“Can you imagine yourself in a situation where circumstances The Back Pages dictate that the world as you know it has perished?” viewpoint “You cannot choose life Death — usually a natural outcome, not a crime for yourself or your HE Shipman Inquiry will suggest changes to the system of death certification. A discussion patients ...” Tdocument1 informs a series of seminars in January 2003 for interested parties, including the RCGP. The Inquiry’s thinking is apparent in draft forms for death certification, viewable online.2 “You lack the resources To summarise briefly, the Inquiry proposes a new two-page Certificate of Fact of Death and to heal, even when the Statement of Circumstances of Death. The certifying doctor then progresses to the Certificate know-how and skills of Cause of Death or Report to Medical Coroner; another two pages. Comprehensive details are there ...” of past medical history are required (for example ‘details of any relevant medication prescribed for the deceased during the six months prior to death’), with specific attention to ten factors that have not caused or contributed to death — factors such as ‘medical error or “You must act against lack of medical care’, ‘an accident’, or ‘self-neglect or neglect by others’. Relatives will be your will, beliefs, involved, with access to the dead person’s casenotes, and with similar boxes to tick excluding factors contributing to death. The level of information required will far exceed that presently ethical codes and required for cremation. A new post of Medical Coroner will be created — the Inquiry invites medical oath ...” suggestions as to necessary qualifications. In turn, Medical Coroners will be supported by Investigative Officers; to assist, for example, in the investigation of the scene of death “You are left to your Of course the purpose of reform, quite rightly, is to respond to the deficiencies in present own devices, facing procedures revealed by the Shipman case. In particular, Shipman was able to lie repeatedly on Cremation Form B to the doctors completing Cremation Form C, in the knowledge that your God and your the family of the dead person would never know what he had written about the death. Other conscience ...” objectives are laudable — certifying the fact of death should be formalised; doctors should know more about the details of death (like who was present), and of health before death; Shmuel Reis, Tomi Spenser, relatives must be more involved; systems throughout the country should be more uniform. Medicine and the Holocaust, page 78 Everyone wants to minimise the risk of concealment of unlawful death, and of medical error. But the Inquiry must also remember that procedures must be workable, sensitive, confidential and humane. That death is usually a natural outcome, not a crime. Death is rarely as explicable, and predictable, as the Inquiry assumes. When patients die, invariably we could have done things better. To find out how, we should perform significant event analyses, not hunt for scapegoats. If death certification follows the Inquiry route, doctors will routinely face bureaucratic hurdles and ethical dilemmas that are insurmountable. Therefore, by default, there will be a huge rise in intrusive and unnecessary coroner’s inquests, often against the interests and wishes of the deceased and their families. Defensive medicine will further become the norm, contents and the doctor–patient–relative–carer relationship will be damaged. Funerals will be delayed. And in any event, will the proposals deter, effectively, a doctor intent on premeditated murder? Quite probably not. 74 news 2nd London Biotechnology This is not a moment for the profession to be obstructive. We all want to do whatever possible Conference, plus flora medica to minimise the chances of another Shipman remaining undetected. But can this be done 76 paisley docs 8 without the complexity of the Inquiry’s proposals? Consider one striking factor in the Patients and populations Shipman case — he was alone with the victim at the moment of death. This is highly unusual. Graham Smith It allowed him to kill healthy patients without witnesses. In our practices, with nearly 300 GP 78 essay years of experience, we have only been the sole person present with the patient at death on a Medicine and the Holocaust handful of occasions. Shipman was alone on probably every occasion. Shmuel Reis, Tomi Spenser 80 essay 2 We propose two uncomplicated, inexpensive changes to the certification of deaths in the War, peace and the relaxing pill — community that could immediately reduce risk and reassure the public that ‘something is psychotropes in the Lebanon. being done’: Saab, Damluji, Lakkis, Usta 82 digest and reflection • Add a question to the death certificate, completed by the doctor then handed to a relative Lipman on critical appraisal and prior to death registration. ‘Who was present at the moment of death?’ If the answer is a Chinese naval history, ‘only a doctor’, automatic referral to the coroner follows. Treweek reviews an IT trio, Beale • Coroner’s officers should investigate a random sample of deaths more fully. on Physician, Heal Thyself, and Cameron on an ethics workbook, Other sensible proposals emerging from the Inquiry can then be debated at length, and with plus poetry from Howe proper seriousness. And with far less chance of inadvertent harm. plus behind the lines 86 matters arising Orest Mulka November RCGP Council Alec Logan plus diary and goodman References on the first NSF failure... 1. http://www.the-shipman-inquiry.org.uk 88 contributors 2. http://www.the-shipman-inquiry.org.uk/gencat.asp?p=2&ID=44#LIBSC85 plus miller’s rotting feet

