‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.’ (Through the Looking Glass by Lewis Carroll)
On page 155 Joshua Freeman challenges us all not to become modern day Humpty Dumptys when using the word ‘holism’. He makes a worthy attempt to tie the meaning down, but I fear that those who care about such things will need to exercise constant vigilance. Now that ‘holistic’ is seen as being a component of good medicine it's easy for practitioners to claim that they practice holistically without being required to justify the statement, and rarely will anyone else be willing to challenge them. Similarly, evidence-based medicine, or, the latest addition to the short list of words that the BJGP treats with suspicion, ‘empower’. Neville Goodman, an inveterate campaigner against sloppy language, has come across another wonderful example of gobbledygook on page 159. In line with the general air of scepticism that the Back Pages so often brings to its deliberations, the review on page 152 casts doubt on the reliability of tympanic membrane thermometers. Isotretinoin may not be associated with an increase in suicidal risk, although establishing the existence of rare, but severe, side effects of any drugs is notoriously difficult (page 134).
Elsewhere, many of the research papers this month tend to support one's gut instincts. Herpes zoster seems to be a marker for subsequent malignancy, at least in women over the age of 65 years (page 102). The authors conclude that it is not an indicator of existing occult malignancy. Clinicians may be relieved that they are not being encouraged to go looking for malignancy in all their older patients who develop herpes zoster, but the paper may prompt them to think of malignancy in such patients in the future. Telephone consultations to review patients with asthma, the subject of a previous trial published in the BMJ, are, not surprisingly, a lower cost option as well (page 119). For once here is a piece of evidence that we may not want to implement immediately to its full potential. It will be important to find out how much work we can complete by telephone or e-mail before the loss of face-to-face contact threatens effectiveness. Doctors in the Netherlands currently prescribe antibiotics in one-third of patients with respiratory tract infections (page 114). The different rates according to the diagnosis are much what one would expect (higher in otitis media; lower for ‘cough’), but the strongest doctor determinant was that older doctors prescribed more. The authors don't speculate whether this was ignorance, habits cast in stone many years earlier, or simple indifference to the national guidelines. Buprenorphine or methadone do turn out to be effective treatments for opiate dependence, although here the message is to be willing to use higher doses of methadone (page 139). When it comes to the diagnosis of asthma, a clinical diagnosis gets very close to the answer, but addition of RAST tests adds precision, and may be helpful clinically in children under 5 years of age (page 125). Regardless of the results, one aspect of this paper is to remind everyone that diagnosis remains a matter of probabilities and not certainties.
Then there is the impact that migraine has on the life of sufferers (page 87). Readers may not be surprised to read how disruptive it can be, and how dissatisfied they are with the care they get from doctors. But the most interesting aspect of the paper is the innovative method, involving a group of sufferers as both researchers and participants in the study. One of the authors of this study, David Kernick, also surfaces in the Back Pages in the unlikely guise of the doctor for Exeter City football club on page 156, celebrating the unlikely draw between Exeter City and Manchester United in the FA Cup in January, reminiscent of JL Carr's novel How Steeple Sinderby Wanderers won the FA Cup. Kernick tries to put it down to chaos theory, but this won't really do. After all, giant-killing legends are one of the great traditions of the FA Cup, happening with enough frequency to demand a cause more predictable than a butterfly flapping its wings in New York (or, for that matter, Steeple Sinderby).
- © British Journal of General Practice, 2005.
