance) between bicycles was 0.2 Newtons. The extra power necessary on the steel bike to overcome this difference was 1.2 watts. Drag The power required to overcome drag on a touring bike— steel, carbon or chocolate framed—at 15 mph (24 kph) is about 170 watts.
Winter versus summer The difference between the mean journey time in winter (20 January to 19 April 2010) and summer (21 April to 22 July 2010) was 00:06:50 (95% CI 00:04:39 to 00:08:59; P<0.01). Discussion There was no measurable difference in commuting time on the carbon frame bicycle compared with the steel frame bicycle. This is at variance to the intuitive assumption that less weight means more speed. Though a 30% reduction in bicycle weight may seem large, the reduction in total weight (bicycle + rider) of 4% is much less impressive and other forces need to be considered.
bmj.com/podcasts ЖЖListen to an interview with Jeremy Groves, who explains his research at bmj.com/podcast
Drag Drag is independent of mass and proportional to the cube of the velocity. The power required to overcome drag on the steel touring bike is seven times that required to overcome rolling resistance. The exponential increase in drag with increase in velocity has the perverse effect of counteracting anything else that may increase the speed of the bike. Acceleration There is a very good explanation of acceleration on Wikipedia,2 particularly with respect to wheels, where lighter rims can confer a significant advantage, but only if there are a significant number of points of speed change on the journey. There were not enough on mine.
Winter versus summer There was a statistically significant difference between times in the first (winter) and second (summer) halves of the trial. Looser shell winter clothing may increase drag by as much as 30%. Fear of falling off might increase journey time in winter; when the road is wet or icy the cyclist is more cautious. Winter is also associated with higher winds. Traffic Regardless of whether the bike is carbon or steel, you still have to stop at junctions and red lights. Implications Why do so many of us buy “performance” bicycles? Marketing must shoulder some of the responsibility, though we must excuse consumerism, particularly at this time of year, because without it our capitalist society would collapse. The purchase of the carbon bike made me feel good, and even though the ride is less comfortable, I still commute on it, especially in good weather. I haven’t compared the brakes but they seem better. Which do I enjoy riding most? Well, after the trial I have to go for the steel bike. I get there as quickly, and it is more comfortable, better value, and has more “character.” If the carbon bike were stolen would I replace it? I’d have to say no. I’d spend the money on high visibility low drag clothing and better lights. As Lance Armstrong, seven times winner of the Tour de France, said, “It’s not about the bike.”3 A new lightweight bicycle may have many attractions, but if the bicycle is used to commute, a reduction in the weight of the cyclist rather than that of the bicycle may deliver greater benefit and at reduced cost. I thank C Cooper and H Spencer for their helpful comments and R Groves for proofreading the manuscript and checking the maths.
Forces acting against the cyclist Gravity The additional energy expended on lifting the steel bike was an extra 5%, the overall effect is less as energy is conserved. Gravitational potential energy gained going up will be converted into kinetic energy going down.
Funding: The study was entirely funded by the author and the author has no commercial relationship with any bicycle manufacturer or commercial cycling enterprise.
Friction (rolling resistance) Friction (rolling resistance) is relatively small for a bicycle on tarmac and is dependent on the tyre contact area and side wall flex. The manufacturers’ literature implied that both sets of tyres had similar resistance.
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Competing interests: None declared. Ethical approval: Ethical approval was not obtained as the sole investigator and subject was the author. The research was conducted on his regular journey to and from work using his normal mode of transport.
2 3
Department for Transport. Cycle to work scheme—implementation guidance. 28 October 2009. http://www.dft.gov.uk/pgr/ sustainable/cycling/cycletoworkguidance/. Wikipedia. Bicycle performance. http://en.wikipedia.org/wiki/ Bicycle_performance. Lance Armstrong. It’s not about the bike: my journey back to life. Yellow Jersey, 2000. 1297
PRIMARY CARE A modest proposal for preventing primary care physicians in America from being a burthen to their profession or the country, and for making them beneficial to the publick Philip Mackowiak finds inspiration in Jonathan Swift’s 18th century satire
HOWARD PYLE: WALKINH THE PLANK/BRIDGEMAN
O
Fixing the primary care problem 1298
nce President Obama has put the US healthcare insurance crisis to bed, he must then figure out what to do about primary care providers, who are crucial (as those who have more expertise in such matters than I believe) to the success of his healthcare programme. Roughly reckoned, there are some 300 000 to 350 000 of them.1 The question is: how do we continue to train, equip, and maintain this number, much less provide for the even larger number that others have suggested is needed to care for our ageing population?2 The current crop is already hard pressed to cover their overheads, to say nothing of supporting their spouses and children, who, given current levels of compensation for primary care services, are soon sure to become wards of the state. As to my own qualifications for offering advice on this weighty matter, I have for years read and ruminated over the subject, carefully weighed the myriad solutions offered by others (including but not limited to: comparative effectiveness research, accountable care organisations (ACOs), patient centred medical homes, capitated/global payment schemes, and sentinel networks) and found each of them grossly mistaken in concept. These prior proposals, concocted mostly by PhDs and other nonclinicians, have focused on the primary care physician as the solution to America’s healthcare crisis. I believe a broader perspective is indicated, one in which the primary care physician is recognised not just as the solution to the problem, but also its cause. In all humility, I offer for consideration the following plan: that a handful of the family practitioners, internists, paediatricians, and obstetricians/gynaecologists self identified as primary care providers currently supported by our system (that is, no more than 1% of the total), be designated for remedial training in dermatology, cosmetic surgery, virtual endoscopy, or some other underserved discipline in which their former training might be of use in refining BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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existing practice guidelines designed to funnel patients to subspecialists. I further propose that the remaining 352 183 primary care providers be dispensed with in the simplest, most expedient, most cost effective, and most humane manner possible—that they be exterminated. I am not suggesting that they be boiled, barbecued, or fricasseed as per Jonathan Swift’s ingenious scheme for transforming the children of the poor people of 18th century Ireland from a liability into an asset.3 That would be illegal. Rather, I propose that they be sacrificed on the altar of a new healthcare paradigm by the immediate interruption of all payments for primary care services, and that the monies saved by the elimination of the cost of training and then supporting primary care physicians be reinvested in a computer based, direct to consumer, healthcare programme in which every American, regardless of race, religion, or ability to pay, is empowered to diagnose and to treat his or her own medical conditions using the most up to date, evidence based clinical guidelines that modern health information technology can provide. Let me now offer a few thoughts on finances, which I am confident will not raise even the slightest objection. As you are no doubt aware, the annual cost of medical care in America has reached $2.5tn (£1.6tn; €1.9tn).4 Of this amount, some $600bn is spent each year to finance the operations of primary care physicians.2 These are monies that would be used more productively to support my proposal for transforming America’s primary care physician from a liability into an asset and for properly medicating the country. Happily, according to my calculations (formula available on request), this will cost a mere $92.4bn per annum. The beauty of my programme is its ability to reduce cost while increasing patient satisfaction, by eliminating primary care middlemen, who too often meddle with practice guidelines by promoting lifestyle modifications over drugs, altering doses or, worst of all, denying patients evidence based medications because of some perceived so called relative contraindication. What is more, those who are more thrifty (as I must confess the times require) will surely bring the cost of my programme down over time by figuring out how to recycle unused medications, so that they might be sold to needy third world countries at a steep discount, not only to help satisfy the appetite for drugs of our less advan-
taged neighbours, but also to begin rehabilitating our image as a nation of peace loving idealists. Some cynics will argue that precious resources will be wasted on lost causes in such a programme, resources that might be used more effectively in the maintainance of health through education and prevention rather than being poured into treating diseases, many of which blossom only during the final year of life. They claim that preventing diseases is vastly more cost effective than treating diseases. I would simply respond to these objections by pointing out that Inspiration preventive measures can reduce the cost of medical care only if they make it possible for patients to drop dead in perfect health.5 Otherwise, they only postpone the cost of terminal care. Let me now consider the advantages of my proposal, which should be obvious to all but those most resistant to innovative solutions. Firstly, as I have already pointed out, it will solve America’s healthcare crisis decisively and permanently by eliminating the primary care physicians responsible for it and the need for the services they provide. Of course, it would leave a not insignificant number of patriotic Americans out of work—but certainly not without prospects. Given their connections and conservative life styles, primary care physicians would be ideal organ donors and might sustain themselves, at least for a time (not to mention alleviate another of our healthcare crises), by auctioning off spare kidneys, left hepatic lobes, lungs, and such. Secondly, those millions of marginalised members of our great society, who heretofore have lacked adequate medical care, will have access to a programme of medical care more comprehensive, more accessible, more uniform, and more satisfying than any yet devised. Thirdly, this would be a great inducement to patient autonomy. Patients would now not just participate in decisions related to their health-
I propose that they be sacrificed on the altar of a new healthcare paradigm by the immediate interruption of all payments for primary care services
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care, they would make those decisions themselves—intelligently, using evidence based data from every conceivable source virtually the minute it is generated. In time, they might even be empowered to perform their own diagnostic tests, perhaps also minor surgical procedures (on themselves, family, and friends), making possible the additional extermination of clinical pathologists and general surgeons. Many other advantages might be enumerated. For instance, what better way to apply evidence at the point of care? With primary care physicians out of the way, clinical judgment will no longer hamper the narrow interpretation or rigid enforcement of practice guidelines. Variations in clinical practice will be eliminated completely. With immediate access to pills of every ilk, sick patients will be made well, and people who are not sick will be made better than well once given unlimited access to Prozac, Levitra, and such. Our entire population will have a personalised electronic medical record from which mountains of data can be mined. Accountable care organisations will be able to run everythingagainst-everything on hundreds of millions of patients being treated for and/or prophylaxed against every conceivable disorder. Countless statistically significant associations will then be translated into a host of new performance measures and practice guidelines used to monitor and manipulate patients’ activities and also to harass subspecialists as relentlessly as primary care physicians once were. Some might object to my proposal by quibbling over the limitations of evidence based medicine or fretting over the theoretical problems of adverse drug events. With regard to the former, they would have us believe that all evidence is imperfect, and that our answers to life’s great questions (for example, hormone replacement therapy, low fat diets, erythropoietin in patients with cancer, and so on) are no more likely to withstand the test of time than those of earlier generations. They claim that much of the evidence upon which clinical decisions are based comes from studies in which industry has exercised undue 1299
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influence, that publication of investigations in medical journals endows their results with a veneer of certainty that is inappropriate and potentially dangerous, and that our expectations for the benefits of treatments are so high we fail to recognise that they sometimes do more harm than good, and that doing nothing is occasionally the best treatment. Some have even gone so far as to question the sanctity of the P value. They argue that hierarchies of evidence, in which randomised controlled trials occupy the highest rung, attempt to replace judgment with an overly simplistic, pseudo-quantitative assessment of the quality of the evidence presented.6 Still others would have us believe that journal editors favour positive results over negative results and, like the general public, readily believe what they earnestly hope for. To those obsessed with such concerns, I would simply ask: which is worse, knowing what might not be so, or knowing nothing at all? With regard to adverse drug effects, there can be no doubt that there will be a few. Fortunately, we have drugs with which to treat most.7
To be sure, this programme, like all innovative programmes, will face not a few challenges during its implementation. Even so, I know of no cheaper, fairer, more comprehensive system of medical care yet proposed. That being said, I am not so violently bent on my own plan as to reject one offered by another that is as cheap, easy, and effectual. But, I humbly request that before some other scheme should be advanced in place of my own, at a minimum, evidence based data from a randomised pilot study involving no fewer than several million participants per arm be conducted to select the best one. Philip A Mackowiak, professor, vice chairman, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA and chief, Medical Care Clinical Center, VA Maryland Health Care System, Baltimore, Maryland
[email protected] Presented as the Nicholas E Davies Memorial Lecture at the ACP Annual Meeting on 24 April 2010, Toronto, Canada. The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no
financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work. None of his friends or associates stands to profit from his proposal. Only his ex-wife is uninsured, and, thanks to their acrimonious divorce, she refuses to have anything to do with the medical profession. Provenance and peer review: Not commissioned; externally peer reviewed. American Medical Association. Physician characteristics and distribution in the US. American Medical Association, 2006. 2 American College of Physicians. State of the nation’s health care 2006: ACP releases proposals to avert looming collapse of primary care. 2006. www.acponline.org/ advocacy/events/state_of_healthcare/statehc06.htm. 3 Swift J. A modest proposal for preventing the children of poor people in Ireland from being a burden to their parents or country, and for making them beneficial to the public. 1729. Project Gutenberg. Available from http:// gutenberg.net. 4 Remaking America’s health-care system [editorial]. Lancet 2009;374:357. 5 Russell LB. Prevention’s potential for slowing the growth of medical spending. National Coalition on Health Care, 2007. 6 Rawlins M. Harveian oration 2008. Royal College of Physicians, 2008. 7 Nurnberg HG, Hensley PL, Heiman JR, Croft HA, Debattista C, Paine S. Sidenafil treatment of women with antidepressant-associated sexual dysfunction. A randomized controlled trial. JAMA 2008;300:395-404. Cite this as: BMJ 2010;341:c6605
1
RICHARD WILLIAMS
Liberating the NHS from its acronyms and abbreviations
They came from the PCT in a GTi. It was a QOF review, PMS visit, and PBC update. Big hair, smart dress, grey suit—but we were not impressed. She’d been at the DH, SHA, and GOEM; he knew his KPIs from KPMG. He hated the LMC, GPC, and BMA. The RCGP were just about OK. COGPED she loved— she was too green to know or care about the FPC, FHSA, PCG, or GMSC. He had never heard of the GPDF. She just didn’t know her NHS roots. 1300
Her agenda was clear: switch to nGMS, upload the SCR, work with PALS or face the GMC. He nailed us on every DES and LES. She loved NPfIT and cFH. We hate them. EMIS?—forget it, he said— old hat. MTAS was great in her eyes, crap in ours. It screwed our VTS and F2s. Our ED stats were poor (“Worst in the trust”): too much COPD, all on DLA from DWP; lots of drug users with HIV and Hep C, but no Hep B vaccs; TOPS forms missed; DAAT up in arms; failed DTTOs
at CJIT; the NTA livid. The PPA news was worse: CVD rubbish; overspent direct access MRI and CT; the APC “would have” us. The MD was fuming—budget blown on LARC, she said. Too many IUDs and Depo. Loads of OOH visits too. So many costly MALT cases. Talk of lots of posh meals with GSK. Check out the MDU, MPS, and PPO, he said. “Have you paid your subs?” Forget about CSIP, NICE, NTORS, CHI, QALYS, QPA, the
PMCPA, and the MRC. She didn’t care if we were GPwSIs, she had never heard of the JCPTGP. We sat them on a sofa with a J2O and let our PM talk GaGa with them. They had a Q and A. They ran QMAS and talked MSF, PSDs, PGDs, CQUIN, and QIPP. She liked our LIFT build paid forever by PFI. He was a big fan of Darzi* and the ISTC. She used to be a CPN and an AMHP— both RGN and RMN. Her spouse worked on ICU. Her mum was a DN, and sister a CMW. Our boss had been an HV. They were like pigs in mud, spoke for hours. Did they all have PD? “Sort the CQC and the HPA, and you’ll be OK,” they told her. I had two DF118s a chap left on my desk for IBS and headed to the GP PLT in my BMW . . . to play golf. TTFO, ANON NOTTS A glossary of all these acronyms is available on bmj.com. *Darzi is not an acronym, but a Labour peer. If Darzi was an acronym what might the letters stand for? Cite this as: BMJ 2010;341:c6615
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CHRISTMAS 2010: PRIMARY CARE
Fulton Street Medical Centre,
94 Fulton Street, Anniesland,
Glasgow, G13 1JE
Are there too many referral for
ms?
a referral form to y, one of us (MM) tried to find Harassed at the end of a surger by hand (with a patient. She filled in the form obtain same-day home care for faster and more realised that the typed word was great effort, having long ago ted discussions with d it off. There followed protrac readily understood) and faxe on “the wrong referral because it was written the staff who had rejected the r delay before she the fur a se calls, which meant form.” MM was now making hou d to the surger y. faxe n new form, which had bee returned to fill out and sign the waiting to know left ion for the patient, who was This caused substantial disrupt what the arrangements were. nt referral wondered just how many differe We discussed this problem, and use. Searching e expected to keep in stock and forms general practitioners wer tabulated them 68 individual forms and have the practice, we found a total of be used once or bmj.com). Some of these might alphabetically (see appendix on to use an old or ht still be rejected if we dared twice a year, but our referral mig wrong form. rce of rral forms and that this is a sou We think there are too many refe ply a large sup and e required to maintain, obtain, deprofessionalisation. The tim cts both affe and demand to all doctors is sizeable number of forms available on es indicat that little ion time. A brief Pubmed search medical staff and administrat concern is that ctiveness of referral forms. Our work has been done on the effe pital colleagues. e our communication with hos they limit rather than improv ther avoidable completed by hand, which is ano These forms usually have to be to write into typed letters. One is expected source of error compared with ds. And, nee t account for individual patien pre-defined areas that do not ary care ond sec now send seem dictated by a although the referrals that we the convenience tion returned is not laid out for protocol, it is clear that informa of primary care. to be filled , with a referral, enclose a form Perhaps primary care should ld reject this ted by return? However, we wou out with the information reques boxes and tick use tors t thinking, holistic doc development, as we believe tha . aim g er than an over-ridin protocols as a base resource rath ether to make ondary care have to work tog We believe that primary and sec is being paid to n it would seem that little attentio the NHS work effectively, but sal referral form”—a Instead, we propose a “univer the ethod of making referrals. rral. ch we can write a letter of refe blank sheet of paper on to whi practitioner Margaret McCartney general om ey.c margaret@margaretmccartn er Philip Ewart general practition Christine Scott secretary
Competing interests: MM is married to a consultant nephrologist. Nephrology in Glasgow is one of the few specialties with no referral forms whatsoever. Cite this as: BMJ 2010;341:c6576
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Reflections of Father Christmas’s GP Father Christmas may not be such an unhealthy role model after all. Quentin Shaw, his GP for 20 years, sets the record straight
A
DUNCAN SMITH
recent article accused Father Christmas of being a poor health role model for children, and “a public health pariah.”1 By impli‑ cation, the authors criticise the quality of his health‑ care, a criticism that I find hard to take, as his general practitioner. Guidance from the Gen‑ eral Medical Council recom‑ mends that doctors should not disclose confidential patient information, even to rectify false assertions made by the patient or others in the press.2 There may be occasions, however, when disclosure “in the public interest” is appropriate. On this basis, with the informed consent of the patient, and after discussion with respected colleagues and my defence union, I would like to set the record straight. Father Christmas (FC) registered as a patient with Stirchley Medical Practice in 1991, using the name Nicholas S Claus. His rela‑ tionship with GPs and staff has been, for much of the past 20 years, some‑ what tense, but despite his repeated threats to leave our list, we have managed to maintain engagement with him. He has not been the easiest of patients to deal with. Despite our policy of encouraging patients to consult a named “usual GP,” he seeks care impetuously, electing to consult medical stu‑ dents, registrars, or other young doctors, rather than wait for a booked appointment with his own GP. Such behaviour is often adopted by patients who want to avoid being confronted about their unhealthy lifestyle. Younger practitioners are often perceived as more likely to comply with the patient’s agenda, and many juniors have proved to be very gullible
ship with him. Perhaps as a consequence of this increase in trust, he accepted the single brief intervention that stopped him smoking in 1994. This has prob‑ ably been the greatest impact we have had on his health. Through the 1990s, the changing nature of his job became a major stress. Increasing marketisation and con‑ sumerisation of public services meant that the demands on him rose steeply: he was less often appreciated as a voluntary benefactor and more often seen as a pub‑ lic servant, to be incen‑ tivised by targets. His young clients (a word he hates) were encouraged by politicians to think that they were entitled to his visits, without them‑ selves accepting any responsibility for their previous behaviour.3 Increasing affluence meant increasing physi‑ cal challenges in his work, as presents became larger and heavier.4 This has resulted in repeated musculoskeletal problems and chronic back pain. He lives under constant political threat of losing his monopoly and being opened up to private competition. Unregulated imposters cherrypick the easier parts of his job. His profit margins have been squeezed, and he has been forced to adopt modern employ‑ ment practices for his workers, using short term contracts and foreign locums. Increasing regulation has impinged on his own traditional working practices.5‑8 The European Working Time Directive has severely disrupted continuity of his junior elf rota,9 and elves don’t seem to want to work as hard as they used to. In many cases, he has managed to continue his
Increasing marketisation and consumerisation of public services meant that the demands on him rose steeply: he was less often appreciated as a voluntary benefactor and more often seen as a public servant, to be incentivised by targets
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when he has been booked into their surgeries. Records show that he has consulted dozens of students and registrars over the years. These con‑ sultations have provided background material for tutorials on subjects such as the angry patient, the demanding patient, and the ethical dilem‑ mas of receiving gifts. Hopefully those students and young doctors have been educated by the experience. Our first opportunity to genuinely help FC came when a reindeer bite became septic in 1993. An inspired microbiologist at our local labora‑ tory (Princess Royal Hospital, Telford) identified Streptococcus rudolfus in a specimen consisting largely of tinsel. Prompt treatment saved Christ‑ mas and established our therapeutic relation‑
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activities only by virtue of being self employed and thus exempt from legislation. The conse‑ quence has been that he has worked harder to compensate for the protections offered to his jun‑ iors and his animals. At the same time, he is not getting any younger, and he continues to work in his late 80s because of pension insecurity. It will be no surprise, then, that his physical and mental health have suffered. He has, at times, been heavily dependent on alcohol and addicted to sweet, fat-rich foods. A shift towards a more managerial role and more computer based work has resulted in further weight gain, lipid disorder, hypertension, and diabetes. For some years he became more irritable, and even less likely to accept lifestyle advice. An attempt to use a moti‑ vational interviewing approach in 2001 met with the response “Bah humbug,” and he walked out of the consultation. His marriage has been under severe strain. One of my more empathetic colleagues, while exploring the context of his depressed mood, elicited a problem with sexual dysfunction, when FC disclosed that he only comes once a year (T Underwood, personal communication, 2004). Sympathetic treatment has resulted in a vast improvement, despite his failing once again to comply with lifestyle advice. Throughout our 20 years, I have been humbled by his determination to continue providing a pub‑ lic service that he believes in, at the expense of his own health. We have found ourselves protecting him from himself, insisting on his accepting “fit notes,”10 giving him drugs for his various health problems and providing brief supportive psycho‑ therapy. We have begun to identify the effect of
CHRISTMAS 2010: PRIMARY CARE
his primary relationship on his health, and tried to protect him from some of Mrs Christmas’s more unreasonable demands, while supporting him in a zero tolerance approach to her domestic violence (S Kumar and S Ughovwa, personal communica‑ tion, 2009). Because of the seasonal and unsocial nature of his occupation, we have made special “easy access” arrangements for him to book appoint‑ ments ahead, at times to suit him. If he cannot get through the appointments system, he knows he can speak to a GP. There have been fewer tantrums at the front desk, and fewer letters of complaint. One of the great unsung benefits of universal NHS registration is that everyone, no matter how eccentric their lifestyle, has a GP. GPs are moral relativists, disinclined to be judgmental, and sanguine about self destructive behaviour. Politicians, other professionals, and the greater public may criticise us for not forcing everyone to adopt a healthy lifestyle, but we have to take the long view. We work to a time scale of decades and have to develop relationships with challenging patients gradually. Only when we fully understand the circum‑ stances of their life and health beliefs do we stand any chance of negotiating the more diffi‑ cult behavioural changes. Whether we succeed or not, we maintain an unconditional positive regard for our patients, no matter what their body mass index, and no matter what they have just said or done at the reception desk. With FC the first chal‑ lenge was simply to keep him coming to the GP and not storming off. After that we had to gain his confidence and respect. Only now, after 20 years, is he engaging with the healthy change message.