The British Journal of General Practice, January 2003 73 4TheBritishJournalofGeneralPractice,January2003 74 news can getthem.Irecommendyou start calling embryonic stemcellsarereally niceifyou Forget theethicsforamoment:human presentations tobegoingonwith: Ipickedoutfrom the some ofthethings repeated frommanysources.Butbeloware newspapers, andanywaythenewsis from theheadlinesofresponsible departures, andyoucangetmostofthose aren’t actuallyallthatmanyradicallynew ‘How doyouGPskeepuptodate?’,there man onastand,inanswertotheperennial, for amomentyoucandoit,asIsaidto to learnafewnewwords.NotthatIdoubt So watchthisspace—youaregoingtoneed new technologytoplaywith. whose careertiminghasgiftedthemabrand up inthetight-lippedexcitementofthose nobody ismessingabout. They arecaught and eloquentlyconveyingthemessagethat by clipped,punchypeople.Preciselytotime in aseriesofclipped,punchypresentations Inside theconferencehallstorywastold beggars imagination. what itmusthavebeenliketwoyearsago hi-tech markets,butifthisisdepressed, sector isalittlethrownbythesetbacksin these peoplewereimpressive.OK,the invigorating slogans. And I’mnotmocking, graphics, missionstatementsand a festivalofplasmascreensandelegant agencies ofhalfadozenuniversities.Itwas sophisticated standsfromthespin-out referencing software. And herewere conferencing, teamworking,and marketing sophisticatedmodelling, firms andtheheadhunterspeople entrepreneurs andthefinancierslaw were theacademicsmeetingwith very muchabusinessperspective.Here smart suits,everyonefocusedandattentive, The conventionwasvibrant,everyonein benefit bothways. the USitself,soweareinapositionto Europe nowrepresentsalarger marketthan with theUnitedStates. Butontheotherhand started theroll. There ishugecollaboration biotechnology since Watson andCrick our verylarge numberofNobelprizesin founded onourexcellentsciencebaseand Europe, secondonlytotheUSA. This is UK biotechnologysectoristhelargest in of theprimedriversfor21stcentury. The The governmentviewsbiotechnologyasone Minister ofScience,wasextremelyupbeat. Biotechnology Convention,LordSainsbury, introductory remarkstothesecondLondon the excitementishere,inBritain.Inhis B 2nd LondonBiotechnologyConvention—London,11December buzzing withexcitement. And alotof shining withfluorescentdyes,and IOTECHNOLOGY is humming. And beneficiaries. doctors andpatientsalike,going tobethe be abletosay? And itlooksasifweareall, environment. Now, isn’t that anicethingto the creditforcreatingnecessary David Sainsburyinparticular, agreatdealof everyone wasgivingthegovernment,and marketing? Itlooksratherlikeit,and development, financing,production,and generating newideaswithworld-class together andcombineditsfamousgiftfor Can thedearoldUKhavereallygotitsact So therewehaveit,averyexcitingpicture. important stuff? Now doesanybodydoubtthatthisis several speakersaspotentiallytractable. ultimately dreadfulthing,wasmentionedby and even Alzheimer’s disease,that Spinal cordrepairseemsremotelypossible, tumours, butsofarthingsarelookinggood. whether thecellsarerejected,orgrowinto seems towork.Everyoneiswatchingsee tomodelParkinson’s, andit been ‘lesioned’ been injectedintothebrainsofratsthathave Embryonic stemcellderivedneuroneshave really seemtohavesetintheirsights. Parkinson’s diseaseisonethatresearchers base sequencesinthechromosome. techniquesfortargeting specific silencing’ Hence theimportanceofnew‘gene repair geneslookparticularlypromising. targeted toknockouttheremaining DNA radiotherapy orchemotherapy. Drugs And thismakesthemvulnerabletoattackby more dependentontheonesthatremain. mechanisms) andthismeansthattheyare (healthy cellshaveanumberofthese repairmechanisms one ormoreDNA context oranother. Mostcancercellslack Almost allcancersgotamentioninone solution forthataswell. expect anadenovirus-vectoredgenetic proliferation oftheliningveingrafts, three years. As fortheproblemof tissue-engineered replacementvalveswithin possible toinducerepair. Failingthat,expect are not,afterall,inerttissueanditmaybe genetically revivetheoldones.Heartvalves damaged cardiomyocytesyoumaybeableto cardiology. Ifyoudon’t wanttoreplace biotechnology couldbeappliedin gave thisasonlyoneofalistways myocardium. ProfessorSirMagdiJacoub That meanspotentialrepairoffailing and integratefunctionallywiththenatives. induced tocolonisedamagedheartmuscle muscle cellsandinanimalmodelscanbe heart musclecellsbutalsorespondlike cardiomyocytes, whichnotonlylooklike them hESCsnow. They canbemadeinto James Willis theophrastus bombastus flora medica

From the journals, November 2002 ...

