All of us (well, almost all of us) agree that increasing numbers of overweight people makes for a major health problem now and a bigger one in the future. But we don't all agree who or what is to blame. Here's my favourite, heard recently on the radio. Polar bears can only hunt at certain times of the year, and have to travel long distances for their quarry. They have to be very efficient at storing the food they catch. Oysters are surrounded by their food, so that they don't even have to move to eat, and have no need of elaborate storage mechanisms. Human beings now live with the metabolism of polar bears, in an oyster's world, with entirely predictable results. Sarah Jarvis on page 654 puts a strong argument that we have to take a lead in tackling the problem, and Scott Brown, in the paper based on his Mackenzie lecture on page 710 is equally convinced that we should be addressing weight problems in children as well. But Jarvis also recognises that the task is fatally hampered by lack of resources. In the account of a carefully constructed, but disappointing, trial to improve the approach to overweight patients on page 674, there is a story of initial enthusiasm turning to disillusionment. Not surprising that the overweight patients themselves finish up ambivalent, simultaneously stigmatised and blaming themselves (page 666). We are far from having really effective answers for this problem.
Not so when it comes to COPD. On page 652 Jones summarises persuasive evidence that early stages of COPD can be detected and the progress of the disease arrested. Without such intervention, the disease progresses in a predictable fashion (page 656). Once again, even when there are clear guidelines, the GPs don't always follow them (page 662), with evidence from the Netherlands of underuse of steroids and overuse of antibiotics. I suspect that many GPs would admit that it is, in practice, very difficult to treat exacerbations of COPD without using antibiotics. But we do have to face up to bacterial resistance, and on page 686 there is an account that symptoms from infections with resistant organisms go on for longer and cause more distress. Sadly we don't seem collectively to be any nearer understanding patterns of antibiotic prescribing (page 680). It's easy to grumble that nothing ever changes, but an encouraging paper on antithrombotic treatment for atrial fibrillation reports that clinical practice observed was in line with the results of clinical trials (page 697). The authors also confirm conventional wisdom, that the patients treated in everyday practice were older, and with more comorbidity than those participating in the trials.
Once again this month an apology is owed to the non-UK readers for all the grumbling about the turmoil afflicting the UK's medical world. Brian Keighley, a long-standing member of the GMC, picks at the CMOs recent report on the regulation of the profession (page 651), and Tony Rathbone thinks that the duties of the proposed GMC affiliate role will simply be impossible to discharge (page 719). Dougal Jeffries casts a sceptical eye on practice based commissioning (page 730), and Neville Goodman takes a characteristically splenetic swipe at the office of NHS chief executive (page 721). One way to keep sane is to be clear about fundamental principles of good practice, and on page 703 a case is made to count respect for patients' values as one of those principles. The authors recognise their difficulty: ‘It is not an easy task to justify the need for a new approach to values in healthcare. Appeals for greater attention to values may elicit reactions ranging from ‘this is already being done’ to ‘this may open a door to a Pandora's box of idiosyncratic, bigoted, discriminatory medicine.’ For an example of the need to pay attention to patients’ values, simply turn to the harrowing account of personal illness on page 726.
Finally, another apology. We had some complaints about an advertisement in August's BJGP for a health facility in Florida explicitly offering inducements to GPs that contravene GMC rules. As readers should know, advertisements are not peer-reviewed; the RCGP has a strict code of practice on their acceptability, but this one slipped through as it was not covered by the guidelines (for one reason, the practice has an archaic feel to it, and it's not something we were expecting to have to look out for). The offending ad will not appear again, and I apologise unreservedly to any readers who were upset or offended.
- © British Journal of General Practice, 2006.