Of course, we have a long way to go, but I remain confident that his health will continue to improve. I now look forward to our appointments, perhaps because we have both mellowed over the years. Like him, I am getting older, but one of the great strengths of group practice is that younger and more able GPs will take over his care when I retire. Children and parents everywhere should be reassured. And our medical practice will continue to be enlivened by his surprise visits to gullible young students and registrars. Merry Christmas. Quentin Shaw, general practitioner principal , Stirchley Medical Centre, Telford TF3 1FB, UK
[email protected] Competing interests: None declared. Provenance and peer review: Not commissioned; not externally peer reviewed. 1
Grills N, Halyday B. Santa Claus: a public health pariah? BMJ 2009:339:b5261. 2 General Medical Council. Confidentiality: responding to criticism in the press. www.gmc-uk.org/Confidentiality_ responding_criticism_press_09.pdf_27493405.pdf. 3 Trinkaus J. Visiting Santa: a supplemental view. Psychol Rep 2008;103:691-4. 4 Pine KJ, Wilson P, Nash AS. The relationship between television advertising, children’s viewing and their requests to Father Christmas. J Dev Behav Pediatr 2007;28:456-61. 5 Stationery Office. Work at height regulations 2005. SI 2005/735. www.opsi.gov.uk/si/si2005/20050735.htm. 6 Stationery Office. Work at height (amendment) regulations 2007. SI 2007/114. www.opsi.gov.uk/si/ si2007/20070114.htm. 7 Stationery Office. Lifting operations and lifting equipment regulations 1998. SI 1998/2307. 8 Stationery Office. Animal Welfare Act 2006. www. legislation.gov.uk/ukpga/2006/45/pdfs/ ukpga_20060045_en.pdf. 9 Directgov. European Working Time Directive. www. direct.gov.uk/en/Employment/Employees/ WorkingHoursAndTimeOff/DG_10029426. 10 Department for Work and Pensions. Statement of fitness for work: a guide for general practitioners and other doctors. 2010. www.dwp.gov.uk/healthcareprofessional/news/statement-of-fitness-for-work.shtml. Cite this as: BMJ 2010;341:c6782
bmj.com/archive ЖЖChristmas 2009: Santa Claus: a public health pariah? (BMJ 2009;339:b5261) BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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Red for danger? The effects of red hair in surgical practice Jonathan D Barry and coworkers discuss whether surgeons and anaesthetists should fear patients with red hair
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raditionally, surgeons and anaes thetists regard red haired patients with some trepidation because of their reputation for excessive bleed ing, a reduced pain threshold, and an, albeit anecdotal, increased tendency to develop hernias. An estimated 1% to 2% of the general population worldwide has the phenotype for red hair, increasing to between 2% and 6% in the northern hemisphere.1 The typical phenotype associated with red hair is fair skin, freckles, and light coloured eyes. This coloration results from high levels of the red pigment phaeomelanin and reduced levels of the dark pigment eumelanin. Red haired people are also sensitive to ultraviolet light.2 Despite several validated methods to stratify surgical risk and outcome on the inten sive care unit, such as the American Society of Anaesthesiology score3 and the acute physio logical and chronic health evaluation score,4 none take into account the effect of red hair. We discuss the magnitude of risk posed to clinicians by patients with red hair.
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Genetics The genetic basis of red hair was identified in 1997 in association with the melanocortin-1 receptor (MC1R) located on chromosome 16. Two copies of a recessive gene on chromosome 16 changes the MC1R protein leading to the red hair phenotype. Overall, 80% of people have the MC1R gene variant.2 The alleles identified (Arg 151Cys, Arg160Trp, Asp294His, and Arg142His) on MC1R are recessive for red hair phenotype,6 although the HCL2 gene present on chromosome 4 may also be related.7
CAMERAPHOTO/AKG IMAGES
A brief history of red hair Red hair is referred to several times in ancient literature. Xenophanes, a Greek philosopher and poet, mentioned the blue eyes and red hair of the Thracians. Boudica, the Celtic queen of the Iceni, was described by the Roman historian Dio Cassius as “tall and terrifying in appearance . . . a great mass of red hair . . . over her shoulders.” Homer included several red haired mythical characters in his epic poem The Iliad, particu larly Achilles, whose fate is the stuff of legends. Several notable paintings depict Judas with red hair, such as the Kiss of Judas by Giotto di Bondone3 and The Last Supper by Carl Heinrich Bloch.4 In Jacopo da Ponte Bassano’s depiction of the last supper, one of the disciples, who is asleep on the table in front of Jesus, has red hair (fig 1). Jesus appears to be admonishing
Methods We carried out a literature search through Google using the terms “redhair”, “pain”, and “surgery”. All relevant scientific or otherwise related papers identified were extracted for review.
Fig 1 | Detail of Jacopo da Ponte Bassano’s Last Supper, 1542 (oil on canvas); Galleria Borghese, Rome
this disciple (probably Judas) with the back of his hand, although no firm conclusions can be drawn from this. The unwelcome stereotype of someone with red hair continues in modern times, as recently highlighted by the deputy leader of the Labour Party Harriet Harman with her controversial reference to the chief secretary to the Treasury Danny Alexander as the “ginger rodent” (fig 2, extreme left).5 Objective assessment of the behaviour of peo ple with red hair is complicated by the ability to artificially colour hair.
Clinical effects Many anecdotes have been recounted about the clinical behaviour of people with red hair. Reports of increased tendencies to bleed are, perhaps, apocryphal although some studies have sought to elucidate the link between red hair phenotype and haemorrhage. Haemorrhage One study attempted to show a link between red hair and bleeding after tonsillectomy (together with full moons and Friday the 13th).8 The inci dence of post-tonsillectomy bleed was almost 7% but this was indistinguishable from that of the control group. In another study, the bleeding tendencies between 50 women (half of whom had red hair and half black or brown hair) by using objective coagulation testing did not differ, despite the red haired women reporting significantly more subjective bruising in the perioperative period.9 Endometriosis An association was observed between natural red hair and the incidence of laparoscopically con BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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Fig 2 | Little bleeders?
Anaesthesia More conclusive perhaps is the relation between red hair and requirements for anaesthesia. Mice carrying mutant MC1R and humans with red hair (both with non-functional MC1Rs) were shown to have a reduced sensitivity to noxious stimuli and an increased responsiveness to opi ate based analgesia.11 One study focused on the increased need of patients with red hair for anaesthetic agents dur ing surgery.12 This study was limited by its small sample size but showed that the need for desflu rane was significantly higher in patients with red hair than in the group with other coloured hair. Moreover, this study showed that of the cohort of 10 patients in the red haired group, nine were either homozygous or compound heterozygous for mutations on the MC1R gene. Supplementary work by these authors in a larger study population looked at the difference in local anaesthetics requirements between peo ple with red hair and a control group of people with black or brown hair.13 Subcutaneous lido caine (lignocaine) was significantly less effica cious in the red haired cohort. That cohort were also more sensitive to the perception of pain from cold and heat than the control group. The authors postulated that the dysfunction of the MCIR gene associated with red hair triggers the release of more of the α-melanocyte stimulating hormone that stimulates these cells, but this par ticular hormone also stimulates a brain receptor related to pain sensitivity (both of these hormones are derived from the same precursor molecule pro-opiomelanocortin).12 Hernias Possibly the most difficult association to iden tify is the postulated increase in the rate of her nia formation in people with red hair. Collagen synthesis may be implicated in the cause of her nia formation,14 although we could find no firm links between red hair phenotype and hernia development in our literature search. Research
on brittle cornea syndrome has, however, shown a link between this autosomal recessive condition and red hair.15 Further work from Israel has shown the gene for brittle cornea syn drome to be on chromosome 16 (16q24)—the chromosome responsible for red hair. What are the chances of that? Probably 46 to 1.16 Indeed, the authors had previously identified the brittle cornea syndrome to be located on chromosome 16 close to the MC1R gene for hair.17 It follows that red hair may be associated with increased rates of hernia formation, but in all honesty it would be difficult to prove.
Conclusion Despite sporadic reports to the contrary, the clini cal implications of red hair phenotype remain questionable. Red hair phenotype may confer an increased requirement for anaesthetics but is associated with no greater operative risk than the remainder of the population. It would seem that the reputation of people with red hair for having increased perioperative risk is without any basis in fact and should only be used as an excuse of last resort by surgeons defending problematic bleed ing or recurrent hernias. Andrew L Cunningham, foundation programme doctor, general surgery, Welsh Institute of Metabolic and Obesity Surgery, Department of General Surgery, Morriston Hospital, Abertawe Bro Morgannwg NHS Trust, Swansea SA6 6NL, Wales, UK Christopher P Jones, foundation programme doctor, general surgery, Welsh Institute of Metabolic and Obesity Surgery, Department of General Surgery, Morriston Hospital, Abertawe Bro Morgannwg NHS Trust, Swansea SA6 6NL, Wales, UK James Ansell, registrar in general surgery, Welsh Institute of Metabolic and Obesity Surgery, Department of General Surgery, Morriston Hospital, Abertawe Bro Morgannwg NHS Trust, Swansea SA6 6NL, Wales, UK Jonathan D Barry, consultant surgeon, Welsh Institute of Metabolic and Obesity Surgery, Department of General Surgery, Morriston Hospital, Abertawe Bro Morgannwg NHS Trust, Swansea SA6 6NL, Wales, UK
[email protected] Contributors: ALC and CPJ carried out the literature search and drafted the initial manuscript. JA drafted the initial and final manuscript. JDB conceived the study and approved the final manuscript. He is guarantor. Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_
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disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work, although JDB’s third child is red haired. Provenance: Not commissioned; peer reviewed. 1 2
3 4
5 6 7 8 9
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14 15
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National Geographic, September, 2007. http:// nationalgeographic.com/news/2007/10/071025Neandertals-Redheads.html. Valverde P, Healy E, Jackson I, Rees JL, Thody AJ. Variants of the melanocyte-stimulating hormone receptor gene are associated with red hair and fair skin in humans. Nat Genet 1995;11:328-30. Kiss of Judas. Wikipedia. 2010. http://en.wikipedia.org/ wiki/Kiss_of_Judas. Oil Paintings Gallery.com. 2010. www.oilpaintingsgallery. com/gallery/oil-painting/item-DV-2012-KA--Bloch__ Carl_Heinrich___Denmark_1834_to_1890-ChristThe_Last_Sup.asp. Harman says sorry for ‘ginger rodent’ jibe. 2010. www. guardian.co.uk/politics/2010/oct/30/harmanapologises-calling-alexander-ginger-rodent?intcmp=239. Harding RM, Healy E, Ray AJ, Ellis NS, Flanagan N, Todd C, et al. Evidence for variable selective pressures at MC1R. Am J Hum Genet 2000;66:1351-61. Eiberg H, Mohr J. Major locus for red hair color linked to MNS blood groups on chromosome 4. Clin Genet 1987;32:125-8. Kumar VV, Kumar NV, Isaacson G. Superstition and post-tonsillectomy hemorrhage. Laryngoscope 2004;114:2031-3. Liem EB, Hollensead SC, Joiner TV, Sessler DI. Women with red hair report a slightly increased rate of bruising but have normal coagulation tests. Anesth Analg 2006;102:313-8. Missmer SA, Spiegelman D, Hankinson SE, Malspeis S, Barbieri RL, Hunter DJ. Natural hair color and the incidence of endometriosis. Fertil Steril 2006;85:866-70. Mogil JS, Ritchie J, Smith SB, Strasburg K, Kaplan L, Wallace MR, et al. Melanocortin-1 receptor gene variants affect pain and mu-opioid analgesia in mice and humans. J Med Genet 2005;42:583-7. Liem EB, Lin CM, Suleman MI, Doufas AG, Gregg RG, Veauthier JM, et al. Anesthetic requirement is increased in redheads. Anesthesiology 2004;101:279-83. Liem EB, Joiner TV, Tsueda K, Sessler DI. Increased sensitivity to thermal pain and reduced subcutaneous lidocaine efficacy in redheads. Anesthesiology 2005;102:509-14. Klinge U, Binnebösel M, Mertens PR. Are collagens the culprits in the development of incisional and inguinal hernia disease? Hernia 2006;10:472-7. Royce PM, Steinmann B, Vogel A, Steinhorst U, Kohlschuetter A. Brittle cornea syndrome: an heritable connective tissue disorder distinct from Ehlers-Danlos syndrome type VI and fragilitas oculi, with spontaneous perforations of the eye, blue sclerae, red hair, and normal collagen lysyl hydroxylation. Eur J Pediatr 1990;149:465-9. Abu A, Frydman M, Marek D, Pras E, Nir U, Reznik-Wolf H, et al. Deleterious mutations in the Zinc-Finger 469 gene cause brittle cornea syndrome. Am J Hum Genet 2008;82:1217-22. Abu A, Frydman M, Marek D, Pras E, Stolovitch C, AviramGoldring A, et al. Mapping of a gene causing brittle cornea syndrome in Tunisian jews to 16q24. Invest Ophthalmol Vis Sci 2006;47:5283-7.
Cite this as: BMJ 2010;341:c6931
OLI SCARF: ANWAR HUSSEIN/WIREIMAGES, JOHN SUPER/REDFERNS: KEYSTONE/HULTON FROM GETTY IMAGES AND PRIVATE COLLECTIONS
firmed endometriosis in women with no known infertility.10 This was the only association found (including parity, race, and body mass index) at 10 year follow-up.
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Middle ear instrument nomenclature: a taxonomic approach You say “alligator;” we say “crocodile.” John Phillips and colleagues would prefer “gharial”
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tarting from a common origin in the early 17th century, the divergent evolution of the English language between North America and Great Britain holds a great deal of interest for linguists, but is a source of confusion to the unwary traveller.1 An example of such confusion arose when the lead author of this article, trained in the UK as an otolaryngologist, found that his use of the term “crocodile forceps”—referring to the commonly used surgical instrument used to perform delicate middle ear surgery—met with bewilderment in US and Canadian hospitals (fig 1). There, as it turned out, the term “alligator forceps” was prevalent. To avoid such communication problems, biologists maintain strict rules relating to their formal nomenclature. The earliest binomial for an organism, published within or since Carl Linnaeus’s Species Plantarum (1753; for plants) or the first volume of his 10th edition of Systema Naturae (1758; for animals), is by international convention considered to be the only valid name.2 On further investigation, however, an organism can be reclassified as
belonging to a different genus, whereupon its scientific name can properly be changed. In the interests of scientific clarity, a dispassionate investigation of the correct terminology for these forceps is clearly long overdue. We address this important issue both through establishing priority of nomenclature within the literature and through original investigations of jaw morphology. Modern crocodyliforms within the suborder Eusuchia appeared in the Cretaceous period3; this group includes the 23 extant species of alligators, crocodiles, caimans, and gharials. We chose to restrict our comparative focus to the two species living in the continental United States: the American crocodile, Crocodylus acutus, and the American alligator, Alligator mississippiensis. Both species inhabit Florida, where they are likely to be familiar to local clinicians.
Methods We sought the earliest post-1758 uses of the terms “crocodile forceps” and “alligator forceps” using a web based literature search concentrating on medical textbooks and catalogues. We obtained representative speci-
Fig 1 | Hartmann Alligator Micro-Forceps, model MCO13B. Manufactured by Microfrance Incorporated. Medtronic Xomed, Jacksonville, FL (reproduced with permission) 1306
mens of the forceps in question (Microfrance Incorporated, Medtronic Xomed, Jacksonville, FL; n=13 models), and we compared measurements with those obtained from adult and juvenile skulls of C acutus (n=8) and A mississippiensis (n=12), from the collections of the University Museum of Zoology, Cambridge and the Natural History Museum, London. Snout width was measured between the positions of the most caudal teeth, while snout length was measured from the midpoint of the line connecting these teeth to the most rostral point on the snout. For the forceps, these measurements were made from the point of articulation at the most posterior tooth. Snout ratio was defined as snout length divided by snout width. We also counted the numbers of teeth in the upper jaws.
Results The first use of the term “alligator forceps” recorded in the Oxford English Dictionary comes from Knight’s New Mechanical Dictionary,4 an American publication. We were able to extend the use of this term back to 1875, where it features in the urological work of
Fig 2 | “Crocodile lever ring forceps” as illustrated by MacNaughton Jones (1889). Reprinted with permission from the Lancet BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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from wounds. 11 The fo rceps were manufactured at around this time by companies including those of Louis Mathieu in Paris and George Tiemann and Company in New York. Nomenclature was evidently labile at first—some authors used both “crocodile” and “alligator” to describe the forceps8‑13 (fig 2)— but over time “alligator” became much the more popular term worldwide: a Google search generated 67 600 hits for “alligator forceps” but only 5560 hits for “crocodile forceps”. Turning to the morphology (fig 3), the mean snout ratio in C acutus was 2.19 (SD 0.24, n=8); in A mississippiensis it was 1.59 (0.28, n=12). In the Microfrance forceps it was 5.58 (1.53, n=13 models). The number of teeth in the upper jaw of C acutus ranged from 17 to 19 (modal number 19), in A mississippiensis from 14 to 21 (20), and in the forceps it ranged from 11 to 27 (11).
Fig 3 | Dorsal view of the skulls of C acutus (spec. no. R6053; left) and A mississippiensis (spec. no. R6301; right), to illustrate the differences in snout morphology. Scale bar represents 10 cm. Specimens from the University Museum of Zoology, Cambridge
WT Helmuth, professor of surgery in the New York Homeopathic Medical College.5 Alligator forceps were frequently referred to in the American urological literature after this date,6 7 and later appeared in otolaryngological sources from the other side of the Atlan-
tic.8 The term “crocodile forceps” was in use at the same period, again first appearing in the American urological literature in 18759 and later the British otolaryngological literature.10 US army surgeons used modified versions of the forceps to remove arrowheads
Fig 4 | Dorsal view of the skull of a juvenile gharial, Gavialis gangeticus (spec. no. R5793). Scale bar represents 10 cm. Specimen from the University Museum of Zoology, Cambridge BMJ | 18-25 DECEMBER 2010 | VOLUME 341
Discussion Our literature search suggests that the terms “alligator forceps” and “crocodile forceps” appeared at around the same time, but “alligator” has become the preferred term worldwide. However, our morphological comparison shows that the snout ratio and the modal tooth number of the forceps are actually closer to that of the crocodile than to the alligator. The tooth number was very variable in the forceps, however, and is therefore not very informative. Notably, even the lowest snout ratio observed in the forceps (4.69) was still almost twice the maximum found in any American crocodile (2.59). Such a long, pointed snout is actually more reminiscent of that of the gharial (Gavialis gangeticus), a rare crocodilian found on the Indian subcontinent (fig 4). In his study of crocodilian snout evolution Brochu states, “Some crocodyliform snouts resemble a pair of toothed forceps,”14 referring the reader to an illustration of the fossil gavialoid Thoracosaurus. Some important differences remain, however; notably the fact that in the forceps it is the upper jaw that moves, whereas in crocodilians—despite Aristotle’s assertions to the contrary in his History of Animals—it is the lower. As Wilkinson has argued, the rule of priority must be flexible when applied to scientific ideas, which evolve over time.15 Mindful of this, and of the potential for offending the sensibilities of clinicians on one side of the Atlantic or the other, we propose that the ethnologically neutral and morphologically more accurate alternative name of “gharial forceps” should be introduced for these vital implements—subject to confirmation following a more detailed study. 1307
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John S Phillips, otology/neurotology fellow, Rotary Hearing Clinic, University of British Columbia, Vancouver, BC, Canada V6Z 1Y6
[email protected] Matthew J Mason lecturer, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK Heather Dixon student, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK We thank Matt Lowe of the University Museum of Zoology, Cambridge; Colin McCarthy of the Natural History Museum; and Jessica Rudd of Medtronic, Canada, for granting us access to their specimen collections. We also thank John Kirkup and Alan Humphries for help and advice regarding the history of scientific instrument manufacture. JP would like to thank B Westerberg and his team at St Paul’s Hospital, Vancouver, Canada for their inspiration. Contributors: JP was involved in the concept, study design, research, and production of the text. MM and HD were
involved in the study design, research, and production of the text. All authors have seen and approved this final version. JP is guarantor. Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_ disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; Medtronic was one of many companies that sponsored JP through his fellowship, this support was not conditional on producing any research or submitting any work for publication. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3
4
Bryson B. Mother tongue: the English language. Penguin Books, 1990. Stearn WT. The background of Linnaeus’s contributions to the nomenclature and methods of systematic biology. Syst Zool 1959;8:4-22. Salisbury SW, Molnar RE, Frey E, Willis PMA. The origin of modern crocodyliforms: new evidence from the Cretaceous of Australia. Proc Biol Sci 2006;273:243948. Knight EH. Knight’s new mechanical dictionary. Houghton, Mifflin and Company, 1884.
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Helmuth WT. Surgical cases. Documents of the Assembly of the State of New York.1875;8:195-227. 6 Ryerson T. [untitled communication]. Transactions of the Medical Society of New Jersey 1876;302-4. 7 Gouley JWS. Some practical points in the treatment of stone in the bladder. Medical Record 1877;12:529-32. 8 MacNaughton Jones H. A treatise on aural surgery. 2nd ed. J & A Churchill, 1881. 9 Keyes EL. An easy method of removing rounded foreign bodies from the urethra. The Medical Record 1875;10:163-4. 10 Pemberton O. Occasional records in the science and practice of surgery. Lancet 1884;123:927-8. 11 Bill JH. Sabre and bayonet wounds; arrow wounds. In: Ashurst J, ed. The international encyclopaedia of surgery, volume 2. William Wood & Co, 1882: 101-18. 12 Kinloch RA. A bulbous-headed dilating urethrotome. Am J Med Sci 1877;74:125-9. 13 MacNaughton Jones H. The etiology and treatment of chronic suppurative catarrh of the ear. Lancet 1889;134:159-61,209-12. 14 Brochu CA. Crocodylian snouts in space and time: phylogenetic approaches toward adaptive radiation. Amer Zool 2001;41:564-85. 15 Wilkinson DM. At cross purposes. Nature 2001;412:485. Cite this as: BMJ 2010;341:c5137
The IKEA pencil: a surprising find in the NHS Better than methylene, Bonney’s blue, and felt tipped skin markers It seems that the IKEA pencil has developed quite a following. A customary Google search identified a Facebook page entitled “IKEA pencil stealing appreciation” with 55 563 members as of the time of writing.1 It appears that pocketing a few pencils during your shopping trip is considered normal. YouTube2 has over 60 videos dedicated in some way to the little brown pencil, and 500 of them have been used to create a chair.3 As popular as these pencils are, we were still a little surprised to be handed one halfway through a surgical case. The use of a pencil to mark osteotomy cuts in
craniofacial and maxillofacial surgery is well established, proving superior to methylene, Bonney’s blue, and felt tipped skin markers that struggle to transfer an ink mark to bone, or are washed away by irrigation or tissue fluids.4 5 Sterilisation, originally achieved with 18 hours of dry heat,6 is now performed by autoclaving, making a pocketful of IKEA pencils from one shopping visit last for many months— important in the current financial climate. The only problem is that on repeated sterilisation even the hardiest of pencil splits. Ours proceeded to extrude its graphite core before it was even removed from the protective wrapper. We have
solved this problem by wrapping silicon cuffs around the pencil—maybe we could suggest this to the designers at IKEA? Despite this, pencils remain a safe and reliable method of marking bone, making the Argos pen safe for now, at least. Karen A Eley research fellow, Nuffield Department of Surgical Sciences, University of Oxford, Oxford
[email protected] Stephen R Watt-Smith consultant, Department of Oral and Maxillofacial Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK Contributors: KAE and SRW-S were equally bemused by multiple broken pencils; KAE wrote the initial draft with revision by SRW-S. KAE and SRW-S share responsibility for the position of guarantor. Competing interests: None declared. Provenance and peer review: Not commissioned; not externally peer reviewed. 1 2 3 4 5 6
Facebook. IKEA Pencil Stealing Appreciation. 2010. www.facebook.com/group.php?gid=2254049316. YouTube. 2010. www.youtube.com. Ohri P. A chair recreated with 500 IKEA pencils. 2010. www.homeqn.com/entry/a-chair-recreatedwith-500-ikea-pencils. Frazee TA, Hauser MS. Use of a bone pencil in maxillofacial surgery. J Oral Maxillofac Surg 1998;56:101-2. Zins JE, Parker M. The bone pencil and the bone surgeon. Plast Reconstr Surg 1987;80:453-4. Husami T, Leffler K, Churnik R, Lehman JA Jr. Sterilization of the bone pencil. Plast Reconstr Surg 1988;82:1100.
