August Focus

David Jewell

The self-styled dinosaur on page 682 has called up the spirit of the much missed Petr Skrabanek in charging current medical practice with (in Skrabanek's evocative phrase) coercive healthism. (In passing, I'm sure I'm not the only one to wonder at the way we use the dinosaur metaphor. Dinosaurs, so the palaeontologists tell us, were phenomenally well adapted evolutionary in terms. They survived for millions of years before a meteorite-induced drop in temperature caused their extinction. Not sure that mammals will last anything like as long in the face of global warming.) Willis is arguing that real doctors have to be free to make their own judgements. While not wishing to return to the days of virtually unfettered clinical freedom, many will share fears about ‘centrally-imposed mistake-making’. For central directives in a different area, now turn to page 608 for the paper on Advanced Access. It turns out that the system was devised in the US to address delays to obtain appointments of 18–55 days. What did the policy makers think they were about? The conclusions of this study (pages 608 and 615) seem fairly clear, that it produces small gains of quicker access, but that it doesn't address what, at least for older patients, has higher priority: being able to book in advance and choose the doctor they want. In the accompanying leader on page 603, Campbell unveils the latest wheeze being presented to the central decision makers: the development of polyclinics to provide better health care in London. General practice in London does have particular problems, not least how to establish satisfactory premises to work from, but it's hard to see this particular solution meeting with loud choruses of support. Then there's the promises of the new prime minister to make general practice open for longer hours …

All of this depends on accepting the view that mistakes will always be made, and the first aim is to minimise the scale of inevitable errors. The report on page 636 hints at something different. Here a careful case-control study has confirmed traditional teaching about the presentation of patients with coeliac disease. It is both humbling and astonishing to realise that those who first described such conditions got it largely right, and it says something about the capacity of the human brain to pick the signal out from a lot of noise. The desire to do this, to make sense out of what may otherwise appear merely random events, isn't always reliable. The leader on page 604 suggests that the reductionist tendency has led us to focus on pain affecting particular parts of the body, where it may be more helpful to patients to look at the bigger picture, how pain is affecting them overall. The review on page 655 tries to do just that, identifying features that will predict poor outcome for painful conditions in different regions of the body. The ones they identify — for instance worse pain at baseline, lasting for longer, multiple sites, previous history, mental health problems — may not be such a surprise, but the review should remind us to think of such things when we are with patients. Pain in the elderly is the subject of the paper on page 630, and Table 3 is a reminder of how disabling it can be for such patients.

On page 671 Willis take us to task on two counts: for restricting access to the electronic BJGP, and for the cumbersome way we handle readers' responses. The first is a tricky one. Despite so much being available ‘free’ online, publishing, both online and in hardcopy has a cost, and someone is paying. We may want to make everything we publish available free as we publish it, but for the moment the sums don't add up, and it is just not possible. However, for the letters we have come up with a solution that's been staring us in the face for some time. While we don't have a rapid response section on the BJGP website, we can use the RCGP website. So, from this month we'll publish all the letters we get (barring the odd abusive or defamatory one), we hope within a few days of receiving them, on the RCGP website (http://www.rcgp.org.uk/college_publications/bjgp/discussion_forum.aspx), and we'll still publish what we can in the hardcopy.