‘What's in a name?’ asks Juliet in Romeo and Juliet. ‘That which we call a rose by any other name would smell as sweet’. (In passing I learnt from the internet that this may have been one of Shakespeare's jokes, since The Rose was the rival theatre, known for its less than adequate toilet facilities). The authors on page 92 ask the same question, discussing the advances in the management of chronic pain. They argue that the problem here is the lack of robust diagnoses (and names) to describe the many patients suffering from chronic pain, so that we look for causes rather than get on to relieve the symptoms. The need to do so is emphasised in the longitudinal study on page 109, looking at patients with multiple regional pain syndromes. The pain was associated with more fatigue, worse general health and poor sleep. A possible approach is explored on page 101. Here the pervasive effects of chronic pain are repeated, but the patients reported considerable benefits from the careful use of opiates. The study is one of a small but growing number with substantial input from an affected patient, who describes his participation in the study on page 163. Where names matter most to patients and doctors is when, as diagnoses, they provide the key to correct treatment. Take, for instance, the really old-fashioned diagnosis of tuberculosis. On page 116 a study of patients with TB who were mostly diagnosed in primary care lists the presenting symptoms: some textbook-familiar, others much vaguer. The accompanying leader on page 94 makes disturbing reading. The condition is becoming more common again in the UK, especially among some vulnerable groups in particular areas, and the nature of the most vulnerable groups may surprise some readers (as it did me).
And what, for that matter, does the description ‘part-time’ mean these days when applied to GPs? The data in the study on page 96 shows quite how flexible a definition this can be. Look at the graphs: there is such a big overlap in hours worked between full-timers and part-timers (both men and women) that the terms don't seem to mean much any more. The paper also includes a small insight into the life of GPs: ‘… the negative effect of children on hours is about twice as large for female GPs as for males.’ In other words the work of child care, even among enlightened GPs, is as unevenly distributed as ever. We all need to address the consequences of more women doctors (see the study on page 152 reporting the referral rates in an out-of-hours primary care service), but Amanda Howe on page 91 mounts a persuasive argument that medicine is better for having more of them, and that the real need is to provide them with more flexible training opportunities. Women are the subject of the study of exercise on page 130. Exercise participation was associated with better general health, but no better scores for vasomotor symptoms (which was associated with obesity). Readers who themselves exercise may not be surprised by this, any more than by the claims made for the benefits of dance on page 166. Zoe Bremer is happy to admit that ‘serious medical research into the benefits of dance is severely limited’, but makes a good case for effects on both physical and mental health, and also points out that compared with other forms of exercise it is commendably cheap.
Making the benefits of advances in health care available to all remains an elusive goal. The trial on page 136 tested a plan for reducing the blood pressures of patients with diabetes through a treatment algorithm. A year's use of the algorithm seemed to achieve little, but close examination suggested that this was from the failure of clinical staff to follow it. The authors suggest some reluctance on the part of clinical staff to prescribe the full range of hypotensive drugs: ‘… there is concern that guidelines … will result in patients requiring up to four, or possibly more, classes of hypotensive drugs … with diminishing benefits in terms of cardiovascular risk for additional drugs and increasing risk of side effects or interactions’. In a similar vein, the laudable attempt to screen patients with other diseases for depression by using a two-question screening instrument looks as if it may in practice cause difficulty because of a low specificity (page 144). On page 168 Emyr Gravell voices a deeper concern, that more regulation and a quest for perfection foster an atmosphere of mistrust and suspicion, that risks crushing goodwill. In contrast, Gervase Vernon on page 161, with a train of thought triggered by his failure to find a book on ‘How to enjoy general practice’ has found a way to sustain his sense of joy and privilege in his work.
- © British Journal of General Practice, 2007.