Cite this as: BMJ 2010;341:c6595
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READING BETWEEN THE LINES
How the growth of denialism undermines public health Espousing unproved myths and legends is widespread during the festive season, but some groups hold views contrary to the available evidence throughout the year. This phenomenon, known as denialism, is becoming more elaborate and widespread, and poses a danger to public health, say Martin McKee and Pascal Diethelm are not. Unfortunately, confusion is encouraged by the liberal use of the term, such as when the current British government uses the term “deficit deniers” to attack critics of its economic policy, a group that now includes large numbers of distinguished economic researchers, among them several Nobel laureates.8 Although contemporary usage of the term is relatively recent, the concept of denialism has been recognised for several decades. A chapter entitled “Denial of reality” in a 1957 book describing the phenomenon of cognitive dissonance notes how “. . . groups of scientists have been known to continue to believe in certain theories, supporting one another in this belief in spite of continual mounting evidence that these theories are incorrect.”9 It highlights, in particular, the importance of selectivity, whereby “one aspect of the process of dissonance reduction [is] obtaining new cognition which will be consonant with existing cognition and avoiding new cognition which will be dissonant with existing cognition.” The extent to which selectivity influences our views is now widely recognised, not least as a result of a best selling book containing many examples of what is termed “confirmation bias.”10 One explanation is that confirmation bias is how we deal with GERARDO GARCIA/REUTERS
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hristmas is a time when many entirely rational p e o p l e wh o s e views are based solidly on empirical evidence the rest of the year suspend their critical faculties and say things they know to be untrue. Just in case any young children have picked up their parents’ copy of the BMJ, we won’t go into detail except to say that the subject of these falsehoods traditionally originates in the far north.1 Such stories are harmless and those telling them will, when their children reach an appropriate age, abandon the pretence. Yet other people hold views that are equally untrue and do so with an unshakeable faith, never admitting they are wrong however much contradictory evidence they are presented with. Some of these views are harmless, but others cost lives. It is easy to think of contemporary examples. “HIV is not the cause of AIDS.”2 “The measles, mumps, and rubella vaccine cannot be considered safe.”3 “Second hand smoke is simply an irritant and there is no conclusive evidence that it is dangerous.” 4 And, with potentially the greatest consequences for our species, “the evidence that the world is warming is inconclusive, and, if not, the evidence that global warming is caused by anthropogenic carbon emissions is unproven.”5
Denialism and its history The term “denialism” has been coined to describe this phenomenon. First popularised by the American Hoofnagle brothers, one a lawyer and the other a physiologist, it involves the use of rhetorical arguments to give the appearance of legitimate and unresolved debate about matters generally considered to be settled.6 The term can be traced to people who deny the existence of the Holocaust, but it has subsequently been applied much more widely. Denialism can be recognised by the presence of six key features (box).6 7 It is, however, important not to confuse denialism with genuine scepticism, which is essential for scientific progress. Sceptics are willing to change their minds when confronted with new evidence; deniers
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evidence that challenges our strongly held beliefs and that would otherwise threaten our self perceived status as intelligent and moral individuals.
Approaches to denialism Recent cognitive research, some taking advantage of advances in brain scanning, has shed light on the neurological processes whereby individuals interpret a message according to who is the messenger. People subconsciously suppress recognition of clearly contradictory messages from politicians that they support, yet easily identify contradictions from those they oppose.11 However, simply ignoring relevant evidence is insufficient. Evidence, including authoritative corrections, that contradicts strongly held views can, paradoxically, reinforce those views.12 Thus, research in the United States has found that registered Republicans who are exposed to evidence on the importance of social determinants of health are less likely to support collective action to address them than are those As with vaccines, you can never be sure not exposed.13 Yet denialism involves more than someone initiative would have redefined a relative risk accumulating a collection of individual errors of less than two as being not statistically sound in information processing. Increasingly, it because of the potential for unrecognised takes on the form of social movements in confounding and was designed to exclude which large numbers of people come together research on the risks associated with passive and propound their views with missionary smoking, which typically yield a relative risk zeal.14 These views combine exploitation of the of 1.3-1.6.16 Other efforts seek to redefine congenuine uncertainty that characterises scien- cepts as essentially unresearchable, such as tific research with the use of simple falsehood. in an industry funded report on alcohol that Denialists emphasise the limitations of stated: “violence is a nebulous concept.”17 statistical associations for establishing causalSelective use of the scientific literature is ity, which are well recognised by aetiological another approach used by denialists, who epidemiologists, yet ignore other criteria that either promote methodologically flawed are used to ascertain whether a relationship is research that supports their world view over likely to be causal, such as biological plausibil- more methodologically sound papers or ity, consistency, and strength of association.15 undertake intensive searches of papers they They may also try to change “the rules of the oppose for anything that might cast doubt on game,” such as in the now notorious example the quality of the science. A now notorious when the tobacco industry sponsored efforts example is “Amazongate,” in which a report to define “good epidemiology practice.” The by the Intergovernmental Panel on Climate 1310
Change inappropriately referenced a statement on a report about the sensitivity of the rainforest to changes in rainfall rather than the relevant primary research. This inconsequential referencing error, in a report of more than 900 pages, was then used to undermine the entire report.18 Deliberate falsehoods are rarely used to convince people that something is true, but rather are used to seed doubt about the actual truth. For example, although only 18% of Americans believe that President Barack Obama, a church going Christian, is a Muslim, an additional 43% are unsure.19 Media commentators don’t actually say that that Obama is a Muslim, they just say that they don’t know whether he is or he isn’t, while consistently using the president’s full name: “Barack Hussein Obama.” In the health arena, this approach is commonly found in debates about vaccines, where denialists play on the argument that “you can never be sure” when it comes to the very small risk of complications of vaccinations.
The spread of denialism Of course, there have always been people who have held strong views in the face of overwhelming evidence to the contrary. Indeed, the Flat Earth Society, although a shadow of its former self, still exists. However, the world has changed in recent decades in three important ways, each facilitating the spread of denialism. The first is the birth of web 2.0, which has transformed the internet from a closed publishing platform into an interactive tool allowing intensive exchange of ideas. People who might once have clung on to dissenting views in isolation can now locate individuals with similar views within seconds. Social media enable communities of denialists to grow by feeding each other’s feelings of persecution by BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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When a seemingly bizarre story appears in the media that risks undermining public health, health professionals should ask: “why is this story appearing now?” CHARACTERISTICS OF DENIALISM Identification of conspiracies: Denialists argue that scientific consensus arises not as a result of independent researchers converging on the same view but instead because researchers have engaged in a complex and secretive conspiracy. They are depicted as using the peer review process to suppress dissent rather than fulfil its legitimate role of excluding work that is devoid of evidence or logical thought. Use of fake experts: It is rarely difficult to find individuals who purport to be experts on some topic but whose views are entirely inconsistent with established knowledge. The tobacco industry coined the term “Whitecoats” for those scientists who were willing to advance its policies regardless of the growing scientific evidence on the harms of smoking Selectivity of citation: Any paper, no matter how methodologically flawed, that challenges the dominant consensus is promoted extensively by denialists, whereas any minor weaknesses in papers that support the dominant position are highlighted and used to discredit their messages. Creation of impossible expectations of research: This may involve corporate bodies sponsoring methodological workshops that espouse standards in research that are so high as to be unattainable in practice. Misrepresentation and logical fallacies: An extreme example of this characteristic is the phenomenon of reductio ad hitlerum, in which anything that Hitler supported (especially restrictions on tobacco) is tainted by association. Other methods of misrepresentation include using “red herrings” (deliberate attempts to divert attention from what is important), “straw men” (misrepresentation of an opposing view so as to make it easier to attack), false analogies (for example, because both a watch and the universe are extremely complex, the universe must have been made by some cosmic watchmaker), and excluded middle fallacies (in which the “correct” answer is presented as one of two extremes, with no middle way. Thus, passive smoking causes either all forms of cancer or none, and as it can be shown not to cause some it must, it is argued, cause none). Manufacture of doubt: Denialists highlight any scientific disagreement (whether real or imagined) as evidence that the entire topic is contested, and argue that it is thus premature to take action.
a corrupt elite. This is encouraged by cynicism with existing political systems. In one study, for example, the people who were most likely to believe in 9/11 conspiracy theories were those who were disaffected and disengaged with the political system.20 Such cynicism is growing, a development that should not be surprising given how politicians feel able to take their countries to war on the basis of dubious evidence.21 A second issue, in some countries, is the espousal of denialism by an increasingly partisan media, which expends considerable energy identifying supposed conspiracies that they then espouse to the general public.22 The third is the growing exploitation of the first two issues by corporate interests. Although the tobacco industry has been at the forefront of such tactics, there are now examples from many other sectors, including the food and drink, asbestos, oil, and alcohol industries. Such activities received considerable official support during the administration of George W Bush, under whose aegis there were widespread attempts to politicise scientific research and advice.23 24
Tackling denialism So how should scientists respond to denialism? The first step is to recognise when it is present. Denialism changes the rules of the game. Conventional approaches to scientific progress—such as hypothesis generation and testing, and argument and counterargument—that seek to elicit the underlying truth no longer apply. In some cases, nothing can or needs to be done. The persisting belief among many people that Princess Diana may have been murdered by the security services (32% of the British public in one poll),25 26 for example, has enabled some tabloid newspapers to fill many pages and has wasted much police time, but has no persisting implications for public policy. In other areas, especially where the views reflect longstanding cultural beliefs, it may be necessary to accept that these views exist and adapt messages to take account of them when developing policies and practices. Examples include the development of health promotion campaigns to prevent the spread of HIV27 or to encourage the uptake of immunisation.28 Such campaigns are based on a detailed assessment of the beliefs that would undermine them if not confronted. For example, early programmes to
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tackle HIV/AIDS in east Africa had to address concerns that promotion of condoms was a covert attempt to control the population. It may be necessary to accept that there are some people who cannot be convinced, but there will be many who can. This leaves those cases where denialist views are being promulgated actively by powerful vested interests. Here, we argue, health professionals have a responsibility to confront the denialists, exposing the tactics they use and the flaws in their arguments to a wide audience. Again, the first step is recognition. When a seemingly bizarre story appears in the media that risks undermining public health, health professionals should ask: “why is this story appearing now?” Many will, however, find this approach uncomfortable because it conflicts with the common tendency to seek compromise and avoid conflict. Confronting denialism may also require the use of less usual methods of communication, such as analogy and narrative. Crucially, it demands speed of response. However, health authorities and non-governmental organisations are rarely able to respond rapidly, especially at weekends when, in our experience, misleading stories tend to appear in the media. Equally, editors of medical journals (with a few exceptions) often seem unable to appreciate the need to counter denialist stories. In this paper we have looked at some of the most outrageous examples of denialism. Yet denialism is often much more subtle, and researchers are far from immune to its effects. There is a wealth of evidence on how reviewers find real or imagined flaws in papers whose messages they disagree with while discounting real errors in those they agree with. Perhaps, during the Christmas break, we, as reviewers and editors, might all take some time out to reflect on our own innate cognitive biases as well as how to overcome those of others.29 Contributors: This paper builds on previous work on denialism by the authors. Both authors contributed equally to writing it, following a commission from the BMJ. Provenance and peer review: Commissioned; externally peer reviewed.
Martin McKee professor of European public health, London School of Hygiene and Tropical Medicine, London, UK
[email protected] Pascal Diethelm president, OxyRomandie, Geneva, Switzerland Cite this as: BMJ 2010;341:c6950 References are in the version on bmj.com 1311
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Integrative medicine and the point of credulity So called integrative medicine should not be used as a way of smuggling alternative practices into rational medicine by way of lowered standards of critical thinking. Failure to detect an obvious hoax is not an encouraging sign
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suggest that so called integrative medicine is somehow confined to the alternative world is a canard. It is sometimes possible to test the status of a notion (the terms hypothesis and theory should be reserved for ideas that are related to at least some form of evidence) by a process of opposition. This involves testing the status of the notion by looking at the limits to which it can be pushed.5 Furthermore, there is an excellent tradition of testing research areas of dubious authenticity by means of a hoax. In 1996, Alan Sokal had a paper accepted in a cultural studies journal, in which he parodied postmodern philosophy and cultural studies by making a series of exaggerated, wrong, and meaningless statements about the potential progressive or liberatory epistemology of quantum physics in the style of the field.5 This he subsequently described in a book, bluntly called Intellectual Impostures.6 In the spirit of Sokal, therefore, I responded to a mass circulated email invitation to submit a
paper to something called “The Jerusalem Conference on Integrative Medicine.” The invitation announced: An International Conference on Integrative Medicine will be held in October 2010 in Jerusalem. It will be a meeting of professionals in the field of medicine from around the world that will deal with ways to unite the scientific principles of modern medicine with the holistic principles of alternative medicine…. The scientific committee of the convention is still open to accept additional topics to the conference program. On 1 June 2010, I sent them the following invented nonsense: I write to ask if you would be interested in a presentation on my recent work on integrative medicine. I am an embryologist by background, with an extensive publication record, in journals including Nature and the Proceedings of the Royal
CLAUDIA BENTLEY
t is a common, and rarely unsuccessful, ploy to change the name of something unpleasant in order to give it greater acceptability. However, changing the name of Windscale nuclear plant to Sellafield after an accident in 1981 made it no less radioactive, and the new name quickly acquires all the connotations of the old. Increasing concern has been expressed about the presence of complementary and alternative medicine (CAM) on the NHS. For instance, the House of Commons Science and Technology Committee recently reported critically on the evidence base for the use of homoeopathy in the NHS.1 Nationally and internationally, there has been a move to disguise the nature of CAM by renaming it “integrative medicine.”2 3 Of course, it is something of an insult to medical practitioners to suggest that they do not take into account their patients’ individuality, autonomy, and views as part of their daily practice. It is certainly a key tenet of evidence based medicine4 and to
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Society, and have written an award winning text book on medical embryology. Recently, as a result of my developmental studies on human embryos, I have discovered a new version of reflexology, which identifies a homunculus represented in the human body, over the area of the buttocks. The homunculus is inverted, such that the head is represented in the inferior position, the left buttock corresponds to the right hand side of the body, and the lateral aspect is represented medially. As with reflexology, the “map” responds to needling, as in acupuncture, and to gentle suction, such as cupping. In my studies, responses are stronger and of more therapeutic value than those of auricular or conventional reflexology. In some cases, the map can be used for diagnostic purposes. Although I resisted the temptation to draw an analogy with the mappings of phrenology, I still had it in mind, and the reference to gentle suction might have been taken by a sceptical reader to refer to the idea of kissing the point of credulity. The organisers replied on the same day. Dear Prof. McLachlan I thank you for your interesting and enriching mail. In order to bring the proposal to the Scientific Committee I would appreciate it if you could send me an Abstract of your proposed lecture. And a short C.V. Yours Sincerely [name redacted] The Jerusalem International Conference on Integrative Medicine I replied on the following day:
ABSTRACT Intensive study of the development of early human embryos indicates that there is a reflexology style homunculus represented in the human body, over the area of the buttocks. This homunculus corresponds to areas of clonal expansion (“Blaschko lines*”), in which compartments of the body have clear ontological relationships with corresponding areas of the posterior flanks. The homunculus is inverted, such that the head is represented in the inferior position, the left buttock corresponds to the right hand side of the body, and the lateral aspect is represented medially. The Blaschko lines mediate energy flows to parent areas, and lead to significant responses to appropriate stimuli. As with reflexology, the “map” responds to needling, as in acupuncture, and to gentle suction, such as cupping. Responses are stronger and of more therapeutic value than those of auricular or conventional reflexology. In some cases, the map can be used for diagnostic purposes. In both therapeutic and diagnostic interventions, a full case history must be taken,
in order to define the best methods of treatment. In the presentation, anonymised case histories, “testimonies” and positive outcomes will be presented. The methodology does not lend itself to randomised double blind controlled trials, for obvious reasons. Obviously, the involvement of a sensitive area of the body poses special challenges. Ethical practice is of significant concern. Informed consent must be obtained from all patients in writing, before either therapeutic or diagnostic procedures are commenced. Although exposure of the gluteal region is recommended, procedures can be carried out using draping if this is required in order to gain patient cooperation. Chaperones or same sex practitioners are recommended in the case of female patients. Unfortunately, this novel paradigm may meet with closed minds and automatic rejection. Patience and understanding of “closed” mindsets is essential in order to advance this new discovery in a way commensurate with its importance. *See for example http://dermnetnz.org/ pathology/blaschko-lines.html. My initial email and abstract were constructed to include appeals to authority, hints of conspiracy theories, and “scienciness,” but with an absence of evidence or plausibility. I received this from the organisers on 26 July 2010. Dear Prof. John C. McLachlan, You have sent a proposal to the The (sic) Jerusalem International Conference on Integrative Medicine. We are happy to inform you that the Scientific Committee has reached its decision and that your paper has been accepted and you will be able to present your lecture. The time frame will be 15-20 minutes. Considering the tight schedule, I will appreciate if you’ll confirm your participation in the convention. Unfortunately, I did not believe that I wished to carry the joke so far as to actually attend, although part of me was tempted. I fully accept that this is just one instance, relating to a particular conference. And conference abstracts are refereed less stringently than full papers. But I also believe that the idea I proposed was intrinsically and self evidently ridiculous. Whereas Sokal’s hoax parodied the incomprehensibility and reductio ad absurdum of some proponents of cultural studies’ approach to natural sciences, this particular hoax parodied the absurdity and credulity of so called integrative medicine. I do not believe that rational medicine could have been fooled with something so
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THE NATURAL HISTORY MUSEUM, LONDON
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intrinsically ridiculous as in this case. Minimum standards of common sense should, I think, have led to a polite but firm rejection—or at least further inquiry. Alternative medicine is not noted for rigorous inquiry, for research designed to prove the null hypothesis, but rather accepts notions on face value. Therefore a face value test is fair. I did also, to be honest, feel a little uncomfortable about it. There was an element of deception involved, and academic intercourse generally relies, to some degree, on good faith. I sent off the abstract in a spirit of fun, but then hesitated about making it public. I did decline the invitation (though I have never been to Jerusalem, and would have enjoyed the trip) but I didn’t want to cause harms by taking up a conference slot. But in the end, just as so called gentle teasing may reveal structures to the anatomist, so a different kind of gentle teasing may reveal something to the philosopher, and may promote an element of self awareness in proponents of alternative medicine, no matter what grand title it is disguised under. It provides, at the least, an opportunity for reflective practice, which I hope proves of some benefit to us all. Competing interests: None declared Provenance and peer review: Not commissioned; not externally peer reviewed.
John C McLachlan, professor of medical education, School of Medicine and Health, Durham University, Stockton-on-Tees TS17 6BH, UK
[email protected] Cite this as: BMJ 2010;341:c6979
bmj.com/archive ЖЖChristmas 2009: Secret remedies: 100 years on (BMJ 2009; 339:b5432) 1313
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On the impossibility of being expert More scientific papers are being published than ever before. Alan G Fraser and Frank D Dunstan call for that new strategies to deal with this avalanche of information
Methods We searched the database of the US National Library of Medicine (PubMed) on 12 September 2010 for references relating to diagnostic imaging in cardiology. The table shows the search terms used. Citations with any reference to echocardio graphy (the mainstay of diagnosis) were searched first, and then the strategy was narrowed to echocardiography as a main topic and restricted to controlled clinical trials (strategies 1-4; table). It is recommended that junior colleagues should be trained in several imaging modalities,3 and so we performed further searches for the concept of “multimodality imaging” in cardiology. This included single photon emission computed tomo graphy (SPECT), positron emission tomography (PET), magnetic resonance imaging, computed
tomography (CT), and coronary arteriography, as which time at least 82 142 more papers would have well as cardiovascular ultrasound (strategies 5-6, been added, accounting for another eight years table). and 78 days. Before our recruit could catch up All searches were performed for each year from and start to read new manuscripts published the 1966 (the year before ultrasonics was introduced same day, he or she would—if still alive and even as a search term in remotely interested— 10 PubMed; echocardi have read 408 049 Echocardiograph* Echocardiography MeSH ography was added in papers and devoted (or 8 Echocardiography Majr 1973) to 2009. Trends served a sentence of) Echocardiography Majr CTs 6 in papers on echocar 40 years and 295 days. 4 diography were mod On the positive side, elled; a good fit—from our recruit would fin 2 a cubic model contain ish just in time to retire. 0 ing time, the square Reading only the 1966 1974 1982 1990 1998 2006 2014 Year of time, and the cube major studies would of time—was used to need more than four Fig 1 | Trends in numbers of papers listed each predict the numbers of year in PubMed, according to search strategies 1-4 years for strategy 3 and publications to the end in table. The numbers to the right of the vertical line, more than five years of 2010 and annually after 2009, are projected totals. MeSH=medical for strategy 6. Alterna subject heading, Majr=as a main topic; to 2015. tively, if only one year CTs=controlled clinical trials was allocated for study, Results then for strategy 3 our The table shows the publications retrieved by each recruit would need to read 95 papers every single search, along with totals for the last full calendar day. If our recruit kept to the European Working year. Figures 1 and 2 show annual totals to 2009 Time Directive, he or she would have to read 138 and predictions from 2010 until 2015. papers a day, or for strategy 6, 162 papers a day at Search 5 without the cardiovascular system a rate of one every three minutes. gave 700 011 citations. A search for “diagnostic To keep up to date, the cardiac imaging special imaging” [Mesh] and “cardiovascular system” ist needs to read 30 papers a week on echocardio [Mesh] gave 195 106 papers, or 159 661 if lim graphy or 43 a week on multimodality imaging. If ited to human studies, core clinical journals, and limited to one paper every working day (estimated Medline. total 250 a year), then the chance that he or she To estimate the time that it might take a new will read any particular paper is 1 in 8.9. The entrant to the subspecialty to read all the previ chance that a colleague on the opposite side of the ous literature, we assumed that he or she could world will read that same paper in the same year read five papers an hour (one every 10 minutes, is 1 in 79. If each reads a random selection of 250 followed by a break of 10 minutes) for eight hours papers a year, then the median number that both a day, five days a week, and 50 weeks a year; this will read can be estimated at 28 (range 16-40) or gives a capacity of 10 000 papers in one year. 1.3% of the total. Reading all papers referring to echocardiography A search strategy restricted to evidence on out (search 1) would take 11 years and 124 days, by comes would not work for this subspecialty. The Papers published per year (000s)
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very doctor has an ethical duty to keep up to date. Is this just get ting more difficult or has it already become impossible? Since Alvin Toffler coined the phrase “inform ation overload” in 1970,1 the growth of sci entific and medical information has been inexorable. There are now 25 400 journals in science, technology, and medicine, and their number is increasing by 3.5% a year2; in 2009, they published 1.5 million articles.2 PubMed now cites more than 20 million papers. One response of the medical profession to the increasing scientific basis and clinical capacity of medicine has been to increase subspecialisation. This may restrict the breadth of knowledge of the ultraspecialist, but can such subspecialists main tain their depth of expertise? Taking one medical subspecialty as an example, we have examined the gap between information and human capac ity, and we explore the implications for any doctor who wants to practise evidence based medicine.
Search strategies for identifying articles on diagnostic imaging in cardiology Strategy 1 2 3 4 5
Question All papers that include any reference to echocardiography All papers cited with echocardiography as medical subject heading All papers with echocardiography as a main topic Papers with echocardiography as a main topic, restricted to human controlled trials All papers referring to the cardiovascular system and any one of multiple imaging modalities cited as a medical subject heading; referred to in text as any “multimodality imaging” All papers referring to the cardiovascular system or diagnosis of cardiovascular disease and any one of multiple imaging modalities, if cited as a main topic and limited to humans; referred to in text as major “multimodality imaging”
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Total no of papers from 1966 to September 2010 113 976 84 689 34 577 457 109 604
Papers published in 2009 7207 4672 1558 23 7083
40 496
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average number of controlled clinical trials that were published during the decade 2000-9 (search 4) was 26 each year. This number is not increas ing, and it represents only 2% of the publications with echocardiography as a main topic (search 3) or 0.5% of all papers referring to echocardiography (search 1) during the same period.
