On page 236 Morten Rostrup describes his experience as a Médecins Sans Frontières doctor in Aceh after the tsunami. The utter devastation made any semblance of standard medical care extremely difficult, so that even there, it seems, some fundamental principles reasserted themselves: ‘The most that I could do in these cases was to listen.’ Listening to patients' needs, rather than telling them what we, or someone else, want them to hear is the key to Mike Fitzpatrick's reaction to being asked to be the agents of the government's public health initiative (page 247), just as it shone through in the account of John Sassall's life in A Fortunate Man, celebrated by Gene Feder on page 246.
Apart from wanting us to listen to them, we assume that patients want the benefit of our knowledge – that is one of the reasons for the existence of academic journals. The more knowledge accumulates about the benefits of treatment, the more able we are to inform them. However, not every patient benefits from effective treatments, which makes even the best trials difficult to interpret for individual patients. One approach has been to develop the methodology of n-of-1 trials, holding out the possibility of yielding individualised information on effectiveness (page 171). On page 175 a study from Queensland explores the feelings of patients involved in n-of-1 trials, reporting increased understanding of the conditions being treated, and a stronger sense of being in control. On page 181 the n-of-1 trial of quinine for nocturnal cramps illustrates how this can work. While the trial gave quite clear results for the participants, all of them opted to continue with quinine, including those whose cramps were apparently not helped by it. But by now we should all have got used to the idea that the best evidence doesn't dictate how every patient should use it. A similar desire on the part of participants in a trial of exercise and quinine for leg cramps (page 186) reports the same reluctance to give up the pills with three out of four who were asked to stop their current quinine taking it again within 12 weeks of joining the treatment, despite an apparent lack of any benefit.
Too often, of course, the knowledge is slim, and any benefit from it equally elusive. A clutch of papers in this issue attempt to shed some light on common orthopaedic problems. Two of them compare hip and knee pain. Patients with painful knees are more likely to consult than those with painful hips, but view knee replacements less favourably than hip replacement surgery (page 192). Consulting was also related to deteriorating function for patients with both knee and hip pain, and also to comorbidity (page 205). Here, over 7 years pain and disability tended to get worse, but about a third of all those with pain at the beginning of the study had improved at the end; again, knowing which third would make the biggest difference to patients and clinicians alike. The study of lateral hip pain from the Netherlands (page 199) reported lower rates of persistent pain, but finds that the diagnosis of osteoarthritis predicted a higher chance of persistent symptoms. This contrasts with the views expressed in a recent paper discussing the value of diagnosing osteoarthritis.1 This month's Journal also reports that injected steroids may increase the chance of recovery from the pain, and the same is reported in a systematic review of steroid injections in the shoulder (page 224). Steroids also emerged as an unlikely but effective remedy for patients with pharyngitis (page 218).
Finally, on page 212 a modern phenomenon that we all love to complain about, the public campaign or research that has patients consulting in their legions, is tested. It's quite a surprise to read that, at least in this study, public warnings had no discernible effect on consultation rates. What on earth was going on? Have we been wrong all along, and simply looking for something else to complain about, or is it that Danish patients are more sensible and phlegmatic than those in the UK? On this question the authors offer no explanation. How wise.
- © British Journal of General Practice, 2005.