Papers published per year (000s)
Discussion The gap between what we can learn and what is known is increasing all the time. We now know less and less about more and more, so being expert means knowing and publicly acknowl edging the limits of your ignorance. Our analysis of one subspecialty showed no evidence whatso ever that the problem is abating, and remarkably similar patterns were reported recently for clinical trials and systematic reviews.4 Keeping up with the literature has already become a Sisyphean task. We are even engulfed by information over ble. Reading the literature has become a collective load about “information overload”5; searching rather than an individual pursuit, and each of us this term on Google gives about 980 000 hits. must change our behaviour to reflect this. We did assume that all papers have equal Medical students and doctors in training can value, which is clearly untrue, but we did not be taught to search databases effectively.15 Doc allow any time in our calculations for obtaining tors can use new information technologies to papers, and we ignored the projected increases. gain prompt and efficient access via the internet Impact factors are concentrated in a few jour to the most relevant new data for their specialty.16 nals,6 and citation errors are common,7 so try The Cochrane Collaboration is admirable, but its ing to use either to select what to read would be programme of systematic reviews is not compre unreliable for a topic such as medical imaging. hensive, so all academic institutions and medi Misconceptions are promulgated when authors cal professional associations should contribute to do not check primary sources,8 9 and even when collective efforts to summarise medical evidence findings are contradicted by randomised control and build trustworthy, interactive repositories led trials.10 Systematic reviews are not all being of knowledge on the internet. Authors of clini kept up to date.11 Thus, delegating the selection of cal guidelines have a particular responsibility to reading material to others might be unrewarding. ensure that their recommendations are based on If anything, we probably underestimated calls rigorous and re-testable meta-analyses of ran on the doctor’s time domised controlled 8 for reading. Accurate trials, health technol Any “multimodality imaging” Major “multimodality imaging” diagnosis is a prerequi ogy assessments, and 6 site for evidence based systematic reviews. medicine, but experts Appropriate resources 4 in multimodality imag must be allocated 2 ing should also know for researchers and something about clini experienced senior 0 cal and other aspects of colleagues to dedicate 1966 1974 1982 1990 1998 2006 Year their specialty. time to these activi Faced by the deluge Fig 2 | Trends in numbers of papers cited each ties. More could also of data, it is tempting to year in PubMed, according to search strategies 5 be done to develop be nihilistic. After all, and 6 in the table decision support being ignorant of 100% tools.17 of the literature in your field is not significantly In fields such as diagnostic imaging the different from being ignorant of “only” 98%. On plethora of publications hides the fact that we the other hand, reading even 2% is more than still lack sufficient evidence for rational practice. reading nothing at all. The average specialist The small proportion of papers that were cited reads 322 papers a year,14 and a few brave, excep as controlled clinical trials (search 4) reinforces tional, and overcommitted people might accept this notion. The best way to assess any diagnostic the challenge of reading more. For most ordinary strategy is a controlled trial in which investiga mortals, this is impossible, and for clinicians who tors randomise patients to diagnostic strategies are not also researchers it may no longer be sensi and measure mortality, morbidity, and quality of BMJ | 18-25 DECEMBER 2010 | VOLUME 341
life,18 but only 2.4% of diagnostic recommenda tions in the guidelines from the American Heart Association and the American College of Cardio logy are supported by this level of evidence.19 It is time for the profession to be more imagina tive. How can we reduce the number and increase the quality of publications?20 Can we remove the responsibility of all researchers to publish all their results? Could they contribute instead to wikis? Can we construct open access internet resources that allow data mining? Only initiatives such as these will overcome our worrying find ing that colleagues in the same medical discipline may inhabit intellectual worlds with little overlap. Happy reading! Contributors: AGF conceived the study, performed the literature searches, and drafted the manuscript. FDD performed the modelling and revised the manuscript. AGF is guarantor. Funding: None received. Competing interests: The authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; FDD does occasional epidemiological consultancy for a law firm (Jacob, Medinger, & Finnegan) and has grants for unrelated work. AGF has no other relationships or activities that could appear to have influenced the submitted work. Provenance and peer review: Not commissioned; externally peer reviewed. For references and search terms for each strategy see bmj.com
Alan G Fraser, reader in cardiology, Wales Heart Research Institute, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK
[email protected] Frank D Dunstan, professor of medical statistics, Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK EDITORIAL by Annas Cite this as: BMJ 2010;341:c6815
bmj.com/blogs ЖЖRead Annabel Bentley’s blog about information overload at bmj.com/blogs 1315
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A dose by any other name would not sell as sweet
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Inventors of drug names suddenly stood the alphabet on its head. Why did z and x become so attractive in the attempt to influence prescribers, asks Rob Stepney
f you leaf through the June 2000 issue of the British Journal of Cardiology you will see advertisements for Zocor, Xenical, and Cozaar before you reach a brand name that does not contain a prominent x or z (and that brand is Viagra). In an issue of Hospital Doctor from the same month (22 June), adverts for Celebrex, Topamax, Flomax, Vioxx, Zispin, Zyprexa, Oxis, Efexor, and Fosamax outnumber those for brands not containing letters from the tail end of the alphabet. Examination of the British National Formulary (BNF) from 1986 to 2004 confirms that z and x suddenly achieved remarkable and previously unexplained popularity in the branding of drugs. Of 1436 products added to the BNF between 1986 and 2005, more than a fifth had names that began with z or x or contained a prominent x or z within them. In 1986, only 19 branded drugs began with one of these letters. Over the next two decades, the number of brands beginning with a z increased by more than 400% (to 63) and those beginning with an x increased by 130% (to 16). In the same period, the overall content of the BNF grew by only 80%. Why did these letters suddenly become so attractive to companies trying to persuade doctors to prescribe their drugs? In linguistics, the “zuh” sound is described as a voiced fricative. The “fricative” element refers to the fact that airflow directed over the tongue becomes turbulent when passing the sharp edges of the teeth, while the “voiced” aspect reflects the vibration of the vocal cords. But there is nothing magical in the sound itself. One suggestion for the popularity of z is that it works well in the Middle East, which was becoming an increasingly important market for drug companies. This
Generic names of drugs listed in the article Brand name Zocor Xenical Cozaar Viagra Celebrex Topamax Flomax Vioxx Zispin Zyprexa Oxis Efexor Fosamax Zyloric Zinacef Zovirax Zantac Zirtek Zoladex Zithromax Zoton Prozac Zoloft Nexium Plavix Xanax Xylocard Xyloproct Xalacom Xenazine Xyzal Xeloda Xatral Zestril Innovace Tritace Pulmicort Flixonase Taxol Oncovin Herceptin Erbitux Aprovel
Generic name Simvastatin Orlistat Losartan Sildenafil Celecoxib Topiramate Tamsulosin Rofecoxib Mirtazapine Olanzapine Formoterol Venlafaxine Alendronic acid Allopurinol Cefuroxime Aciclovir Ranitidine Cetirizine Goserelin Azithromycin Lansoprazole Fluoxetine Sertraline Esomeprazole Clopidogrel Alprazolam Lidocaine Lidocaine Latanoprost Tetrabenazine Levocetirizine Capecitabine Alfuzosin Lisinopril Enalapril Ramipril Budesonide Fluticasone Paclitaxel Vincristine Trastuzumab Cetuximab Irbesartan
has a superficial plausibility: think of how Arab scientists launched astronomy with the terms zenith and azimuth. X, though representing the unknown for centuries, has been famously associated with medical advance since x rays. So this too would have appeal. 1316
More likely, though, is that use of these letters relates to the imperative to make a brand name highly visible in a crowd. Reflecting their infrequent occurrence in English words, x and z count for 8 and 10 points in Scrabble, the highest values (along with j and q) in the game. So names that contain them are likely to seem special and be memorable. “If you meet them in running text, they stand out,” is the way one industry insider explained. Generally, they are also easy to pronounce. That is an old insight in the wider field of marketing. But in pharmaceuticals z did not really take off as a brand initial until after 1996, with the number of drugs beginning with the letter rising steeply from 29 to 51 in 2000 (figure). And the widespread use of x (often also pronounced as “zuh”) is later still. Something additional started the bandwagon rolling.
Z and x spell Zuxess Whatever the initial thinking that lay behind the use of the letter, the people responsible for marketing drugs spotted in the 1990s that an unusually large number of z brands had already achieved blockbuster status or were well on the way towards it. Both Wellcome and Glaxo—then unrelated companies—showed an early liking for z and enjoyed conspicuous success. Wellcome had introduced Zyloric for gout in 1966 and Glaxo the intravenous antibiotic Zinacef in 1978. But it was in 1981 that both companies hit the jackpot with Wellcome’s launch of the antiherpes drug Zovirax and Glaxo’s launch of the H2 receptor antagonist Zantac. In 1985, Zovirax became the world’s first billion dollar drug; and Zantac was the world’s best selling drug by 1986.1 2 In its first 20 years, it was used to treat more than 200 million people.3 The antihistamine Zirtek and the first agonist of luteinising hormone releasing hormone Zoladex (both introduced in 1989), the antibiotic Zithromax (1991), and the proton pump inhibitor Zoton (1994) all became highly successful; and Prozac (1987) made such an impression that its name branded a generation. In 2003, three of the world’s top 10 drugs (each grossing between 3 and 10 billion dollars annually) were Zocor, Zyprexa, and Zoloft.4 Also among the top BMJ | 18-25 DECEMBER 2010 | VOLUME 341
No of drugs
READING BETWEEN THE LINES
70 60
Z
X
50 40 30 20 10 0
1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Year
Fig 1 | Number of drugs with a brand name beginning with z or x listed in March edition of BNF for each year. New formulations of existing brands and zinc related compounds have been excluded
ten drugs that year were two with the X factor: Nexium and Plavix. The widespread use of x at the start of a brand is a more recent ploy in drug marketing, seemingly designed to achieve the sound of a z while looking different. In the 1985 BNF there are a few (notably Xanax, Xylocard, and Xyloproct). The big year for brand introductions with this feature did not come until 2002, but by 2005 there were more than a dozen including Xalacom, Xenazine, Xyzal (successor to Zirtek), Xeloda, and Xatral. People who work in branding speak of it as a means of making a product more than it actually is. In many areas, this is achieved by adding persuasive emotional (and some would say irrational) content. If you buy a car named after an animal famed for its exhilarating speed and elegance, that is what you associate with the vehicle. But in the tightly regulated world of pharmaceuticals, drug names are supposed to be devoid of what the Medicines Control Agency used to call “unsubstantiable beneficial” connotations.
Certain drug names have always alluded helpfully to the chemical class of the agent (as in Innovace, Tritace), its target organ (Pulmicort, Flixonase), the plant species from which the prototype drugs were derived (Taxol, Oncovin) or the drug’s molecular target (Herceptin, Erbitux). Otherwise, when they are sticking to the rules, those inventing brand names for drugs have little scope to play with anything but the sound of letters, and to some extent the appearance of the word. This is presumably why we have the odd repetitions seen in Vioxx and Cozaar) If any alphabetical quirk seems to be working well, there must be a strong temptation to follow suit. Sometimes, though, the rules get bent or broken. Aprovel manages to convey the idea of endorsement and Celebrex and Zestril a clear joie de vivre. Indeed, the contrasting stories of the two brands of lisinopril, both launched in the late 1980s, would make an interesting case study. ICI Pharmaceuticals called its lisinopril Zestril. Its competitors marketed the same molecule as Carace. Whereas Zestril became one of the medical world’s most successful brands, Carace sank pretty much without trace. Was the difference due to the z, the zest, or both? Product naming, of course, is an art that extends across all commercial activity; and z and x have played an important role elsewhere. Of the 10 cars currently listed as fastest in the world (all capable of 0-60 mph in under four seconds), four—including the Ferrari Enzo and the Jaguar XJ220—have a z or x in their names.5 For some brands, the prominence of a key letter is fortuitous: Zanussi, the white goods manufacturer, apparently derived its name from the early 20th century blacksmith and stove manufacturer
Antonio Zanussi. But there are many examples of brand name coinage that are as contrived as those used to market drugs and precede them. For the best part of a century, marketing has gone for certain arbitrary syllables like “ex”, “ax” or “ox.” These are stuck on to a meaningful word, as in Timex, Artex, or Tampax, or a meaningful word misspelt, as in Kleenex (introduced in 1924). Xerox, which became a trademark in 1948 (50 years before the double x stratagem became popular for drugs) is an acknowledged classic. That said, the use of x and z in drug brands suddenly became extraordinarily prevalent. I suggest that this phenomenon arose because of the fast rate at which new products were being introduced, the fact that the difference between many “me too” drugs was more apparent than real, the immense rewards that were seen to accrue from innovative marketing, and the fact that the ploys available for use in the naming of drugs are so restricted. I thank the staff of the BMA library for their help in enabling me to consult copies of the British National Formulary from 1985 to 2005. Competing interests: None declared Provenance and peer review: Not commissioned; externally peer reviewed.
Rob Stepney, freelance medical and science writer, Charlbury, Oxfordshire, UK
[email protected] Cite this as: BMJ 2010;341:c6895
A Christmas tree cataract
A 73 year old woman referred for cataract surgery had on examination a right Christmas tree cataract (fig 1A). Highly reflective, iridescent, polychromatic crystals were noted within the lens. Their colours varied according to the angle of the incident light, (fig 1B, C). It has been postulated that Christmas tree cataracts result from the accelerated breakdown of membrane associated proteins. The peptides and amino acids accumulate in the lumen of the reticular meshwork, and cystine is concentrated beyond the level of crystallisation, giving rise to growing crystals. Ebube E Obi specialist trainee, ophthalmology, Gartnavel General Hospital, Glasgow G12 0YN, UK
[email protected] C Weir consultant ophthalmologist, Gartnavel General Hospital, Glasgow G12 0YN, UK Cite this as: BMJ 2010;341:c6644
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CHRISTMAS 2010: READING BETWEEN THE LINESREADING
BETWEEN THE LINES
Pie sharing in complex clinical collaborations: a piece of cake?
A
Little Red Hen lived in a university hospital where she took care of the sick animals in the different wards. She did this under the overseeing eye of her wise and learned mentors. There was the Cow, who had a degree from a prestigious overseas university. There was the Pig, who had led mergers of several high standing hospitals in the country. And there was the Sheep, who had an outstanding treatment record with almost no animal morbidity and mortality. One day the Little Red Hen thought: “Why don’t I see if I can use my scarce free hours at the end of the day and make an excellent pie. Not only will this pie add to the gastronomic knowledge, it could be that the sick animals will benefit from this pie in the long run.” So the Little Red Hen ran her idea past her mentors. “Great idea,” said the Cow. “I will supply the milk and the butter. Of course, I would like a piece of the pie when it is baked.” “Excellent,” said the Pig. “I happen to know the editor of a prestigious cook book. I expect a piece of the pie once it is finished.” “Good thinking,” said the Sheep. “My laboratory will provide the necessary utensils. Just make sure I get a share of the pie.” The Little Red Hen wasted no time. Every day, after taking care of the sick animals she spent the last few hours of daylight planning the pie. She took classes in pie making, wrote pie making protocols, and even obtained approval from the institutional pie review board. And after a few months, all preparations were in place. The Little Red Hen first went to the Cow and asked for the milk and the butter. “I have the milk and the butter for you. However, I heard that the Sheep will also have a part of the pie. I 1318
FLORENCE WHIT WILLIAMS/THE LITTLE RED HEN
The Little Red Hen learns some important new lessons in K T Buddingh’s cautionary, but entirely fictitious tale
want you to make sure that my piece of the pie is larger than that of the Sheep.” The Little Red Hen continued to the Pig. “Hold on,” said the Pig. “I have submitted a grant application for possibly an even bigger pie, so I cannot actively co-operate any longer on the current pie. However, if you do bake it, don’t forget to give me a piece.” The Little Red Hen then visited the Sheep. The Sheep was abroad for a conference on an imal wellbeing with an extended postconference tour, and his laboratory had received no instructions to provide any utensils. The Little Red Hen went to work. She tested her own recipes, made do with her limited utensils, and fluttered between different departments to keep everybody satisfied. Finally, after many long hours and many failed pies, an acceptable pie came out of the oven. Overjoyed, the Little Red Hen called together
her mentors to share the news. “Welcome everyo ne,” said the Cow. “I would like to present the outstanding result of our cooperation.” She then took half of the pie and left the room. The Pig was next. “Excellent work, Little Red Hen.” He cut himself a sizeable piece of the pie and left the room. Then the Sheep stepped forward. “What a feat of culinary craftsmanship did we achieve! Congratulations on your first pie.” He cut a small piece of the pie, and took the rest. The Little Red Hen sat in the conference room and stared at the small piece of pie that remained. Although happy to have baked her first pie and to have contributed to the gastronomic knowledge, she was left with an inexplicable feeling of disappointment. It did take quite some time before the Little Red Hen attempted to bake another pie.
Disclaimer: This tale is based upon coffee table stories and a compilation of reported experiences in the academic hospital at no specific place. Any names, characters, places, and incidents are either the product of the tale or are used fictitiously. Any resemblance to actual events or locales or persons, living or dead, is entirely coincidental. Contributors: KTB came up with the idea and wrote the first draft. LMAC gathered opinions and experiences from colleagues in the university hospital and contributed significantly to the description of the characters in the tale. GMvD ran a spell check on the document and demanded that, as senior investigator, he received a prime author position. After negotiations, he edited the paper for style, contributed to the plot of the tale, and settled for the middle author position. Competing interests: None declared. Provenance and peer review: Not commissioned, not externally peer reviewed.
K T Buddingh, research physician
[email protected] G M van Dam surgeon, L M A Crane research physician, Department of Surgery, University Medical Centre Groningen, Post Box 30.001, 9700 RB Groningen, Netherlands Cite this as: BMJ 2010;341:c6641 BMJ | 18-25 DECEMBER 2010 | VOLUME 341
WHODUNIT
The rise and fall of celebrity pathology What has happened to the thoughtful, bowler-hatted figure of the forensic pathologist, the spectacular but fallible artist of battered flesh?
GEORGE BELCHER/WELLCOME LIBRARY
C
elebrity pathology was born in England one hundred years ago, when Sir Bernard Spilsbury’s identification of scar tissue on a fragment of putrefied flesh found in the cellar of 39 Hilldrop Crescent secured the conviction of Hawley Harvey Crippen for the murder of his wife. Exactly a century later, the same case that witnessed the rise of this new star in the forensic firmament is engulfed in a controversy that suggests his time has passed. According to a multi-authored research paper recently published in the Journal of Forensic Sciences, the key to the 21st century version of Crippen’s story does not lie in rotting remains interpreted by a publicly celebrated master of the mortuary. Instead, it is to be found in sanitised biomatter abstracted from the body and analysed in a high tech genetics laboratory. “DNA testing of remains, such as those found in Crippen’s cellar”, the article insists, provides “far more objective results . . . than interpretation of small physical abnormalities in highly decayed flesh.”1 The paper, The conviction of Dr. Crippen: new forensic findings in a century-old murder by Foran and colleagues represents a marker of the boundaries of the celebrity pathologist’s century long reign. Before the Crippen case there was no such forensic being. Of course, the postmortem encounter with the corpse for medicolegal purposes has a long historical pedigree, but it was only in the first decades of the 20th century, in England, that the encounter between the body and the pathologist became a high profile and personalised practice. Even in the most widely publicised of Victorian homicide investigations, like the Ripper murders, victims’ bodies were examined by faceless investigators, often local practitioners with no claims to forensic expertise. In fact, it was the toxicologist waging war on the dreaded secret poisoner, not the pathologist, that captured the Victorian forensic imagination.2 3 The Crippen case launched Spilsbury on a career spanning four decades that was contin-
Bernard Spilsbury, who ushered in the celebrity pathologist’s century
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COURTESY OF THE ROYAL LONDONHOSPITAL ARCHIVES
WHODUNIT
uously marked by high profile cases involving ism, his lack of interest in academic research exhumed, decomposed, and mutilated cadav- and dialogue, and his refusal to train students. ers. The discovery of a mass of confused flesh They sought to counter this limiting and risky began a familiar drama in which Spilsbury insular virtuosity by embracing (in principle if single handedly assembled a story about the not always in practice) the ideals of consultabody from within the enclosed space of the tive exchange more in keeping with the norms mortuary, and then emerged to defend it in the of contemporary science. public and contested space of the courtroom. Yet the cult of the celebrity pathologist did The mortuary was the site for his deployment not die with Spilsbury. If anything, Simpson, of a unique, highly individualised and embod- Camps, and their contemporaries deepened ied set of skills (smell, touch, sight, physical and extended the pathologist’s public image strength, patience) that transformed the raw by becoming prominent figures not merely in material before him first into a postmortem the mortuary and the courtroom but at crime report and then into polished courtroom per- scenes—a space that Spilsbury was not pubformances, where Spilsbury spoke in easily licly identified with. Newspaper photographs accessible language about the ultimate deci- of the celebrity pathologist captured in action pherability of the chaos that had initially con- in the field became a stock feature of any high fronted him. His case file is littered with examples of his extraordinary powers: in the Crippen case, an unremarkable crease on one piece of flesh, a mark that others considered an artefact of burial, became evidence of a hysterectomy. In the Patrick Mahon case (1924) and in the Toni Mancini case, the second of the so called Brighton trunk murders (1934), he was confronted with a riot of body parts that he painstakingly and convincingly reassembled. In the trial of Norman Thorne in 1925 and the case of Sidney Fox (1930), Spilsbury confounded lay expecta- Francis Camps confronts his raw material tions about the relation between bruising, putrefaction, and violence profile case from mid century onwards. These to send the accused to the scaffold. public glimpses of their work also served to As contemporaries and his numerous bio intensify their standing as so called personaligraphers have noted, however, the very virtu- ties: both Simpson and Camps, for example, osity of Spilsbury’s mortuary and courtroom were regularly photographed with their secreperformances threatened to undermine the taries at the scene, lending human interest, by foundations of forensic pathology as a mod- contrast with Spilsbury’s isolated figure. ern and objective specialism. Spilsbury acted Indeed, attendance at the crime scene as a lone figure, often insisting on the accuracy became written into the peculiar heroics of of observations that could not easily be veri- the celebrity pathologist. From the 1960s fied by his peers, and his commanding pres- onwards, in the context of chronic complaints ence lent him an aura of infallibility that for about the decline of forensic pathology in Engmany raised concerns that it was his celebrity land, the fact that they were willing to be called rather than his science that persuaded juries out at all hours to a scene of horror, smell, and to credit his evidence over all others. Follow- intense labour was identified as the distincing Spilsbury’s suicide in 1947, a younger tive contribution of the forensic pathologist generation of forensic pathologists sought to to homicide investigation. It was at the crime distance themselves from his legacy, and in so scene, in his cooperative interaction with the doing carve out a more “modern” public image police and scientific investigators, and his willfor their art. Led by Keith Simpson and Francis ingness to extend his deductive powers beyond Camps, they criticised Spilsbury’s provincial- the body and into a world of traces, that, in 1320
Simpson’s view, the forensic pathologist practiced his singular art.4 Camps and Simpson translated their intimate contact with the murderous side of human nature into forms of popular entertainment. Both consulted on crime shows, were featured in documentaries on their work, and participated in broadcast interviews in which their views, not merely on their work but on wider social issues, were sought. Both also wrote about their work in the burgeoning market for true crime literature— Simpson, most successfully in his best selling 1978 memoir, Forty Years of Murder. Such developments indicate that Spilsbury’s successors had to adapt the model of celebrity pathology in order to maintain their relevance to, and status within, a modern regime of homicide investigation. When Spilsbury was at his peak, the seemingly scientific analysis of crime scenes, and the organic and inorganic traces they contained, was in its infancy, and homicide investigation—as public drama— began at the mortuary. But from the 1930s onwards this model was challenged by an increasingly scientised and specialised approach to investigation, with the detection and collection of traces in crime scenes becoming routine. The growing complexity of trace analysis in turn demanded knowledge and equipment beyond conventional autopsy practices at the mortuary slab, and this, in principle, threatened forensic pathologists with relegation to the role of harvesting material from the body for analysis by other experts in other domains. However, by extending the professional and public facets of their work, as they did at crime scenes, mid century pathologists managed to maintain overall command of this expanding investigative regime. The case of John Reginald Halliday Christie (1953) provided the most spectacular platform for dramatising this new interdisciplinary forensics. The meticulous and patient excavation of 10 Rillington Place led by Francis Camps enabled experts to make sense of the profusion of objects, traces, and bodies retrieved from Christie’s infamous house of horror. Despite these efforts, the days of the celebrity pathologist were numbered. Multidisciplinary, team based, and technologically mediated and BMJ | 18-25 DECEMBER 2010 | VOLUME 341
WHODUNIT
standardised protocols of homicide investigation increasingly threatened to marginalise the lone pathologist’s art. Indeed, as practitioners themselves acknowledged, it was not only the pathologist, but forensics itself as a publicly celebrated activity, that was being dislodged. A 1964 editorial in the Journal of the Forensic Science Society captures this sense of decline. Forensic experts, it observed, were once “men of character, personality and renown,” who “descended as from Olympus.” At present, it continued, it was still possible to conjure an “aura of hushed respect about the doings of one of the most eminent whose thoughtful, bowler-hatted figure is to be seen, sometimes even on television, perambulating the scene of some murder or the gruesome remains of a sudden tragedy.” Yet this was fast becoming a relic from a by-gone age:
But why, if the era of celebrity pathology is dead, are we now awash with biographies and television dramas that draw on the exploits of its most famous exponent? Perhaps the answer lies in the very power of the modern forensics of DNA. In one sense genomic forensics obliterates—figuratively and, through reviews of iconic cases like Crippen, literally—the synoptic art of the celebrity pathologist. Yet at the same time it invites a form of nostalgia for Spilsbury’s brilliant and idiosyncratic performances. Spilsbury represents an era when crime mysteries could be unravelled by the heroic encounter of a solitary medical expert with the corpse. This contrasts with contemporary crime scene investigation, where evidence is first collected by a team of Scenes of
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CEDRIC KEITHSIMPSON BY JUDITH ARONSON/NATIONAL PORTRAIT GALLERY
The complexity of the science, the sweep of its interests, the Babel of its languages seldom fully permeate public consciousness. It is easy to venerate the wisdom of a greybeard, but the anonymous toiler at his laboratory bench stirs little applause. And those faceless individuals among whom the great man’s interests are fragmented seldom communicate with one another and may soon find it impossible to do so.5
Keith Simpson—anything but anonymous
Crime Officers (SOCOs), identities hidden by white suits and masks, and is then stored, classified, and analysed by laboratory technicians, who are themselves concealed within a highly bureaucratised landscape of the modern day institutions of forensic science. As a result, we are at once intrigued and repulsed by Spilsbury—a spectacular, but fallible, artist of battered flesh. Abstracted, disembodied, and sanitised, genetic forensics, though undoubtedly a source of public fascination, speaks to an entirely different register of wonderment. Ian Burney, senior lecturer, Centre for the History of Science, Technology and Medicine, University of Manchester, UK
[email protected] Neil Pemberton, research associate, Centre for the History of Science, Technology and Medicine, University of Manchester, Manchester M13 9PL, UK
Contributors: IB and NP produced the text. IB is guarantor. Competing interests: Both authors have completed the Unified Competing Interest form at www.icmje. org/coi_disclosure.pdf (available on request from the corresponding author) and declare: both authors had financial support from the Wellcome Trust for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; and no other relationships or activities that could appear to have influenced the submitted work. Provenance and peer review: Commissioned; not externally peer reviewed. 1
2 3 4 5
Foran DR, Wills BE, Kiley BM, Jackson CB, Trestrail JH 3rd. The conviction of Dr. Crippen: new forensic findings in a century-old murder. J Forensic Sci 2010: published online 23 August. Burney I. Bodies of evidence: medicine and the politics of the English inquest, 1830-1926. Johns Hopkins University Press, 2000. Burney I. Poison and the Victorian imagination. Manchester University Press, 2006. Simpson K. The art of forensic pathology. J Forensic Sci Soc 1969:9:199-203. Shriving a Science. J Forensic Sci Soc 1964:4:183.
Cite this as: BMJ 2010;341:c6500 1321
CHRISTMAS 2010: WHODUNIT
WHODUNIT
Dr Watson: regular BMJ reader Ross Philpot brings Sherlock Holmes, Dr Watson, and their creator together in a new adventure facilitated by the BMJ online archive CHAPTER I
ILLUSTRATION BY PHIL CORNELL
“Holmes,” said I, one fine morning, as we lit our pipes refilled with yesterday’s carefully saved plugs and dottles. “For a change, I have a chal‑ lenge for YOU.” “Indeed, Watson?” “It’s a nice little problem of medical detec‑ tion, to be set out with proper documentation and referencing, the whole project to be com‑ pleted by the end of next week.” “What, my dear fellow, have you and your mischievous colleagues at the British Medical Journal been up to this time?” “Holmes!” I exclaimed in astonishment. “How in Heaven’s name could you have read my thoughts to perceive that it is indeed my editorial friends and their famous BMJ that I have in mind?” “My good man, when I observe that a doctor has spent sleepless hours scribbling in the mar‑ gins of the latest edition of his favourite medical
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journal and covered several foolscap pages with notes and lists, it needs no great effort of the imagination nor great deductive reasoning to discern that something of that nature is afoot.” “Quite right, Holmes. I see your reasoning now. Well, what do you think? Should you and I collaborate to match up some medical comments in the Sherlock Holmes canon with articles published in the BMJ?” “Surely, my friend. We’ll need a list of doctors, and of diseases, plus some remedies, which I can provide from a combination of copious chronicling over the years and my good old index, together with your accumulated readings from the BMJ, and then we can link them all up together.” “By Jove, Holmes, I’m much gratified by your immediate enthusiasm for this worthy project.” “But first, Watson, should we not ask our‑ selves a few pertinent questions about the rea‑ soning behind this seemingly simple challenge?
The first question which we may ask ourselves is ‘Why should we choose this topic at all?’” “Aha, my old friend, the clue to that lies in the very wording of a proposal last year by the BMJ and is to be found in its leader entitled ‘The new BMJ online archive,’ wherein 10 particular authors are selected for mention including, and mark this, Holmes, the famous Arthur Conan Doyle.”1 2 “Very well, then. A second question that arises is ‘Does the BMJ itself actually receive any men‑ tion anywhere in our Sherlock Holmes literary canon?’”3‑5 “The answer, pleasingly, is ‘Yes.’ We need seek no further than the second paragraph of The Stockbroker’s Clerk, set in 1889 and published four years later, where we read: ‘one morning in June, as I [that is, Dr John Watson] sat reading the British Medical Journal after breakfast, I heard a ring at the bell followed by the high, somewhat strident tones of my old companion’s voice. ‘Ah, my dear Watson, said [you, Holmes], striding into the room, ‘I am very delighted to see you.’’” “Very good, Watson. Very good indeed. Is that where it starts and ends, or do we have more?” “You won’t be disappointed to learn that there is in fact another mention of the BMJ. In The Adventure of the Blanched Soldier, set in 1903 and published in 1926, you yourself remark on the pos‑ sibility that a journal being read by Dr Kent may have been the BMJ. You said: ‘You will remem‑ ber . . . that I felt round for points, asking you, for example, about the paper which Mr Kent [the doctor] was reading. Had it been the Lancet or the British Medical Journal it would have helped me.’” “Well found. Conversely, does the BMJ mention either Sherlock Holmes or Doctor Watson?” “Good question. Once again, the answer is a definite ‘Yes,’ at least for Sherlock Hol‑ mes, so supporting our mission even further.” “And where might that be?” “Firstly, it’s in a BMJ editorial published in 1893, entitled ‘The Method of BMJ | 18-25 DECEMBER 2010 | VOLUME 341
WHODUNIT
Sherlock Holmes’6; very nice accolade there, Hol‑ mes, don’t you think? A certain author scores a big mention too, thus: ‘In creating the character of Sherlock Holmes, Dr Conan Doyle owed much to the training he received as a student of medical diagnosis.’” “I note that this author was made mention of for an interesting variety of reasons over several years in the BMJ: in October 18937 and Dec‑ ember 1894.”8 “Other mentions are made of you, Holmes, in articles in June 1895,9 July 1899,10 October 1899,11 December 1899,12 and January 1900.”13 “I think we’ve done very well already, Watson. Let’s move on to illnesses and injuries, and see what we can come up with next.” “Good idea, Holmes.”
CHAPTER II
Several days later, after having shared a hearty breakfast of ham and eggs washed down with the contents of a pot of strong coffee, we laid out our foolscap pages displaying the fruits of our labours, and surveyed the results. While Holmes had produced an impressive number of items of medical relevance from the 60 Holmes and Watson stories, I had delved into my records of the BMJ and sought out articles on those topics that had been published in or about those decades in which the adventures had taken place. The outcome, then, was a fascinating match up of the scientific with the lit‑ erary, apparently for the first time in the history of both the journal and of Sherlock Holmes. “Wonderful, Holmes, marvellous. How do you do it?” “A we l l t r a i n e d memory, Watson, a tidy uncluttered mind, a comprehensive system of detailed note books and reference material, no interruptions, and a lot of strong coffee and rough shag tobacco—you know my metier.” “This is all very promising, Holmes.” “You may be intrigued to know, Watson, that the contemporary of your father, by the name of Arthur Conan Doyle, once had a single scien‑ tific report published in the BMJ. Young Arthur wasn’t even a doctor at the time, just a medical student. You won’t find it under his full name, as it was attributed to a person identified only as ‘A C D.’ Nevertheless, it’s all there to be seen by anyone who chooses to look, at the top left
hand corner of page 483 of the issue of 20 September 1879.14 “His topic was gelsemi‑ num as a poison, a curi‑ ous choice of title, given that the report is actu‑ ally a graphic first hand description of how he experimented upon him‑ self and recorded the physiological effects of gelseminum on his mind and body as he applied it as a treatment for his persistent neuralgia. “Conan Doyle specifically refers to this self experimentation in a letter to his mother in June 1879, when he writes: ‘I increased the dose until I . . . had some curious physiological results. I drew them up and sent them to the British Medical . . .’”14 15 “But Holmes, that sounds to me to be some‑ what ethically suspect.” “Watson, I believe I actually know how Arthur felt at such trying times.” “Interesting, Holmes. But remember, honi soit qui mal y pense.” “I’ll ignore that playful barb, doctor. Again, in November the following year, young Conan Doyle wrote to his mother, ‘the Ma’m,’ ‘I am going to write a case for the British Medical. I will tell you when it appears.’ Evidently, however, it never did appear in that journal. So, young Watson, have we reached the limits of what reason can sup‑ ply?” “Not quite, Holmes. I’ve taken the trouble to consult the Medical Directory of Britain for 1886 and am delighted to find yet another allu‑ sion to the BMJ on the same page on which is documented the details of James Mortimer, the very doctor who brought to you that strange and ancient handwritten document recording the legend of the Hound of the Baskervilles.”16 “Fancy that. And just what is this extra men‑ tion of the esteemed BMJ, pray?” “A case of gastroenterostomy for cancerous obstruction of the pylorus, by Arthur Barker.”17 “Well, well, is there no end to the ubiquity of this journal?” “It certainly is cosmopolitan in its tastes.” “Now Holmes, back to the present, and to the task we’ve taken on for ourselves. Having
A well trained memory, Watson, a tidy uncluttered mind, a comprehensive system of detailed note books and reference material, no interruptions, and a lot of strong coffee and rough shag tobacco— you know my metier
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succeeded in documenting the connections we have uncov‑ ered between the stories and published medical articles, why don’t we now package them up and offer them to the BMJ for possible publication?” “And hope that they and their readers enjoy them as much as we have.” —Report by Dr James Scott Watson, BMedSc (Honours, physiology), MBBS (Adelaide) Golfe Josephine, South Australia, 6 January 1951. Note: Lest it be thought strange that Sherlock Holmes and Dr Watson the younger could possibly have met in Adelaide in that year, it should not be forgotten that Holmes has been said to have lived to the ripe old age of 103, having been born on 6 January 1854.5 He might have travelled by sea to that city much as Arthur Conan Doyle had done in 1920, to deliver his first lecture on Australian soil in the Adelaide town hall on Saturday 25 September. Furthermore, the young Dr Watson in our story, which should best be regarded as a contribution to perpetuation of “The Game” rather than as a pastiche, might have been the son of Dr John Watson and Miss Mary Morstan, conceived in the throes of passion in the week of the adventure of The Sign of (the) Four. After all, Sherlock Holmes was said to have fathered a son with the woman Irene Adler, according to Holmesian authority William Baring-Gould.5
C Ross Philpot, senior consultant physician, Adelaide, Australia
[email protected] I thank fellow Sherlock Holmesians Mark Chellew, Bill Barnes, and Phil Cornell for their wise comments on the manuscript, and extend very special thanks to Phil for the original illustrations. I also thank Anna Witty, Roni Wayne, Rachel Davey, and staff of the library at the Queen Elizabeth Hospital, Adelaide, Australia. Competing interests: None declared Provenance and peer review: Not commissioned; externally peer reviewed. 1
Gunn RI. Mr Holmes and Dr Watson. The Sherlock Holmes Society. BMJ 1934;2:278. Delamothe T. The new BMJ online archive. BMJ 2009;338:b1744. 3 Conan Doyle A. The original illustrated ‘STRAND’ Sherlock Holmes. The complete facsimile edition. Wordsworth Editions Ltd, 1989. 4 Klinger LS. The new annotated Sherlock Holmes. Vols 1, 2 & 3. W W Norton & Co Inc, 2005. 5 Baring-Gould W. Sherlock Holmes. A biography of the world’s first consulting detective. Rupert Hart-Davis, 1962. 6 The method of Sherlock Holmes. BMJ 1893;2:1442-3. 7 Special correspondence: Manchester. BMJ 1893;2:866-7. 8 Literary notes. BMJ 1894;2:1320. 9 Wanted: a Sherlock Holmes. BMJ 1895;1:1225. 10 Personal experiences of plague officers in India: the epidemic in Poona. BMJ 1899;2:25-7. 11 The influence of Zadig on the progress of medicine. BMJ 1899;2:1120-1. 12 The method of Sherlock Holmes in medicine. BMJ 1899;2:1808. 13 Harveian Society of London: annual meeting, Thursday 18 January 1900. BMJ 1900;1:197. 14 From our archive. Arthur Conan Doyle takes it to the limit (1879). BMJ 2009;339:b2861. 15 Rugman F. Observe cases minutely, improve in my profession, write to the Lancet. BMJ 2007;335:1315. 16 Goodenough S. The hound of the Baskervilles. Based on the story by Sir Arthur Conan Doyle. Webb and Bower, 1984. 17 Barker A. A case of gastro-enterostomy for cancerous obstruction of the pylorus. BMJ 1886;1:618. Cite this as: BMJ 2010;341:c6898 2
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Agatha Christie’s doctors The world’s best selling novelist had it in for doctors, Herbert Kinnell believes “Christie had a . . . partiality to murderous medical people who have both the specialized knowledge and the opportunity to administer such lethal agents.”1 This partiality persisted through her 101 short stories and novels. In her first book, The Mysterious Affair at Styles, a doctor tries to cover up a murder. In her first play, Black Coffee, a doctor is the prime murder suspect. And in her last book, The Postern of Fate, a doctor is one of the two murderers.
Murderous doctors Where the occupation of the murderer is known, doctors make up the largest group (table). In Christie’s most famous thriller, The Murder of Roger Ackroyd, Dr James Sheppard is the culprit and her choice of a doctor murderer may have been influenced by the real life poisoning of Charles Bravo, who Christie believed was killed by Dr James Manby Gully, the lover of Bravo’s wife. In Cards on the Table Dr Roberts murders not only his lover’s wife, by poisoning her travel immunisation typhoid injection, but he also kills a rich man in whom she confides, by putting anthrax on his shaving brush. Roberts’s other victims included witnesses to his crimes, who are injected by him with the anaesthetic Evipan, falsely described as “a simple restorative,” and the doctor comments that he has “always been interested in crime. Bad thing for a doctor, perhaps mustn’t say so to my nervous patients!” Another quadruple serial killer was the GP in The Pale Horse, who murders his patients with morphine. Dr Anderson, in The Flock of Geryon, one of the books in the short story collection The Labours of Hercules, in which Poirot feels he must destroy various monsters, is a crazy bacteriologist. Anderson devises a scheme of scientific mass murder, which involves cultivating a bacillary-enhancing substance that would spread deadly infection without suspicion. Anderson also injects cannabis into his followers to keep them docile. Likewise, the lady psychiatrist in another one of the short stories in this collection, The Capture of Cerberus, gets her rich patients addicted to cocaine. Dr James Alfred Kennedy, a GP turned psychiatrist, is the triple killer in The Sleeping Murder. He is in love with his half-sister Helen and when it becomes clear she might marry and leave him, she is strangled and buried under the garden steps. Dr Kennedy pretends Helen has 1324
eloped, forges letters supposedly from her which accuse her of nymphomania, and gives her father psychotogenic drugs that lead to his incarceration in an asylum. However, the doctor comes undone when he tries to strangle his step-niece during a police sting. One of the two murderers in Postern of Fate was the non-medical granddaughter or greatniece of a doctor who murdered a female spy six decades previously. In The Adventure of the Egyptian Tomb, the expedition’s doctor, Dr Robert Ames, wrongly diagnoses eczema as leprosy, causing the patient to commit suicide. He murders one person by giving them tetanus, infects another with septicaemia, and even tries to kill Poirot. In And Then There Were None there is a cowardly, secret-drinking doctor who is cynical about medicine yet a believer in phrenology and in collusion with the killer. The greedy Dr Quimper in Murder She Said plots to marry an heiress after eliminating the remaining members of her family, including his own estranged wife. In Four-And-Twenty Blackbirds Dr George Lorrimer tries to inherit the family fortune by murdering his supposedly “unmarried” uncle.
The GP Dr MacAndrew says it’s an accident, but Poirot knows better. In Mrs. McGinty’s Dead, the doctor dabbles in euthanasia, though Poirot does not think he’s doing it for the money.
Red herrings In Christie’s novels, doctors are often wrongly included on the list of prime suspects in murder investigations and treated with suspicion. In Curtain: Poirot’s last case, all of the evidence in the murder of Dr John Franklin’s invalid wife points to him as the perpetrator. In his eyes, he married the wrong ‘‘type’’ of woman: “It’s maddening for a doctor. Doctors like healthy people” and later delights at her death. Also, he announces in public that there are “Lots of people I’d like to kill,” causing one onlooker to remark: “Let us hope our friend the doctor does not practise what he preaches.” Physostigmine was the drug used to kill his wife and came from his own laboratory. He is also described as “a suspicious character . . . a strange man, a ruthless man, a man who if he made up his mind to murder, might murder again and again,” and Christie intimates that he could have slowly poisoned his wife. Killer Dr Quentin, who administers poisonous yellow jasmine to poor Mr Paynter in The Big Four, is an imposter masquerading as a doctor. Dr Pritchard in The Will That Went Missing is chairman of the medical foundation, which appears to be the will’s beneficiary, framing him as the prime suspect. However, he is later found to be innocent, despite once running a euthanasia group. The murderess in Lord Edgware Dies reveals how “A doctor in San Francisco . . . showed me just where to stick it in [a corn knife].” Dr Rise, the psychiatrist and hypnotist in The Hound of Death, is described as so unscrupulous as not to shrink from murdering his wealthy uncle. The doctor thinks he can tap therapeutically into some ancient supernatural power, and writes in his notebook: “Am I mad? Or shall I be the Superman, with the Power of Death in my hands?” Psychiatrists generally fare badly in Christie’s work2 and in Appointment with Death it is said of sexist psychiatrist Dr Theodore Gerard that “it is perfectly possible for Dr Gerard to have committed the crime. Being a doctor, he could easily
Her family’s experiences of the medical profession may help to explain her attitude
Frequency of murderers’ occupations in Agatha Christie’s 101 novels and short stories Occupation Indeterminate/unemployed Doctor* Actor/actress Secretary Aristocrat Ex-soldier Policeman† Foreign spy Maid Nurse Accountant, archaeologist, athlete, bank clerk, builder, businessman, butler, dentist, estate manager, financier, gardener, housekeeper, insurance agent, inventor/ mechanic, journalist, ladies’ companion, laundrywoman, librarian, member of parliament, mine director, model, naval officer, pharmacist, private detective, prospector, scientist, socialite, solicitor, stockbroker
Number 32 11 6 6 5 4 3 2 2 2 1 each
*Not including a doctor who kills by operating while drunk. †Not including a deranged bogus policeman.
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counterfeit the appearance of malaria.” Aunt Ada, the victim in By the Pricking of My Thumbs, says, “[You] can’t really trust doctors, can you? … I’m told there’s a lot of poisoning going on here. To get hearts for the surgeons, so I’m told.” In Dumb Witness the murderess wife of the doctor tries to frame her husband. One could be forgiven for thinking the doctor son of the victim in The Mysterious Affair at Styles was the malefactor, as he repeatedly insists, even in court, that the death is due to natural causes, or perhaps his mother has mistakenly taken an overdose of her strychnine tonic medication. He lies about a door being bolted, and crushes beneath his feet what he believes is an incriminatory coffee cup. But in the book’s original version—Agatha Christie’s publisher insisted she change the ending—the doctor may be the actual murderer: we won’t know until new research3 is published in 2011.4 Until well into Why Didn’t They Ask Evans? the reader suspects Dr Nicholson, who owns the sinister psychiatric institution, but this turns out to be a false lead. One should perhaps include in this section Drs Horriston and Kleber (The Case of the Missing Lady), because one is wrongly led to believe the missing woman may have been murdered, but if she had been the nefarious doctors were the obvious culprits. A menacing Italian, Dr Carelli, a suspect in Black Coffee who gets repeatedly blamed for the murder, was not the murderer, although he was not entirely innocent. Finally, “Superior ass” Dr Geoffrey Thomas was one of the suspects in Murder is Easy.
Good doctors Not all Christie’s doctors are baddies. If the guilty culprit was always a doctor, guessing the identity of the perpetrator would have been too easy and predictable. There are many ‘‘walkon’’ doctors who are mostly not sufficiently characterised to be judged. Thus, Dr Cazalet, who appears in The Under Dog and is a Harley Street hypnotist is “not a quack.” There are some reputable and honest doctors in Chrstie’s novels, including the sports doctor Dr Giles in The Market Basing Mystery, Dr Graham in A Caribbean Mystery, Dr Griffiths in The Moving Finger, and Dr Constantine in Murder on the Orient Express. Also, two doctors Dr Calgary BMJ | 18-25 DECEMBER 2010 | VOLUME 341
(Ordeal by Innocence) and Dr Haydock (Murder at the Vicarage) are central characters in the plot but retain unblemished reputations, and Dr Thomas Humbleby in Murder is Easy is a good chap.
Discussion If one adds Christie’s ‘‘red herring murderers’’ to the list of real murderers, 23 of the actual or potential murderers in her thrillers are doctors, which the reader may feel is prima facie evidence of iatrophobia on her part. Her family’s experiences of the medical profession may help to explain her attitude.5 Her father was a rich stockbroker, her mother the daughter of an army captain, and the family had at least three servants. Agatha Christie had an upper middle class upbringing – she was educated at home, her siblings were sent to boarding school, and she spent two years at finishing school in Paris. She was accustomed to dealing with doctors as social equals (or even inferiors, they having to use the tradesman’s entrance) and they would be invited to dinner only as a favour, so it was hard for her to be obsequious towards them. Her mother was a frustrated would-be doctor who read the British Medical Journal and the Lancet and considered herself as being as fully trained as her brother Ernest, who eventually abandoned medicine because he
could not stand the sight of blood. When Agatha’s father became ill, he was diagnosed by different specialists; first as having kidney disease, then a heart condition and finally as having a gastric problem, which led her to remark that medical science was “of little use.” When her mother became ill upon returning from a trip from Paris, again various diagnoses were made (appendicitis, gallstones, paratyphoid, and a few others). At one point Agatha hired as housekeeper for her brother the widow of a morphine addicted doctor who had left her with 13 children. Christie had been a nurse and a pharmacist but her experience of hospital left a lot to be desired: “one never learned what a 0.1 solution meant, yet such substandard individuals tended to be venerated as higher beings just because they worked in hospitals.” There seems little doubt that doctors are over-represented among Agatha Christie’s killers, but she has left us with an enduring puzzle. Was this because of her fondness for toxicological methods of murder, and that throughout history physicians have often been consulted on medicine’s harmful as well as healing properties? Or was it because doctors were often easily trusted and accepted in every social milieu, and therefore acted as a perfect foil to carry out foul deeds? Or did her family’s experience of the profession give her a jaundiced view? Perhaps it was a combination of all these. To see details of Christie’s incompetent doctors and those with foibles see bmj.com
Herbert G Kinnell, retired NHS consultant psychiatrist, c/o 3 Welwick Close, Lower Earley, Reading, Berkshire
[email protected] Competing interests: None declared. Provenance and peer review: Not commissioned, not externally peer reviewed. 1 2 3 4
5
Gill G. Agatha Christie. The Woman and Her Mysteries. Robson Books, 1991, p 224. Wagoner MS. Agatha Christie. Twayne Publishers, 1986, p 62. Curran J. Agatha Christie’s Notebooks and Beyond Harper Collins, 2011. Heathcote C. Solved: The mystery of the missing Marple. Sunday Express 2010 Oct 10. www.express.co.uk/ posts/view/204552/Solved-The-Mystery-of-themissing-MarpleSolved. Agatha Christie: An autobiography. Harper Collins, 2010.
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Multidisciplinary medical identification of a French king’s head (Henri IV) Philippe Charlier and a multidisciplinary team explain how they confirmed an embalmed head to be that of the French king Henry IV using a combination of anthropological, paleopathological, radiological, forensic, and genetic techniques
S
ince the desecration of the French kings’ graves in the basilica of SaintDenis by the revolutionaries in 1793, few remains of these mummified bodies have been preserved and identified. After a multidisciplinary analysis, we confirmed that an embalmed head reputed to be that of the French king Henri IV and conserved in successive private collections did indeed belong to that monarch.
head also showed evidence of baldness—no hair was present on the pate. Dental health was poor, with considerable antemortem tooth loss; this corresponds with testimonies from contemporaneous witnesses about the king.2 Lastly, three postmortem inferior cervical cutting wounds were visible, corresponding to the separation of the head from the body by a revolutionary in 1793, in the context of deliberate mutilation.3
Analysis of various grey deposits on the head showed an elemental and organic composition corresponding to successive mouldings of the head. We know that three mouldings were carried out on Henri IV’s head: firstly on the fresh head in 1610,2 then on the mummified head in 1793 just after the desecration,3 and lastly by a previous owner (Bourdais) of the head at the beginning of the 20th century. A digital facial reconstruction of the skull was fully consistent with all known representations of Henri IV and the plaster mould of his face made just after his death, which is conserved in the Sainte-Genevieve Library, Paris. The reconstructed head had an angular shape, with a high forehead, a large nose, and a prominent square chin.2 Superimposition of the skull on the plaster mould of his face and the statue at Pau Castle showed complete similarity with regard to all these anatomical features.
Death of “the green gallant” Henri IV was probably the most popular French king. He was known as “the good King Henry” or, because of his attractiveness to women, “the green gallant.” Despite being admired by his people, he was assassinated in Paris at the age of 57 years on 14 May 1610 by François Ravaillac, a fanatical Catholic.
Other evidence in favour of the identification Radiocarbon dating with 2-sigma calibration yielded a date of between 1450 and 1650, which nicely bracketing the year of Henri IV’s death (1610).2 We could not recover uncontaminated mitochondrial DNA sequences from the head samples, so no comparison was possible with other relics from the king and his descendants.
Identifying the remains of the French king The human head had a light brown colour, open mouth, and partially closed eyes (fig 1). The preservation was excellent, with all soft tissues and internal organs well conserved. Two features often seen in portraits of the monarch (fig 2) were present: a dark mushroom-like lesion, 11 mm in length, just above the right nostril (fig 3A),1 and a 4.5 mm central hole in the right ear lobe with a patina that was indicative of long term use of an earring (fig 3B). We know that Henri IV wore an earring in his right earlobe, as did others from the Valois court.2 A 5 mm healed bone lesion was present on the upper left maxilla, which corresponds to the trauma (stab wound) inflicted by Jean Châtel during a murder attempt on 27 December 1594.2 Many head hairs and remnants of a moustache and beard were present; they were red and white in colour, with a maximum length of 7 mm, 24 mm, and 60 mm, respectively. This fits with the known characteristics of the king’s hair at the time of his death.2 The
Fig 1 | Left lateral (A) and right lateral (B) view of the mummified head
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A very particular embalming method The autopsy report of King Henri IV, published in the complete works of the surgeon Guillemeau (1549-1613),4 showed that the brain was not examined. Such an examination was not systematically performed when the cause of death was known (which for Henri IV was two knife wounds made in the thorax by Ravaillac).2 Another practitioner, Pigray (1532-1613), was in charge of the embalming process,5 and he took into account the king’s wish to be embalmed “in the style of the Italians.” This form of embalming minimises the mutilating aspect of the embalming procedure by not opening the skull—the brain and all internal structures remain in the skull (no vault sawing, no evacuating trepanation, no ethmoidal perforation). Computed tomography of the head confirmed that no sign of skull base or vault trauma (except for the old maxilla lesion), sawing, or opening of the cerebral cavity was present. A circumferential band of black pigment was seen on the skin at the base of the neck. Using Raman spectroscopy, it was identified as ivory black, a variety of amorphous carbon. This charcoal, obtained by anaerobic calcination of animal bones, corresponds to that deposited by the surgeon Pigray on the surface of the cadaver to absorb decomposition fluids and putrefactive gases5; the precise upper limit of the cervical deposit may be explained by the head being protected by strips of cloth so that it was not blackened during the process. We found many unidentifiable vegetal deposits in the mouth, which were, among other things, used to mask unpleasant odours that emanated from the oral cavity.6 Mercury was sometimes used when the skull was left intact. It was usually deposited as cinnabar salts within the nostrils, which were tightly packed with segments of textile.6 In this case, no trace of mercury was found in samples from the nostrils or the nasal cavity. Pathological background Computed tomography also showed partially conserved dura mater and dried brain parenchyma, with no identifiable anomalies.7 Mummified vascular and nervous structures were seen in both orbital cavities, and the right orbital cavity contained a dense biconvex 7 mm disc. This disc corresponds to the eye lens, the high density (137 Hounsfield units) of which indicates the presence of a cataract. We also identified diffuse and moderate marginal spondylarthrosis in all cervical vertebrae. Conclusion Now positively identified according to the most rigorous arguments of any forensic anthropology examination, the French king’s head will be reinterred in the royal basilica of Saint-Denis after
A
B
Fig 2 | A: Right sided view of the statue of King Henri IV at Pau Castle showing the nasal skin lesion. B: French engraving by Ganières showing the king wearing an earring in the right ear lobe
A
B
Fig 3 | Details of the different facial characteristics: (A) nasal naevus (arrow), (B) pierced right ear lobe
a solemn funeral ceremony. Similar methods could be used to identify all the other kings’ and queens’ skeletons lying in the mass grave of the basilica, so that they can be returned to their original tombs. Philippe Charlier forensic medical examiner and osteo-archaeologist
[email protected] For list of all authors see bmj.com 1 2 3 4 5 6
Lever DE, ed. Histopathology of the skin. 10th ed. Lippincott Williams and Wilkins, 2008. Babelon JP. Henri IV. Fayard, 2009. De Lamartine A. Histoire des Girondins. Armand Le Chevalier, 1865. Guillemeau J. Oeuvres de chirurgie. Re-edition. Jean Viret, 1649. Pigray P. Epitome des préceptes de médecine et de chirurgie. Jean Berthelin, 1625:398-400. Charlier P. Evolution of embalming methodology in medieval and modern France (Agnès Sorel, the Duc de Berry, Louis the XIth, Charlotte de Savoie). Med Secoli 2006;18:777-97.
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Rühli FJ, Chhem RK, Böni T. Diagnostic paleoradiology of mummified tissue: interpretation and pitfalls. Can Assoc Radiol J 2004;55:218-27.
Cite this as: BMJ 2010;341:c6805
bmj.com/podcasts ЖЖListen to Philippe Charlier explain the horrible history of Henri IV’s head at bmj.com/ podcasts bmj.com/video ЖЖSee more images of the investigation at bmj.com/video bmj.com/archive ЖЖChristmas 2009: A gold elixir of youth in the 16th century French court (BMJ 2009;339:b5311) 1327
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HISTORY
Mozart’s 140 causes of death and 27 mental disorders The plethora of proposed causes of death and mental disorders suggested for Mozart stems from some obscure need to cut great artists down to size, writes Lucien R Karhausen
SEAN GALLUP/GETTY IMAGES
A
recent epidemiological study esis of an acute condition such as influenza; has reintroduced the hypothesis staphylococcal, streptococcal, or meningococthat Mozart died from a nephritic cal infection; various septicaemias; scarlatina or syndrome caused by a streptococcal measles; typhoid or paratyphoid fevers; typhus; epidemic.1 It rests on the assump- tuberculosis; trichinosis; and so on. Postinfectious tion that “according to the eyewitness accounts, glomerulonephritis was first proposed by Barraud the hallmark of Mozart’s final disease was in 1905. Schoental, an expert in microfungi, severe edema.” However, the assumption is thought that Mozart died from mycotoxin poisonundocumented. In fact, four of the eyewitnesses ing. Drake, a neurosurgeon, proposed a diagnosis reported their observations and none noticed of subdural haematoma after a skull fracture idensevere oedema: Guldener wrote that he “made a tified on a cranium that is not Mozart’s. Ehrlich, a careful inspection of the cadaver and saw nothing rheumatologist, believed he died from Behçet’s unusual.” Sophie Haibel, who attended his last syndrome. Langegger, a psychiatrist, contended illness, mentioned a swelling of the extremities.2 that he died from a psychosomatic condition. Is this an isolated case? Not at all. This diag- Little, a transplant surgeon, thought he could nostic inflation springs from the procrustean have saved Mozart by a liver transplant. Brown, bed fallacy (selection and manipulation of the a cardiologist, claimed he succumbed to endocarditis. On the basis evidence),3 as well as from the build-up of of a translation error undocumented maniof Jahn’s biography of festations, such as Mozart, Rappoport, a severe oedema, dyspathologist, thought pnoea, convulsion, Mozart died of cerebral haemorrhage. Ludewig, hemiplegia, lancinating pain, tender joints, a pharmacologist, sugand such like4; moreogested poisoning or ver, the “Mozarteum” self poisoning by drinkskull is now known not ing wine adulterated to be Mozart’s.5 with lead compounds. I have identified 140 For some, Mozart (sometimes overlapmanifested cachexia or hyperthyroidism, but for ping) possible causes others it was obesity or of death, in addition to 85 other conditions. hypothyroidism. LudenBut Mozart died only dorff, a psychiatrist, and once. Some causes are her apostles, claimed in Last known portrait of Mozart plausible, only few— 1936 that Mozart had maybe one, or maybe none of them—can be true, been murdered by the Jews, the Freemasons, or so most if not all of them are false. the Jesuits, and assassination is not excluded by Several dividing lines separate those authors musicologists like Autexier, Carr, and Taboga. who believe in foul play and those who reject Deutsch, a Mozart musicologist, listed some it, between those who cling on to some sort of methodological concerns such as mixing fact and chronic disease process and those who believe in fiction, and the spreading of errors to produce a an acute condition, between those who twist the saleable story. The diagnostic criteria may themevidence and those who display a critical respect selves be adapted to the hypothesis. for the facts, as well as between those who seek In clinical medicine, we try to reach a diagnosis some rare condition and those who are satisfied on which every reasonable and informed doctor with some commonsensical explanation.6 agrees. But in historical medicine all the facts Many authors have favoured the hypoth- are in, so that alternative hypotheses cannot be 1328
eliminated through further investigation. Some diagnoses, such as rheumatic fever, have been carefully considered. Many others, such as heart or kidney failure, have been aired without proper assessment. Yet others have been arrived at by rigging the evidence through “data torturing,” usually in good faith. The probability of a diagnostic hypothesis decreases as the number of alternative possibilities increases. Preference should be given to the most common ones; the rarer a disease the stronger the evidence needed for its support. Finally, preference should be given to contemporary rather than retrospective sources and to observational rather than inferential ones. Henoch-Schönlein purpura has been one of the most successful among the groundless hypotheses: myths and legends as well as startling diagnoses have a strong selective advantage over mundane hypotheses in the competition for successful circulation. The upshot is that the whole exercise becomes vacuous. One author gave us a key to this situation: “Shapiro proposed that Mozart’s fatal illness was due to streptococcal septicaemia complicated by acute renal failure. Bär argued in favour of rheumatic fever. Franken diagnosed a toxic carditis and heart failure following staphylococcal, streptococcal or meningococcal sepsis, or toxic scarlet fever. We have argued in favour of HenochSchönlein syndrome.”7 This brings to mind a horse race where gamblers bet on their cherished horse although they know that no horse will win because the race will not be run. Lange-Eichbaum complained early in 1930 that too often pathography becomes a “historical game, a literary feuilleton, or a medical entertainment.” The motto of Mozart’s biography written by Nissen (Constanze Mozart’s second husband) was: de mortuis nil, nisi vere.8 What clearly emerges is that Mozart’s medical historiography is made out of various alternatives, with a general time trend as tenable diagnostic hypotheses are progressively exhausted: the more recent they are the less probable. The most likely diagnoses—such as influenza, typhoid fever, and typhus—were proposed first, and only rare and irrelevant conditions such as Goodpasture’s syndrome, Wegener’s granulomatosis, Still’s disease, or Henoch-Schönlein syndrome were left for those who came later. BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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Even in the absence of new evidence, there is still some future in the business for those who want to attach their name to some new speculative hypothesis. It will always be possible to suggest a new diagnosis, so that a complete tabulation, although denumerable, could be theoretically infinite. Mozart’s death has become a free for all, a grabbing of hypotheses.9 Even so, Nissen held that Mozart’s health was “always delicate like all men of weak constitution.” Ever since, the legend that Mozart was delicate and in poor health has been the accepted view. The contrary view Mozart’s Requiem, left unfinished at the time of his death from whatever is that Mozart had a strong constitution: he did not have an unusual number of and vomiting,19 or between musical expression childhood illnesses and he recovered safely from and defecation.20 So the final account leaves us the life threatening ones; neither did he show evi- with those 19th century speculations that Mozart, dence of any serious chronic disease.10 like most geniuses, was mentally and physically Most of the 27 psychiatric disorders attributed degenerate: didn’t he show signs of atavism,21 22 to Mozart result from disregarding or misquoting such as reptilian23 or cercopithecoid ears?24 For the criteria that demarcate normal from abnormal all that, psychobiographers often indulge in the behaviour.11 Some authors upgrade daily worries illusion of uncovering Mozart’s hidden mental life into paranoid ideas or anxiety neuroses; blues or while they actually described their own preoccugenuine worries into depression; elation into pations and obsessions. hypomania; linguistic games into jargonophasia; Eliot Slater, a Maudsley hospital psychiatrist, wit into immature or manic behaviour or into a observed about Mozart that critics of today “are childish, psychotic other self12; the dissonant fascinated so much by the breaking of convenharmonies of the Haydn quartets into Tourette’s tional restrictions, by the chaotic and disorderly, syndrome13; and, at the end of his life, a small by the neurotic and the deviant, even by pheshuddering into a convulsion. nomena which are directly evil, that they can Thus, highly selective readings of the sources, find little interest or merit in the products of an blatant misquotations, and perversions of the energetic and healthy normality.” Did not Mozart diagnostic criteria have led to shoddy medical himself write: “Talk much—and talk badly, but interpretations. Mozart allegedly had thought this last will follow of itself: all eyes and ears will disorder, delusions, musical dysfluency, and epi- be directed at you.” leptic fits, plus he did not actually compose music Slater added, “If, however, we find [the but merely displayed musical hallucinations.14 He composer’s] personality strange or difficult to was a manic depressive,15 a pathological gambler, understand, then we may only be able to bear and had an array of psychiatric conditions such as comparison by trying to cut down the man or his Capgras’ syndrome, attention deficit/hyperactive work to our own scale. We can do this more easdisorder, paranoid disorder, obsessional disorder, ily if, at any point, we are able to look down on dependent personality disorder, and passive- him from above, from a superior level of sanity, or aggressive disorder. This has resulted in psychi- social competence or moral integrity.”25 atric narratives that blend an uninterrupted long This phenomenon is Mozart’s medical nemtradition of defamation—the film Amadeus was esis. It covers the hidden intent to pull an excepone of the last public expressions of this tradition. tional creator down from his pedestal through With psychoanalytical stereotypes, the shad- some obscure need to cut great artists down to ows keep lengthening. Being an artist, Mozart size. It is reminiscent of Rameau’s nephew in was not far removed from being a “psychoneu- Diderot’s novel who says about people of exceprotic.” Mozart’s music is characterised by its “fem- tional creativity: “I never heard any single one of inity or lack of sexual provocativeness”7 and its them praised without it making me secretly furi“feminine polarity.”16 Some have learnedly made ous. I am full of envy. When I hear some degradanalogies between Mozart’s musical ornamenta- ing feature about their private life, I listen with tion and urinary dribbling,17 between musical pleasure. This brings me closer to them. It makes creativity and farting,18 between writing music me bear my mediocrity more easily.” BMJ | 18-25 DECEMBER 2010 | VOLUME 341
If there ever was a musician in the whole history of music who was mentally healthy it was beyond the shadow of a doubt Mozart, in the probable company of Joseph Haydn.26 Lucien R Karhausen, retired (former officer of the Commission of the European Communities), Paris, 75004, France
[email protected] Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. The listing of Mozart’s causes of death, mental disorders and other conditions is available from: http://karhausenlmd. blogspot.com. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Mackowiak PA. Post mortem: solving history’s great medical mysteries. American College of Physicians, 2007. Karhausen LR. Questionable conclusion [eLetter]. Ann Intern Med 2009; October 13. Mills JL. Data torturing. N Engl J Med 1993;329:1196-9. Karhausen LR. Mozart’s terminal illness: unravelling the clinical evidence. J Med Biog 2001;9:34-48. Karhausen LR. The Mozarteum skull: a historical saga. J Med Biog 2001;9:109-17. Karhausen LR. Was Mozart’s final illness preceded by a gathering storm ? J Med Biog 2002;10:109-20. Davies PJ. Mozart in person, his character and health. Greenwood Press, 1989. Nissen GN. Biographie WA Mozarts. Georg Olms Verlag, 1991. Karhausen LR. Weeding Mozart’s medical history. J R Soc Med 1998;91:546-50. Karhausen LR. The myth of Mozart’s poor health and weak constitution. J Med Biog 1999;7:111-7. Karhausen LR. Mozart in person [letter]. TLS 1990, December:1375. Bittner G. Wolfgang Amadeus Mozart. Die Erziehung eines Genie. In: Lipp W, ed. Wolfgang Amadeus Mozart. Genie und Musik. Ergon Verlag, 1992:27-68. Karhausen LR. Mozart’s scatological disorder [letter]. BMJ 1993;306:522. Scheidt W. Zur Frage nach dem Mechanismus der Halluzinationen. Medizinische Klinik 1965;60:1789-92. Karhausen LR. Contra Davies; Litt Mozart unter Affektstörungen? Mitteilungen der Internationalen Stiftung Mozarteum 1996;44:60-5. Rivère J. Pour un portrait de Mozart. De l’écriture aux révélations du visage. Musica (Paris) 1956;27:23-30. Bone JM. Mozart’s death: a musical/aural diagnosis. Medical Historian. Bulletin of Liverpool Medical History Society 1992;5:20-6. Autexier PA. Les œuvres témoins de Mozart. Editions Alphonse Leduc, 1982. Ferenczi S. Final contributions to the problems and methods of psycho-analysis. Hogarther Press, 1955. Gelber GS. Mozart’s wobbly self-worth. In: Ostwald P, Zegans LS, eds. The pleasures and perils of genius: mostly Mozart. International Universities, 1993:67-81. Lange-Eichbaum W. Irrsinn und Ruhm. 2te vermehrte Auflage. Verlag van Ernst Reinhardt, 1935. Heine EW. Wer ermordete Mozart? Wer enthauptete Haydn? Mordgeschichten für Musikfreunde. Diogenes Verlag, 1984. Kerner D. Mozarts äusseres Ohr. Zeitschrift für Laryngologie-Rhinologie-Otologie 1961;40:475-8. Gerber PH. Mozart’s Ohr. Deutsche Medizinische Wochenschrift 1898;22:351-2. Slater E, Meyer A. Contributions to a pathography of the musicians. 2. Organic and psychotic disorders. Confin Psychiatr 1960;2:129-45. Karhausen L. Letter to the Editor. Perspect Biol Med 1995;39:152-5.
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HISTORY
A shopping list of doctors Success in the supermarket shouldn’t deny these innovative doctors their due, thinks John Scott
T
he season of dietary indulgence seems a good time to celebrate doctors whose names have become linked with items of food and drink. From antiquity to the present, doctors have attempted to influence the diet of their patients. Some have developed foods that became so popular that they have achieved lasting commercial success. Although many are forgotten as doctors, their names remain well known to the public, becoming famous brand names and trademarks.
Christopher Rawson Penfold (1811-70) and Henry John Lindeman (1811-81) Doctors played a major role in the development of the Australian wine industry, and two remain as popular brands today: Penfolds and Lindeman’s. Christopher Rawson Penfold1 studied medicine at St Bartholomew’s Hospital, London, graduating in 1838. For six years he practised medicine in Brighton, before emigrating to Australia in 1844 and settling close to Adelaide. He believed in the medicinal power of wine, particularly for the treatment of anaemia, and before he left Britain had obtained vine cuttings from France. In Australia he developed a successful medical practice and began to make wine. Originally this was intended for medicinal use, but demand understandably grew and soon his wine was being sold throughout the country. Although he reduced his clinical work as demands of the vineyards increased, he continued to practise some medicine until the year of his death. After his death, his wife, who had
been involved in wine production from the beginning, took over the business. It has now become internationally successful. Henry John Lindeman2 graduated from St Bartholomew’s Hospital in 1834 and became a naval surgeon. Dissatisfied with his prospects in the navy, he left in 1840 for Australia, where he started a medical practice. He believed that the Australian climate made wine a healthier drink than spirits, and before leaving Europe had visited French and German vineyards and studied their wine making techniques. In 1843 Lindeman bought land at Cawarra where the soil and climate were suitable for growing vines. He was building up a successful business when a fire destroyed this property and stock of maturing wine. Undeterred, he went to the Australian goldfields, where he worked as both a doctor and miner until he had acquired sufficient funds to rebuild the winery. He expanded throughout Aus-
tralia and soon had a reputation for producing wines of high quality.
William Oliver (1695-1764) William Oliver3 was an English physician, philanthropist, and inventor of the Bath Oliver biscuit. He studied medicine at Cambridge and Leiden then practised for a time in Plymouth. In 1725 he moved to Bath, where he spent the rest of his life. He soon built up the largest practice in the city. Oliver had a wide range of interests outside medicine, including literature, art, and architecture. However, he is best remembered today for his invention of the Bath Oliver, a hard savoury biscuit, which he initially used in treatment along with Bath mineral water. He is also said to have invented the Bath Bun, a sweet fruit bun that his patients loved. They ate them to such excess and gained so much weight that he abandoned buns in favour of biscuits.
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Although many are forgotten as doctors, their names remain well known to the public, becoming famous brand names and trademarks BMJ | 18-25 DECEMBER 2010 | VOLUME 341
HISTORY
Shortly before his death Oliver gave his iscuit recipe to his coachman, along with b £100 and a quantity of flour to set him up in business. The coachman opened a shop and soon made his fortune.
John Abernethy (1764-1831) The Abernethy biscuit, a hard biscuit originally flavoured with caraway, is named after John Abernethy, 4 an English surgeon who studied and worked for most of his life also at St Bartholomew’s Hospital. His robust sense of humour and histrionics made him a popular teacher. Abernethy was renowned for his rudeness to patients no matter what their social status or wealth, which paradoxically only served to increase his practice and income. He believed that disorders of the digestive tract were responsible for all diseases and that frequent purges and a restricted diet were vital in the treatment and prevention of disease. After his death his emphasis on diet led to the naming of the biscuit after him. Thomas Richard Allinson (1858-1918) Thomas Allinson5 was a British doctor who founded a bakery which still produces bread under his name, manufacturing the loaf that claims to have “nowt taken out.” He qualified in Edinburgh in 1879, and practised throughout his life in London. He was a vegetarian who condemned alcohol, coffee, tea, and tobacco, as well as meat, at a time when much of the medical profession was in favour of smoking as being beneficial to the lungs. He believed that the whole wheat grain was the perfect food for man and that bran was important to health, almost a century before the work of Dennis Burkitt convinced the medical profession. His outspoken criticisms of his medical colleagues and widespread self promotional advertising led to the erasure of his name from the Medical Register in 1892. Despite this he continued to practise successfully, to give public lectures, and to write on his methods of preventing and treating disease. Joseph Fry (1728-87) Joseph Fry6 was an English physician, businessman, and chocolate manufacturer. He served an apprenticeship to an apothecary
Kellogg’s extraordinary exploits were the basis for a film
and settled in Bristol, where he set up an apothecary’s shop and developed a large medical practice. He was a strong believer in the health value of cocoa powder, which in his day made a bitter, definitely medicinal drink. He began to make a chocolate drink in his shop in 1759. Fry was an astute businessman and soon abandoned medicine, except for charitable cases, in favour of various successful business activities. In 1761 he purchased a chocolate business, which was successful, and he was soon selling chocolate throughout the United Kingdom. In 1764 Fry passed control of the chocolate company to his wife and sons, while he concentrated on his other business activities, retiring only in the year of his death. His chocolate company continued to expand and became the largest manufacturer of chocolate in Britain. In 1847 the company was first to develop a technique for producing solid chocolate bars and in 1866 the Fry’s Chocolate Cream bar was invented.
John Harvey Kellogg (1852-1943) John Harvey Kellogg7 was an American surgeon, hygienist, and food manufacturer who accidentally invented cornflakes. He graduated in medicine from Bellevue Hospital Medical College in New York City in 1875 and the following year became superintendent of the Battle Creek Sanitarium, Michigan. He practised a brand of holistic medicine advocating a vegetarian diet, abstinence from alcohol and tobacco, frequent enemas, and exercise. He believed most diseases could be alleviated by altering the intestinal flora. To this end he used, among other treatments, yoghurt enemas.
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In 1884 Kellogg obtained a patent for the manufacture of “flaked cereal.” Looking for a digestible bread substitute for use in the sanatorium he had accidentally left a pot of boiled wheat to stand. This wheat emerged from rolling as large, thin flakes, which, when baked, became crisp. His patients liked the result so much that he formed a company with his brother to manufacture and market corn flakes (although he and his brother later fell out and parted company). Kellogg also invented peanut butter.
Conclusion Lists of doctors best known for their contribution to fields outside medicine—called medical truants by Lord Moynihan—are dominated by those who have achieved success in areas such as politics, literature, science, exploration, and natural history.8 9 It may be thought that commercial success makes doctors undeserving of professional recognition. This article attempts to rescue some from medical oblivion. C John Scott, retired consultant physician, Aberdeen AB16 5BB, UK
[email protected] Competing interests: None declared. Provenance and peer review: Not commissioned; not externally peer reviewed. 1 2 3 4
5 6 7
8 9
McDonald DI. Penfold, Christopher Rawson (18111870). In: Australian Dictionary of Biography. Vol 5. Melbourne University Press, 1974: 429-30. Woodhouse FL. Lindeman, Henry John (18111881). In: Australian Dictionary of Biography. Vol 5. Melbourne University Press, 1974:89. Borsay A. Oliver, William (1695-1764). In: Matthew C, Harrison B, eds. Oxford Dictionary of National Biography. Vol 41. Oxford University Press, 2004:764-6. Jacyna LS. Abernethy, John (1764-1831). In: Matthew C, Harrison B, eds. Oxford Dictionary of National Biography. Vol 1. Oxford University Press, 2004:99101. Scott CJ. The life and trials of T.R. Allinson ex-L.R.C.P.ED. 1858-1918. Proc R Coll Physicians Edinb 1999;29:258-61. Mosley J. Fry, Joseph (1728-1787). In: Matthew C, Harrison B, eds. Oxford Dictionary of National Biography. Vol 21. Oxford University Press, 2004:99-100. J. H. Kellogg dies; health expert, 91. The New York Times. 1943. http://www.nytimes.com/ learning/general/onthisday/bday/0226. html?scp=1&sq=Kellogg%20Dies.%20December%20 16,%201943&st=cse. Moynihan BGA. Truants: the story of some who deserted medicine yet triumphed. Cambridge University Press, 1936. Lock SP. Truants—doctors in other walks of life. In: Lock S, Last JM, Dunea G, eds. Oxford illustrated companion to medicine. 3rd ed. Oxford University Press, 2001:827-31.
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CHRISTMAS 2010: HISTORY
HISTORY
Teapots: the short and stout physicians’ friends
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Resourceful doctors have put the teapot to many different uses over the years, finds Katharine Cranfield
he teapot and the BMJ: two quintessentially British objects (well perhaps not the teapot, given its Chinese origins, but definitely adopted by the British). Both have helped the nation’s doctors in providing the best possible care for their patients over the past 260 years. The BMJ has provided up to date research, case reports, and articles to its readers, but what about the teapot’s contribution? Some people may think that the teapot serves only one (fairly obvious) purpose, while others view it as completely superfluous. I would like to offer my findings from the BMJ archive, with a view to making teapot sceptics consider whether it really is just “a little teapot.” The teapot first features in the BMJ as a medicinal aid in 1844, when it was used in the management of hydrophobia (late stage rabies).1 At a meeting of the Sheffield Medical Society, the case was presented of an 18 year old apprentice tiler who was able to drink fluids only through the spout of a teapot with the lid on. An unlidded teapot (or any other vessel)
increased the patient’s panic, inducing endless paroxysms of coughing and spluttering and leaving him unable to swallow.
Poisoning One particularly perceptive physician used a teapot and its contents to understand the cause of death of two of his patients.2 In 1852 Mr Skevington was called to see a lady and her maidservant, who had both become acutely unwell after drinking a cup of tea made to Mrs Beeton’s instructions.3 These stated that “few grains of carbonate of soda, added before the boiling water is poured on the tea, assist to draw out the goodness: if the water is very hard.” Unfortunately, some varieties of tea contain arsenic, and the bicarbonate of soda reacted with the tea to produce arsenic acid, delivering both ladies a fatal dose. Although these findings did not help Mr Skevington to save his patients, they did provide him with an interesting case report to submit for publication. The teapot’s shady reputation as an accomplice in poisoning continues in a
case report from 1856, in which a servant girl attempted to poison her mistress by adding arsenic to her teapot.4 The lady, who had severe rheumatism, noticed an unusual taste and therefore drank only a spoonful of the tea. She had mild symptoms of arsenic poisoning for a week, but her rheumatic pain and joint stiffness settled for many months. This hints at the potential for arsenic based rheumatic treatments, although to date none have been successful because of their toxic side effects. A slightly more eccentric rheumatic treatment involving a teapot was described in 1904.5 Black slugs “masked in a teapot with water and salt, supply an oil” that is reportedly excellent for pouring directly on to rheumatic joints. Perhaps we should consider re-evaluating such a treatment. It would certainly solve many gardeners’ slug problems, although I wonder how many patients would be prepared to test such a therapy. Other teapot “poisoning” cases have also featured in the BMJ. An 1853 article described delirium tremens, probably secondary to excessive tobacco intake.6 The worst cases were in “sailors who would fill a teapot and smoke through the spout.”
Public health After cholera was discovered in London in 1854, the teapot aided Professor Franklin in discovering that even boiling water contaminated with “excrement and organic matter” does not prevent sickness and diarrhoea.7 When two of his patients became acutely unwell after drinking a pot of tea, he tested the well water used to make the drink. Finding it to contain traces of human excrement from a leaking sewer, but no cholera, he ensured that this water source and several others nearby were permanently closed. Mr Smee (physician and chemist turned “man of self-purification”) continued to echo such sentiments in campaigning for ground sewerage for London. In 1869, most of the city’s sewerage ended up in the river Thames, which people used as a source of drinking water and fish. Mr Smee astonished the public with his “somewhat unrefined, but not inappropriate warning” that “the teapots of London are filled from the waterclosets of Oxford.”8 1332
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Winter holidaymakers should perhaps take heed of an 1880 article suggesting that teapots are the ultimate travel accessory. Following an outbreak of typhoid fever in Switzerland, Sir Henry Thompson suggested that no traveller should be without “a teapot and a filter,” enabling you to “practically abolish some of the danger of impure water.”9
Cup of cheer The effects of tea on psychological wellbeing are also well documented. One 1886 article states that “It is known to all English-speaking peoples as ‘the cup that cheers but not inebriates.’”10 I suspect that all doctors have realised the veracity of this statement 11 hours into a busy on-call session. The teapot was felt to be vital for dealing with “neuroses in wartime.”11 When outlining the essential equipment in first aid shelters for managing this, a 1939 article suggests that “in the first place the teapot and sugar basin” should always be present. Although a hospital is very different from an air raid shelter, wards may occasionally resemble a battle zone. At such times, a cup of hot, sweet tea still seems to work wonders for patients and staff alike. Medical aid Before the arrival of drinking straws, teapots provided a novel method of feeding patients who had had oral surgery. In 1891, Jonathan Hutchinson described a method of fixing a “long, flexible nozzle” on to a teapot spout, and passing this down the back of the patient’s throat to provide nutrition immediately after tongue surgery.12 Perhaps hospital juniors ought to remember this trick when unable to pass a difficult nasogastric tube. BMJ | 18-25 DECEMBER 2010 | VOLUME 341
The sequencing of actions required to make a cup of tea forms a vital part of the assessment of a patient’s cognitive and functional ability, to the extent that a 1988 article suggests “patients are not allowed home from a British geriatric ward until they have proved that they can make a cup of tea.”13 However, this testing method is not new. James Edmonds used a tea set as part of the routine assessment of a woman with a right sided weakness and expressive dysphasia in 1900.14 Mr Edmonds would regularly take afternoon tea with his patient, and while she was always capable of using the teapot and milk jug, she was rarely able to name them. It was in the resource scarce cholera camps of the Middle East that the teapot really came into its own as a life saving piece of equipment. In a letter dated 7 June 1916, Victor Horsely (a surgeon with the Mesopotamian Expeditionary Force) describes finding one of his medical officers resuscitating a moribund patient by “pouring saline into his veins from his own teapot.”15 Although no further details are given regarding the logistics or outcome of such an infusion, an article from 1947 may shed some light. It explains that many a “devoted missionary has performed wonders with a teapot, a piece of rubber tubing, a hollow needle and water from a local well,” to fashion a crude giving set.16 War time rationing and the lack of medical supplies once again thrust the teapot into the spotlight. In 1941, the BMJ advised medical staff to use large teapots filled with either sodium bicarbonate or warm water when irrigating patients’ eyes following mustard gas or lewisite exposure.17 Douche cans were a scarcity, and as just about every building in the country seemed to possess at least one teapot this seemed the ideal substitution.
CHRISTMAS 2010: HISTORY
Dr E Lyth wrote to inform the rest of the medical profession how to stay well when attending to patients with influenza in 1929. He advised filling an atomiser with fresh tea from the morning teapot and using it both hot and cold for the duration of the next 24 hours. Dr Lyth suggested “2 to 3 compressions of the bulb for each nostril and for the throat before going out and on returning, with an extra use of the atomizer before and after seeing a suspicious case.”18 Infection control teams nationwide may wish to take heed and provide their staff with a traditional, cost effective method of protecting themselves ahead of this year’s flu outbreak. With such a vast array of contributions to modern day medicine, I hope that at least some sceptics are convinced that it is certainly not just “a little teapot.” Anyone who still believes that it is a superfluous item can always give it away. No fewer than 16 physicians over the years have not only been given such an object as a retirement or thank you gift but had the fact published in the BMJ. Perhaps the next time you pick up an object you feel is defunct in today’s society, you might consider looking it up in the BMJ archives? Who knows, you might be surprised at what you find. Katharine Cranfield, CT1 doctor in acute care common stem anaesthetics, Wansbeck Hospital, Ashington, UK
[email protected] Competing interests: KC has a probable tea addiction and is a teapot fan. Provenance and peer review: Not commissioned; not externally peer reviewed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Sheffield Medical Society. Hydrophobia. Prov Med Surg J 1844;s1-8:496-7, doi:10.1136/bmj.s1-8.32.495. Skevington J. A case of poisoning with arsenic acid. Prov Med Surg J 1852;s1-16:9 – 10, doi:10.1136/bmj. s1-16.1.9. Beeton I. Mrs Beeton’s book of household management. Beeton Publishers, 1861. Wheatcroft J, The effects of arsenic on men and animals. Assoc Med J 1856;s3-4:17, doi:10.1136/bmj. s3-4.157.17-b. Literary notes. BMJ 1904;i:1458-9, doi:10.1136/ bmj.1.2268.1458-a. Hayes B, Reports of societies. Assoc Med J 1853;s31:400-4, doi:10.1136/bmj.s3- 1.18.400. The propagation of cholera. BMJ 1866;ii:308-12, doi:10.1136/bmj.2.298.308. Water analysis for sanitary purposes. BMJ 1869;i:427-8, doi:10.1136/bmj.1.436.422. Warning to travellers. BMJ 1880;ii:51-9, doi:10.1136/ bmj.2.1019.51. The use and abuse of tea. BMJ 1886;ii:170-81, doi:10.1136/bmj.2.1334.170. Neuroses in war-time. BMJ 1939;i:234-7. doi:10.1136/ bmj.1.4074.234. Hutchinson J. An address on the surgery of the tongue. BMJ 1891;ii:1247-9, doi:10.1136/bmj.2.1615.1247. Mulley GP. Help and support. BMJ 1988;296:636-8; doi:10.1136/bmj.296.6622.636. Edmunds J, Remarks on will-making in aphasic paralysis. BMJ 1900;i:749-53, doi:10.1136/bmj.1.2048.749. Obituary of Sir Victor Horsley. BMJ 1916;ii:162-7, doi:10.1136/bmj.2.2900.162. Annotations. BMJ 1947;ii:619-21, doi:10.1136/ bmj.2.4528.619. Stocken LA, Thompson RHS. Procedure for the treatment of gas casualties. BMJ 1941;ii:448-51, doi:10.1136/ bmj.2.4212.448. Letters, notes, and answers. BMJ 1929;i:583-4, doi:10.1136/bmj.1.3559.583.
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HISTORY
HISTORY
Acting on evidence John Powell describes how the BMJ archive was used to raise three ghosts of The London Hospital
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he arrogant junkie surgeon, the maverick heart throb, and the pioneering genius: it could be a roll call for the medical department of any teaching hospital. Casualty 1909 was a BBC1 drama series (14 June–19 July 2009) set in The London Hospital in Edwardian times. The series made extensive use of the BMJ archive to construct convincing medical storylines from the first decade of the twentieth century, and to put flesh on the bones of the principal medical characters, who were based on real doctors of the period.
Henry Percy Dean In 1909, Henry Percy Dean was a surgeon and teacher of operative surgery at The London Hospital.1 As his obituary in the BMJ noted, Dean was a brilliant medical student at University College London1 and became one of the leading figures in the introduction of spinal anaesthesia, authoring a classic paper on the use of stovaine in the BMJ of 1906.2 The sentiment of this paper was succinctly paraphrased in Dean’s line, as used in the BBC series: “Observe how the possibility of surgical shock previously common in abdominal surgery has been all but eliminated by the use of stovaine anaesthesia via lumbar injection.” Unfortunately Dean’s predilection for tropane alkaloids extended beyond his professional practice and his cocaine addiction became an open secret at The London. Sir Arthur Keith, responding to the announcement of Dean’s death, gave this revealing portrait in a letter to the BMJ of 1931: “If he had fulfilled the promise which we who were associated with him at the London Hospital thirty-five years ago perceived, he would have died the leading surgeon of his time . . . He seemed destined to reap the highest rewards his profession could confer on its most distinguished votaries. What happened? I cannot tell. All I know is that some tragedy in his life robbed modern surgery of a man who, if things had been otherwise, would have left on its progress an enduring memorial.”3 In the drama of Casualty 1909, the story of the early days of spinal anaesthesia is interwoven with Dean’s personal struggles. Dean’s professional performance begins to suffer and ultimately one of his ward nurses turns whistleblower. In his own case reports Dean acknowledged the incidence of headache following 1334
again of The London, also drew attention to the dangers of single handedly anaesthetising and operating.8
Fig 1 | One of the prosthesis artists puts the finishing touches to a perforated femoral vein
spinal anaesthesia,2 a finding replicated in other contemporary case series,4 and in Casualty 1909 Dean’s patients increasingly complain of this side effect. Dean makes a (fictionalised) mistake in the administration of spinal anaesthesia in one patient, who does not regain movement in his lower limbs, and subsequently misses the diagnosis of a ruptured urethra while operating on a patient with a fractured pelvis and punctured femoral vein. Figure 2 shows the reconstruction of the surgery. Disappointingly, reference to Poupart’s ligament (the inguinal ligament), which appeared in the initial script, did not make the final draft. Other details from the 1912 BMJ source article were used by the prosthetics department to construct the pelvic model for the procedure: “A long itudinal incision about 4 in long was made over the tumour. On cutting through the integument and deep fascia, dark clots and about a pint of dark fluid blood were turned out.”5 Although Dean’s struggle with cocaine would cost him his role as full surgeon at The London, he won a victory in the battle over the introduction of spinal anaesthesia. In a key scene he persuades the house committee of The London to release an unprecedented statement in support of this innovative method. This announcement was noted in the BMJ of 12 June 1909 by hospital surgeon Lawrie McGavin.6 In fact, the BMJ archive revealed that 1909 was a key year in the regulation of anaesthetic practice and the emergence of the specialty of anaesthetics. As well as reports of the passage of the Anaesthetic Bill7 and the accompanying debate, in the Christmas 1909 issue of the BMJ, one correspondent, the eminent anaesthetist Sir Frederic Hewitt,
Millais Culpin Millais Culpin worked in the receiving room of the London Hospital in the early 1900s,9 and he was later to become a leading figure in psychology. Culpin was one of the first to recognise the benefits of psychological treatment for post-traumatic stress disorder (in people with shell shock from the first world war).10 Culpin’s early interests in hysteria and so called functional disorders11 12 are dramatised through his dealings with the psychological issues affecting many of the patients passing through the receiving room. One fictionalised case is that of a Mrs Anderson, a woman with depressive symptoms and a fondness for gin who is admitted after ingesting a questionable anti-corpulent preparation. Such “secret remedies” were a widespread phenomenon of the period, as recorded in a series of BMJ articles and a book published by the BMA in 1909.13 14 In Casualty 1909, Culpin takes a keen interest in cases of attempted suicide (illegal in England and Wales until 1961) and in one incident deals with a case of caustic soda ingestion. The symptoms and treatment (“gastric lavage and lemon juice”) were recorded in a BMJ case study.15 In another case, continuing his encounters with the social and legal issues of the time, Culpin completes an abortion in a prostitute who has only partly succeeded in undertaking the procedure herself. The woman has symptoms of lead poisoning, having consumed lead pills as an abortifacient. The archive revealed this was a common practice of the time.16 Culpin’s work in the receiving room is also useful to demonstrate some now outmoded treatments revealed by the archive, for example, the use of strychnine as a “vascular tonic” in heart disease.17 All dramas require romance, and in Casualty 1909 this is provided by a nurse Ethel Bennett. One passionate kiss is as far as the relationship between Culpin and Bennett progresses on screen, but from his BMJ obituary we know that, “In 1913 Dr. Culpin married Miss Ethel Maude Bennett, daughter of Mr. E. Dimery Bennett.”9 The production company were also able to trace the couple’s descendants and read Nurse Bennett’s own diaries from the time. In the series, Ethel’s brother dies following an appendicectomy, an BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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HISTORY
PHOTOS COURTESY OF STONE CITY FILMS
bmj.com/video � Watch a BMJ collection of videos “Tales from the archive” at bmj.com/video
Fig 2 | Mr Dean (actor Paul Hilton) operates under spinal anaesthesia to remove a spicule of bone from the vein
operation which at the time had “an acknowledged mortality of 3.3 per cent.”18
Henry Head The appositely named Henry Head is a key figure in the history of neurology, in particular for his pioneering work on sensation.19 In 1909 he was assistant physician at The London Hospital. Head is perhaps best known for his experiment in nerve regeneration when, as Head himself related in the BMJ, he “determined to bring clinical results to an experimental test by dividing the radial and external cutaneous nerves.”20 Head undertook the procedure on his own arm and the (in)famous scene is re-enacted in Casualty 1909. In the years following this pioneering self-experiment, Head and his renowned colleague W H R Rivers meticulously documented the slow recovery of sensation.19 Head’s discursive papers in the BMJ, such as an essay on the nomenclature of disease,21 and an address on the nature of pain,22 reveal something of the philosophical character of this Renaissance man, who was also a published poet and close friend of Siegfried Sassoon. Indeed, he coauthored a letter in the BMJ, affirming that “philosophic studies would be of advantage to many medical men, both by expanding and defining their outlook in relation to general or individual experiences and by affording assistance in the solution of practical difficulties.”23 Like Culpin, Head had an early interest in psychology and in BMJ | 18-25 DECEMBER 2010 | VOLUME 341
the relation between mental states and physi- London School of Hygiene and Tropical Medicine cal illness. In an address on hysteria, he wrote, and became president of the British Psychological “the general physician is scarcely familiar with Society.9 He died in 1952, aged 78. Henry Head the psychical aspect of continued to practise medicine; he and his and teach medicine, colleague, the surgeon, and to undertake neurarely consider how rological research, until his retirement in 1925, large a part the mind plays even in the sympaged 64, when Parkintoms of gross structural son’s disease began to disease.”24 take its toll. He received In Casualty 1909 , a knighthood in 1927 Head’s thoughtful and died in 1940.19 nature and clinical acuWith the assistance of Henry Head (left) played by Anton Lesser (right) men are illustrated in the BMJ archive, Sir his astute diagnosis of polio in a recent immi- Henry Head and his colleagues were able to walk grant (unusual in London at that time, although the wards of The London once again. sporadic cases did occur)25; in his treatment of John Powell, associate clinical professor in epidemiology an unusual case of disseminated sclerosis (mul- and public health, Health Sciences Research Institute, tiple sclerosis, treated with strychnine); and in his Warwick Medical School, University of Warwick, Coventry dealings with a histrionic young actress who has CV4 7AL, UK
[email protected] concealed her identity and thrown herself under JP worked as medical adviser to Casualty 1909 and undertook research on the BMJ archive to inform the work of the writers and a horse tram.
Postscript Henry Percy Dean retired from the active staff of the London Hospital in 1913 at the age of 49, to take up the teaching post of consulting surgeon.1 He died 16 years later having never fulfilled his early promise.3 Millais Culpin went on to hold the chair in medical and industrial psychology at the
script executive. Casualty 1909 was produced by Bryn Higgins and executive produced by Clare Duggan as a Stone City North production for BBC1. It was written by Colin Heber-Percy, Lyall B Watson, Stephen Davies, and Simon Block. The script executive was Hilary Norrish. The London Hospital archives were researched by Jonathan Evans, archivist at The Royal London Hospital. Provenance and peer review: Not commissioned; not externally peer reviewed. Full version and references are on bmj.com Cite this as: BMJ 2010;341:c5168
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“In consequence of enemy action” Stephen Casper describes the Rockefeller’s programme that led to 84 medical students studying in North America for part of the Second World War Introduction Between 1940 and 1945, the Rockefeller Foundation offered fellowships for British medical students to complete their medical training in North America.1‑4 These fellowships arose from the damage caused by the extensive aerial bombardment of medical facilities across Britain and shortages of qualified teachers to train students. To the American committee at the Rockefeller Foundation that provided their fellowships, these medical students became another thread in the enlarging fabric of the “special relationship.” To the British committee charged with selecting them, these students represented a last line of defence, a contingent of students able to fight on should Britain be occupied.5 6 What was the Rockefeller scheme? Documents from both sides of the Atlantic record the programme that emerged, although the story is chiefly captured by papers held in the Rockefeller Archives (but for a pithy discussion, see Hill7). An early memorandum by Robert Lambert (Rockefeller Foundation) and John Fulton (a Yale physiologist) from September 1940 offers a sense of the origins of the programme: “Fulton has in mind a limited group—not more than a hundred. Thinks US and Canadian medical schools would give free tuition. Yale might take 5, Harvard 10, Columbia 10, etc.”8 The Rockefeller Foundation subsequently allocated $5000 per student,9 while articles in medical journals justified the programme as a consequence of enemy action and the beginning of a new era of cooperation between British and American medical schools.10 In a letter to the BMJ Henry Dale observed that the interchange of medical personnel was the continuation of international collaborations begun by AngloAmerican physiologists.11 By March 1941, a letter between the Rockefeller’s Alan Gregg and Edward Mellanby (secretary of the MRC) reveals that the programme was operational and hailed enthusiastically as a “practicable service with some long-term results almost sure to be satisfactory.”12 Satisfactory perhaps, but some saw the programme differently. The students were ostensibly selected on their academic merits and likelihood of graduation. Yet, to cynics the interchange placed sons in safer environments; to pessimists the medical students represented a contingent of physicians for the British forces should Ger1336
many occupy the nation. Pragmatists observed that training mattered less than the diplomatic service young, attractive men and women offered the British cause in America. As Desmond Pond, one of the students, recalled, nominees had to be academically qualified and “presentable.” He added, “I know at least one or two eminently suitable people . . . who . . . were not chosen because of their known pacifist or left-wing views.”13
Who went to America? What did they find? In total, 75 men and nine women medical students are known to have enrolled in 24 North American medical schools between 1941 and 1944 (see tables 1 and 2). They attended schools in California, Toronto, Montreal, Louisiana, Iowa, North Carolina, and throughout the northeastern United States. (See appendix on bmj.com for details of individual students) Almost all kept in close contact with the Rockefeller’s Robert Lambert. Lambert, despite sighing to the registrar at Yale that he would be glad “when all these nice British boys and girls are back home,”14 adopted a paternalistic role, writing towards the end of the programme that “the pleasures [the students] have brought have greatly exceeded the few worries they have occaTable 1 | British medical schools that sent students to North America with the Rockefeller scheme Medical school University College of Dundee St Mary’s Hospital, London St Bartholomew’s Hospital Queens, Belfast London School of Medicine for Women Durham Birmingham Aberdeen University College South Wales and Cardiff The London Bristol University of St Andrews Liverpool Edinburgh Glasgow Leeds University College London Oxford Manchester Cambridge
No of students 1 1 1 1 1 1 1 1 2 2 2 3 3 3 4 5 9 11 11 19
In all, 22 students were sent in 1941, 29 in 1942, 24 in 1943, and eight in 1944. Details are missing for some students, who are not included in the table.
sioned.”15 Such an attitude probably explains why the students kept in touch with him. Some treated him as a de facto father figure, asking for money, advice on personal and professional matters, and for permission for excursions. Many continued to write to him after they returned home. Often students regaled Lambert with stories of their arrival in North America. The voyage could be harrowing: some experienced dive-bomber attacks, and one arrived in Montreal in his pyjamas, having been rescued from a lifeboat after his ship was torpedoed. Many students described their first hours in America as profoundly confusing. Others recorded more amusing experiences. David Kerfoot (nicknamed Lend-Lease) reported that two English medical students met him at the train station in Iowa City in July 1944. However, the local police subsequently escorted them to the police station, the two students having borrowed a car and, en route, “backed into another car and removed one of its man-guards, failed to stop at all made matters worse by the fact that neither had a driving license.” Thankfully Kerfoot’s story ended happily, for “when the police discovered that I had just arrived, and (better still) that the boat I had sailed on carried a cargo of Scotch Whiskey . . . they took a lenient view of the situation . . . Since then the Iowa Police have been very friendly to Iowa City’s English colony.”16 Such levity often appeared in conjunction with an almost anthropological curiosity on the diversity of America. Grace Andrews, from Bristol University and at Tulane in New Orleans, described the variety of diseases she encountered in the wards of the local charity hospital and noted: “I shall have to . . . brush up on my French somehow. We have so many patients here who cannot speak anything else.”17 William Butterfield, from Oxford and at Johns Hopkins, described to Lambert his experiences in the American South: “for Christmas, I went to South Carolina . . . I loved the South and had a magnificent time being instructed in ‘hunting’ and the American style of dancing.”18 In an article in the Lancet another marvelled at the opportunities for cultural exchange in the New World: “I have heard Toscanini, Heifetz, Rachmaninoff, and Horowitz, and have seen a production of Macbeth that left as little to be desired as any production could; I have driven to Chicago and back and seen . . . the Mid West without realizing that it was as if I had been from BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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WWW.JACKVETTRIANO.COM
London to Wa rsaw in two days; I have acquired an old blue jalopy which rears at a traffic light like a bustled suffragette; I have grown fat eating irradiated oats, polyvitamin chocolate bars and aseptic hot dogs; I have almost essayed to jitterbug but find the cut of English trousers rather a handicap; I have shouted at football games but still can’t fathom why; I have made many friends, both students and faculty, in my own and other universities; I have got engaged to be married. I like America.”19 Between two worlds (Jack Vettriano’s On the Border, 1995) In the same article, another student observed that his peers would do they correspond to our system?”19 Another have possessed a “rugged, insular ideology…at student at Chicago noted that the medical curvariance with ‘Americanism’” but that gradually riculum was biased towards the application the attitudes transformed, because “The Ameri- of science to the practice of medicine. Others can student is three years older than his British commented that American education emphabrother and the chances are that he will marry in sised theory over practice, while British medical his junior years. Before coming to medical school schools preferred a combined approach. Amerihe has spent four years can medical teach“I have shouted at football games in college, ostensibly ers also engaged in but still can’t fathom why; I have pursuing premedical clinical lectures rather science; but from what than didactic instrucmade many friends, both students I can gather this is the tion, and the medical and faculty, in my own and other wild-oats period for universities; I have got engaged to be exams tended to test most American boys. objective knowledge married. I like America.” By the time he reaches through single word medical school he is an honest citizen again.”19 answers, true/false questions, and multiple Essentialist commentary became a typical choice questionnaires. Although the students practice. David Kerfoot, who took to driving often described the British system as better, they across America, commented to Robert Lambert seem to have admired the tenacity and specialithat Iowa City struck him as a provincial town sation demanded by the American system. populated by nice people. William Butterfield enthused: “What a vast and wonderful city Wash- After their return ington DC is! And yet it has a bureaucratic air, and Of the 84 students, two did not survive. One a less dynamic atmosphere than New York City. I died from tuberculosis; the other committed felt that the people were associated with vast fil- suicide. There is much more research to be ing systems . . . as opposed to the citizens of New done on the subsequent careers of the remainYork, who seemed to be associated with money, ing students, although piecing them together is either the amassing of it or the spending of it.”20 a painstaking process. We know, for instance, Their educational experiences had differences that most trained in America for two years and too. “The first problem,” wrote one in the Lan- that three proved unsuccessful academically. cet article, “that confuses the English student Many letters, moreover, indicated that the stualready awhirl with Coco-Cola, air-conditioning, dents felt homesick and were eager to return. It and high-balls, is the correlation of American is also clear that most of the returning students and English educational standards. High school, were mobilised on their return and thus had not junior college, university ‘med’, ‘pre med’—how “escaped” to America to avoid military service. BMJ | 18-25 DECEMBER 2010 | VOLUME 341
For many, their American experiences also transformed their views of British medical culture. Many found their transition home difficult. Ewan Cadman wrote to Robert Lambert that the emphasis on science was not helpful for the British exams: “I think that if one is not careful one forgets that one ultimately has to sit exams and practice in a country in which the scientific aspects are not as advanced as in the US.”21 Michael Newton described another difficulty the British students encountered upon return: “There was I think a slight prejudice among the teaching staff against the intrusion of American idioms and practice: this also occurred to many other Rockefeller students in other London hospitals as I heard afterwards. The change, too, from intern to student was itself considerable. The English hospital equipment I found to be different in many small and perplexing ways—and so Table 2 | North American medical schools that enrolled British students as part of the Rockefeller scheme Medical school University of Cincinnati Tulane University Medical School Vanderbilt University of Illinois Medical School Stanford New York University University of Wisconsin University of Toronto University of Pennsylvania University of Michigan University of California McGill University Columbia Western Reserve Washington University University of Rochester University of Minnesota University of Iowa Medical School University of Chicago Duke University School of Medicine Harvard Medical School Yale University Cornell University Johns Hopkins Medical School
No of students 1 1 2 2 2 2 3 3 3 3 3 3 3 4 4 4 4 4 4 4 5 6 6 7
Details are missing for some students, who are not included in the table.
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HISTORY
it seemed to me—woefully deficient in certain things.”22 Perhaps such observations account for the number who eventually emigrated: of the 84 students, 18 eventually settled outside of Britain. Some had also became romantically involved with Americans. William Butterfield quipped to Robert Lambert that the Rockefeller Foundation could have “stupendous profits as a matrimonial agency. This should help those elusive ‘AngloAmerican Relations’.”23 Butterfield’s jest, however, played upon a broader pattern in Lambert’s correspondence. Lambert joked, for instance, in a letter congratulating Joan Gannon on her engagement that: “We expected a few ‘casualties’. It looks now as though the number, referable largely to marriages on this side, would be somewhat larger that we contemplated. We had not figured on
the Committee sending over a group of such attractive young women.”24
Larger questions Obviously more could be said about the experiences of these students and especially their subsequent careers, the focus of which would require a much longer study. Several larger questions arise from this short account. In what ways, if at all, did the experience of these medical students influence the structure of British medicine? Did the presence of these students in American medical schools exert an influence on American medicine? Were these students representative of a larger informal collaboration? Were they victims of the process historians term Americanisation? Certainly in the postwar period, geopolitical
and economic influence shifted to the United States. This student programme, at the least, harkened to a larger shift in the global relations of science and medicine—one pointing towards North America. Stephen T Casper assistant professor in history of science, Clarkson University, Humanities and Social Sciences, 8 Clarkson Avenue, Box 5750, Potsdam, NY 13676, USA
[email protected] A draft of this paper was first presented at the Annual Meeting of the American Association for the History of Medicine, Rochester, Minnesota, 2010. The author thanks Professor John Burnham and Karen Buckle for comments on an earlier draft. STC is a historian of science and medicine at Clarkson University. He has published and lectured on the history of neurology and neuroscience and the globalisation of science and medicine. Competing interests: None declared. Full version and references are on bmj.com Cite this as: BMJ 2010;341: c7041
The first XV: New Zealand doctors and rugby Background New Zealanders are passionate about rugby and no professional group is an exception. The medical community in New Zealand has a proud tradition of many individuals playing international rugby and then going on to succeed in their medical career. In anticipation of the impending rugby World Cup, and as a point of historical interest, we conducted a search of medically qualified New Zealanders who played rugby at university, provincial or national level to identify a first 15 as well as reserve players. Methods No database recording players’ occupations is currently maintained, so a systematic search was not possible. We undertook the search with the help of the New Zealand Rugby Museum, the New Zealand Rugby Almanak, representatives from all the provincial rugby unions, and conversations with the knowledgeable individuals acknowledged below. The criteria for selection required that a player must be a medically qualified professional and eligible to play for the New Zealand national team, the All Blacks. Once identified as eligible, players were selected for the team on the basis of their playing abilities and not for their off-field exploits. All Blacks were given preference for each position if more than one candidate was eligible. 1338
Results We identified over 150 potential candidates, the majority of whom had represented their university. Twenty eligible candidates had played for either the All Blacks or the New Zealand Maori team (see box). The first 15 are listed here. Prop Mark Irwin (All Black, born 1935) played for Otago in the 1950s and trialled for the All Blacks as a prop at age 18. He later made his debut for the All Blacks as a 20 year old medical student in Wellington, against an Australian side led by Dr John Solomon. He was named as one of five promising players in the New Zealand Rugby Almanak in 1954. His representative career was spread over 10 years between 1953 and 1962, but he did not manage to reach 100 games owing to injuries and his decision to concentrate on his medical career. He was an excellent all round athlete and also represented New Zealand at rowing. He worked as a general practitioner and anaesthetist in Rotorua and retired from clinical practice in 2006. Hooker Nicholas Mantell (born 1967) played for Auckland, Waikato, New Zealand Universities, and the Northern Maori team in the early 1990s. He was part of the Ranfurly Shield winning Waikato team in 1997 and currently practises as an ophthalmologist in Auckland.
Prop Geoffrey Gordon (1923-2002) played mostly as a hooker for Otago University, Canterbury University, New Zealand Universities, Canterbury, and Otago between 1942 and 1946. He played a total of 35 games over his career. After graduation from medical school, he had a distinguished career as the local general practitioner in Kaikoura for over 40 years. Lock Ian Prior (1923-2009) played in either the lock or loose-forward positions for Otago from 1941 to 1944 and also represented New Zealand Universities and the New Zealand Army. He also played for the South Island versus the North Island during the second world war, when no All Blacks teams were selected, alongside Nitama “Doc” Paewai (see below). Ian Prior is widely recognised as the founder of epidemiology in New Zealand and made substantial contributions towards the arts. Lock Lawrence Knight (All Black, born 1949) played for Auckland and Poverty Bay provincially. He played a total of 35 games for the All Blacks including six test matches. His father (Lawrence Knight Senior) and uncle (Arthur Knight) were both All Blacks; unfortunately, his father died just before Lawrence’s selection for the team. His crowning on field moment was scoring the game winning try against the British Lions at BMJ | 18-25 DECEMBER 2010 | VOLUME 341
HISTORY
it seemed to me—woefully deficient in certain things.”22 Perhaps such observations account for the number who eventually emigrated: of the 84 students, 18 eventually settled outside of Britain. Some had also became romantically involved with Americans. William Butterfield quipped to Robert Lambert that the Rockefeller Foundation could have “stupendous profits as a matrimonial agency. This should help those elusive ‘AngloAmerican Relations’.”23 Butterfield’s jest, however, played upon a broader pattern in Lambert’s correspondence. Lambert joked, for instance, in a letter congratulating Joan Gannon on her engagement that: “We expected a few ‘casualties’. It looks now as though the number, referable largely to marriages on this side, would be somewhat larger that we contemplated. We had not figured on
the Committee sending over a group of such attractive young women.”24
Larger questions Obviously more could be said about the experiences of these students and especially their subsequent careers, the focus of which would require a much longer study. Several larger questions arise from this short account. In what ways, if at all, did the experience of these medical students influence the structure of British medicine? Did the presence of these students in American medical schools exert an influence on American medicine? Were these students representative of a larger informal collaboration? Were they victims of the process historians term Americanisation? Certainly in the postwar period, geopolitical
and economic influence shifted to the United States. This student programme, at the least, harkened to a larger shift in the global relations of science and medicine—one pointing towards North America. Stephen T Casper assistant professor in history of science, Clarkson University, Humanities and Social Sciences, 8 Clarkson Avenue, Box 5750, Potsdam, NY 13676, USA
[email protected] A draft of this paper was first presented at the Annual Meeting of the American Association for the History of Medicine, Rochester, Minnesota, 2010. The author thanks Professor John Burnham and Karen Buckle for comments on an earlier draft. STC is a historian of science and medicine at Clarkson University. He has published and lectured on the history of neurology and neuroscience and the globalisation of science and medicine. Competing interests: None declared. Full version and references are on bmj.com Cite this as: BMJ 2010;341: c7041
The first XV: New Zealand doctors and rugby Background New Zealanders are passionate about rugby and no professional group is an exception. The medical community in New Zealand has a proud tradition of many individuals playing international rugby and then going on to succeed in their medical career. In anticipation of the impending rugby World Cup, and as a point of historical interest, we conducted a search of medically qualified New Zealanders who played rugby at university, provincial or national level to identify a first 15 as well as reserve players. Methods No database recording players’ occupations is currently maintained, so a systematic search was not possible. We undertook the search with the help of the New Zealand Rugby Museum, the New Zealand Rugby Almanak, representatives from all the provincial rugby unions, and conversations with the knowledgeable individuals acknowledged below. The criteria for selection required that a player must be a medically qualified professional and eligible to play for the New Zealand national team, the All Blacks. Once identified as eligible, players were selected for the team on the basis of their playing abilities and not for their off-field exploits. All Blacks were given preference for each position if more than one candidate was eligible. 1338
Results We identified over 150 potential candidates, the majority of whom had represented their university. Twenty eligible candidates had played for either the All Blacks or the New Zealand Maori team (see box). The first 15 are listed here. Prop Mark Irwin (All Black, born 1935) played for Otago in the 1950s and trialled for the All Blacks as a prop at age 18. He later made his debut for the All Blacks as a 20 year old medical student in Wellington, against an Australian side led by Dr John Solomon. He was named as one of five promising players in the New Zealand Rugby Almanak in 1954. His representative career was spread over 10 years between 1953 and 1962, but he did not manage to reach 100 games owing to injuries and his decision to concentrate on his medical career. He was an excellent all round athlete and also represented New Zealand at rowing. He worked as a general practitioner and anaesthetist in Rotorua and retired from clinical practice in 2006. Hooker Nicholas Mantell (born 1967) played for Auckland, Waikato, New Zealand Universities, and the Northern Maori team in the early 1990s. He was part of the Ranfurly Shield winning Waikato team in 1997 and currently practises as an ophthalmologist in Auckland.
Prop Geoffrey Gordon (1923-2002) played mostly as a hooker for Otago University, Canterbury University, New Zealand Universities, Canterbury, and Otago between 1942 and 1946. He played a total of 35 games over his career. After graduation from medical school, he had a distinguished career as the local general practitioner in Kaikoura for over 40 years. Lock Ian Prior (1923-2009) played in either the lock or loose-forward positions for Otago from 1941 to 1944 and also represented New Zealand Universities and the New Zealand Army. He also played for the South Island versus the North Island during the second world war, when no All Blacks teams were selected, alongside Nitama “Doc” Paewai (see below). Ian Prior is widely recognised as the founder of epidemiology in New Zealand and made substantial contributions towards the arts. Lock Lawrence Knight (All Black, born 1949) played for Auckland and Poverty Bay provincially. He played a total of 35 games for the All Blacks including six test matches. His father (Lawrence Knight Senior) and uncle (Arthur Knight) were both All Blacks; unfortunately, his father died just before Lawrence’s selection for the team. His crowning on field moment was scoring the game winning try against the British Lions at BMJ | 18-25 DECEMBER 2010 | VOLUME 341
HISTORY
Flanker David Dickson (All Black, 1900-78) played for both Otago and Canterbury and later played for the All Blacks in 1925. Although he played a total of seven tour games, he did not play a single test match for the All Blacks. He was also a rugby referee during the 1930s and practised as a surgeon in Christchurch. Number 8 Hugh Burry (All Black, born 1930) played for Otago, Canterbury, and New Zealand Universities. He also played 11 games for the All Blacks but did not play a test match. Along with Kel Tremain and John Graham, he was a part of the highly effective forward combination, and he was an integral part of the Canterbury team that beat the All Blacks in 1957 and the Lions in 1959. He made his debut for the All Blacks at age 29 but his international career was hampered by a recurring groin injury. He has had a distinguished medical career; he was involved in sports medicine from its inception and later practised as a professor of rheumatology in both Australia and New Zealand. Flanker Desmond Oliver (All Black, 1930-97) played for Otago and Wellington and took part in 20 games for the All Blacks, including two test matches. He only played for the All Blacks from 1953 to 1954 and afterwards retired from top level rugby at age 23, probably because his rugby career coincided with his rise in the medical profession. He is recognised as a pre-eminent researcher in renal medicine and is credited with many discoveries related to modern day renal transplantation. Half-back David Kirk (All Black, born 1961) played rugby for both Auckland and Otago and played 34 games for the All Blacks, including 17 test matches and 11 as captain. He is recognised as the World Cup winning captain of the 1987 All Blacks but was only made captain as a result of injuries to Andy Dalton and Jock Hobbs. After the World Cup victory, he also led the All Blacks to a Bledisloe Cup win. He retired from rugby at age 25 to accept a Rhodes scholarship. He had a brief clinical career and subsequently took up various senior man-
agement positions, including acting as the chief executive of Fairfax media.
First five-eighth William Fea (All Black, 1898-1988) played rugby for Otago, South Island, and the New Zealand Service team after the first world war. His sole test match for the All Blacks was a scoreless draw against South Africa at age 22, and he retired after 1923 to concentrate on his medical career. He also served as a lieutenant-colonel with the 8th Field ambulance in the second world war. He was the youngest member of the New Zealand army team. RUGBYRELICS.COM
Eden Park, a match won 10-9 by the All Blacks. Records indicate that he was the unofficial medical adviser on his All Blacks tours. He moved to France after the 1977 season and later played for Paris University. He practised in Johannesburg and returned to live in Auckland in the late 1990s.
Left wing Graham Moore (All Black, 1923-91) played for Hawke’s Bay and Otago. He was part of the Ranfurly Shield holding side from 1947 to 1950. He also played a sole test match for the All Blacks in 1949. He was initially chosen as the fullback but was later shifted to the wing after Jack McLean was injured. He was a graduate of Otago University and practised in Masterton.
Otago in Super Rugby. He also played three tour games for the All Blacks in 1997 but was unable to cement a regular position in the test team. His career was cut short by a serious spinal injury while playing for Auckland in 2001. He is currently training to be an orthopaedic surgeon.
Right wing Russell Watt (All Black, born 1935) made his All Black debut in 1957 and played 42 games including nine test matches. Although he only scored three test points, he scored 28 tries in the tour games. His 17 tries in the season of 1957 equalled the previous record set by Albert Asher in 1903. He was recently presented with his All Black cap in Wellington in 2009 during a special ceremony to honour past All Blacks. Fullback William Anthony Davies (All Black, 1939-2008) played for Auckland, Otago, and New Zealand Universities from 1958 to 1967. He also played three test matches and 14 tour games for the All Blacks from 1960 to 1962. He was regarded as one of the best utility backs of his era and also played as a second five-eighth. He was renowned for his inventive style of play and attacking prowess.
Reserves Don Macpherson (All Black, 1882-1956) played for Otago between 1905 and 1907 and played one test match for the All Blacks against Australia in Dunedin. He later played for Scotland while furthering his medical studies in London. He was renowned for his speed and ability to score tries by the corner post. Peter Tapsell (born 1930) played for Otago and New Zealand Universities and was the vice captain of the New Zealand Maori team in 1954. He qualified as an orthopaedic surgeon and worked in Rotorua. He also had a successful career in politics, including acting as the first Maori speaker of the house from 1993 to 1996. Robert Sinclair (All Black, 1896-1932) played for Otago and Taranaki and took part in two tour games for the All Blacks in 1923 while he was still a medical student. His accurate goal kicking made the difference in the match between New Zealand and New South Wales in 1923. He was a general Ron Elvidge, All Black and practitioner in Hawera before his Medical First XV captain untimely death.
Second five-eighth—captain Ron Elvidge (All Black, born 1923) was chosen as the captain of this team. He played for Otago and participated in nine test matches for the All Blacks including five as captain. Elvidge was recognised as one of the leading backs in the post second world war era and was also part of the Ranfurly Shield-holding Otago sides of 1946-48. In 1950 he sustained sternal and rib fractures and a head laceration during a match against the British Lions, but despite being in great pain he returned to the field, because injuries had already reduced the All Blacks to 14 players. He went on to score the only try of the match as the All Blacks won 6-3. He later went on to become one of the most established obstetricians in the country. Centre Jeremy Stanley (All Black, born 1975) played for Auckland in provincial rugby and for Auckland and
BMJ | 18-25 DECEMBER 2010 | VOLUME 341
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HISTORY
The New Zealand Rugby Football, Medical First XV 1 2 3 4 5 6 7 8
Geofrey Gordon Nicholas Mantell Mark Irwin Lawrence Knight Ian Prior David Dickson Desmond Oliver Hugh Burry
Reserves r1 Don Macpherson r2 Peter Tapsell r3 Robert Sinclair
9 10 11 12 13 14 15
David Kirk William Fea Graham Moore Ron Elvidge Jeremy Stanley Russell Watt William Davies
r4 r5 r6 r7
Arnold Perry Donald Stevenson (AB) Kevin O’Connor Nitama Paewai
2 6
4
3 5 7
8
10
11
1 15
13 14
Arnold Perry (All Black, 1899-1977) played for Otago and New Zealand Universities and in one tour game for the All Blacks. He formed a potent combination with Robert Sinclair and William Fea in the Otago team. After his career as a player, he provided many years of distinguished service as an administrator to the Otago Rugby Union. Donald Stevenson (All Black, 1903-62) played for Otago and played four games for the All Blacks from 1926-1930. He was known to be adept as both a fullback and a centre, performing well in the tour games for the All Blacks. However, on the eve of a potential debut test match, he fell ill and was not selected. Kevin O’Connor (1922-2002) played for Otago, South Island, and New Zealand Universities and for the Harlequins alongside Ron Elvidge. He was a general practitioner and police surgeon until his retirement and was also a chief propagator in the establishment of the International Association of Forensic Surgeons. Nitama Paewai (1920-1990) played for Otago, New Zealand Universities, and the South Island Army Team. He was named as a reserve in the 1946 All Black team but did not take the field. He worked as a general practitioner in Kaikohe and was later the divisional surgeon to the St John Ambulance Brigade.
Discussion We selected a rugby team composed entirely of doctors after a thorough search and discussion with knowledgeable individuals. We took on this 1340
endeavour as a point of historical interest and we expect debate about the team selected. For many positions, the selections were relatively straightforward because an eligible All Black was automatically chosen, making the selection of certain positions more contentious than others. The selection of the captain is also likely to provoke debate. Our chief contenders in this team were Ron Elvidge and David Kirk and though it was difficult to pass over a World Cup winning captain, Ron Elvidge was selected on the basis of his on the field exploits and the various anecdotes shared about his leadership qualities. An obvious feature of this team is the lack of contemporary players, with the exception of David Kirk and Jeremy Stanley. Certainly, the transformation of rugby as a professional occupation rather than the national pastime has allowed rugby to be a viable career choice for able individuals. As a result, talented medical students may be unable to fully pursue rugby with the time and commitment required. The frequent assessment in medical education1 might also prevent potential players from playing international rugby. Postgraduate training also requires a substantial commitment of time; many of the individuals noted here were forced to prematurely quit top level rugby to pursue their medical career. The changing demographics of medical students might also have influenced the selected team. In the past decade, medical students in New Zealand have been from cosmopolitan backgrounds2 with a historically poor rugby pedigree and, thus, the number of individuals who could
meet the criteria of playing top level rugby and being medically qualified might have been lower overall. We have created a team of the best New Zealand rugby players who were also medical professionals. Similar projects from other countries and in other fields would provide recognition for our multitalented colleagues and would also preserve the rich history of the contributions of the medical community to fields other than clinical and academic practice. Sanket Srinivasa, research fellow, surgical registrar, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, Auckland, New Zealand
[email protected] Yu-Mwee Tan, medical student, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, Auckland, New Zealand Andrew Connolly, consultant surgeon, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, Auckland, New Zealand Andrew G Hill, associate professor of surgery, consultant surgeon, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, Auckland, New Zealand We thank Hugh Tohill, John Graham, Peter Sinclair (Otago Rugby Football Union), Ron Palenski, Clive Akers (editor of the New Zealand Rugby Almanak), John Heslop, Barbara Heslop, and the New Zealand Rugby Museum. All authors have contributed equally to this work as attested to by the senior author. SS is a recipient of the Auckland Medical Research Foundation Ruth Spencer Medical Research Fellowship. Competing interests: None declared Provenance and peer review: Not commissioned, not externally peer reviewed. 1
2
Wilkinson T, Frampton C. Comprehensive undergraduate medical assessments improve prediction of clinical performance. Med Educ 2004;38:1111-6. Fitzjohn J, Wilkinson T, Gill D, Mulder R. The demographic characteristics of New Zealand medical students: the New Zealand Wellbeing, Intentions, Debt and Experiences (WIDE) survey of medical students 2001 study. NZ Med J 2003;116:U626.
Cite this as: BMJ 2010;341:c5127
bmj.com archive � Christmas 2008: Rugby (the religion of Wales) and its influence on the Catholic church: should Pope Benedict XVI be worried? (BMJ 2008;337:a2768) Challenge: We’re looking for fantasy medical First XVs from other rugby playing nations. For example, the captain of the British and Irish Lions 1950 tour of Australia and New Zealand was Karl Mullen, a consultant gynaecologist. The honorary archivist of the Irish Rugby Football Union has located over 190 Irish internationals who were doctors, including the team that played against Scotland in 1920 when there were 11 doctors and medical students in the side. BMJ | 18-25 DECEMBER 2010 | VOLUME 341