N Engl J Med Vol 347 1447 No link between autism and MMR vaccine in this comprehensive study of all children born in Denmark between 1991 and 1998. 1483 Another study finding that heart protection from exercise is dose-related, and may be mediated by a change in lipoproteins. 1557 And another population study of 28 000 women confirming that C-reactive protein is an important independent cardiovascular risk factor — more than LDL-cholesterol. 1645 A vaccine to prevent cervical cancer? Given to women seronegative for human papilloma virus 16, it eliminated carriage and cervical dysplasia in this short-term study. 1687 A good review of transient ischaemic attacks: there is also an opinion piece on page 1713 suggesting that the label should only be given to attacks that resolve within one hour.

Lancet Vol 360 1347 The global burden of disease. The place to go if you like to begin your lectures ‘It has been estimated that in the coming decade, 5 billion people will die/suffer/seek medical help as a result of (insert lecture topic)’. 1447 Ximelagatran is the name on everyone’s lips (if it can get that far) as the warfarin of the future: it provided equal protection against thromboembolism following hip or knee replacement in this study, without the need for INR monitoring. 1477 Heavy coffee drinking is associated with a lower risk of developing type 2 diabetes, according to this study. More support for the statement recently featured in a TV hospital comedy, that ‘without coffee, the NHS would collapse’. 1531 The Multicentre Aneurysm Screening Study showed the value of whole-population screening for abdominal aortic aneurysm in men aged over 65. But the data which would allow risk stratification are absent. 1623 The PROSPER study looked at the effect of giving pravastatin to elderly people at risk of vascular disease. It also triggered an editorial complaining about the coercive effect of these cheerful acronyms (if you want to prosper, join our trial …). CRUMBLE just wouldn’t have had the same effect. 1631 A big survey of primary care management of heart failure throughout Europe: could do better. 1714 Put away the peak flow meter and buy a microscope and some stains: sputum eosinophil counts are the best guide to managing moderate-to-severe asthma, with the potential to reduce unnecessary treatment.

JAMA Vol 288 2123 Prior use of hormone replacement therapy protects against Alzheimer’s, but once you have it, it’s too late. 2144 Less than half of clinical heart failure in the elderly is associated with a lowered systolic ejection fraction: ‘diastolic’ failure in stiff old hearts gets an excellent observational study here. 2271 Keep your brain active and your cognitive abilities will remain good over the age of 65. 2307 But you still may lose your sense of smell if you live beyond 80 years (60% risk). 2411 Two antiplatelet agents are better than one following percutaneous coronary interventions: we shall probably be adding long-term clopidogrel to aspirin in many of our patients. 2441 And warfarin is better than aspirin in every subgroup of patients with atrial fibrillation (meta-analysis).

Other journals Arch Intern Med 162: 2278 follows up 8816 postmenopausal women for 10 years and finds that continuous HRT users have a 20% risk of non-vertebral fracture. Ann Intern Med 137: 798 finds that use of HRT for more than five years combined with more than 20 g of alcohol per week doubles the risk of breast cancer. What about alternatives remedies for menopausal symptoms? Page 805 gives the review you need — soy may or may not work, and black cohosh does work, but may be too directly oestrogenic to be safe for hot flashes (we say flush, they say flash, let’s call the whole thing off). Spine 27: 2564 is a review of cognitive behavioural therapy for all kinds of pain, not just spinal. ‘Helps many patients,’ it concludes. Thorax 57: 967 looks at 20 000 Danes to see if stopping smoking really does reduce COPD morbidity. It certainly does — by 40%, whereas merely cutting down has little effect. Planning a round-the-world trip? QJM 95: 723 has good news about spider bites in Australia — most are trivial, but it may still be worth looking under the toilet seat for redbacks. However, avoid exotic dishes in the Philippines (Neurology 59: 1664 Cycad neurotoxin, flying fox consumption, and ALS/PDC disease in Guam).

Plant of the Month: Daphne bholua This is the plant of the entire winter season, if the weather is kind: evergreen and covered in pink intensely scented flowers from Christmas to Easter. But a single hard frost can kill all the flowers and the leaves too. Still worth growing, because it usually recovers well.

The British Journal of General Practice, January 2003 75 An oral history of general practice 8: Patients and populations

References N the past 50 years the transformation of be seen more efficiently in surgeries that 1. Tait I, Graham-Jones S. General the doctor–patient relationship in general many GPs had recently improved. More practice, its patients and the Ipractice has included the weakening in effective team working, especially with public. In: Loudon I, Horder J, the deference of patients towards doctors, district nurses, further reduced house calls,5 Webster C (eds). General Practice under the National Health Service the decline of the ‘traditional personal and more recently some Paisley practices 1948-1997. London: Clarendon intimacy’ of the doctor–patient relationship, have adopted triage systems that have Press, 1998: 224-246. The oral and the increasing effectiveness of general almost eliminated home visits and it is history evidence was extracted practice medicine which, along with an claimed that the out-of-hours co-operative from transcripts held at the arguable rise in the culture of consumerism, has encouraged patients to make daytime Wellcome Institiute for the History has helped to raise patient expectations. visits to their own GPs. Even those GPs — of Medicine. The original Examples of these and other changes in and there are many in the town — who pride interview recordings by Michael society, in patient attitudes and in general themselves on practising with care and Bevan are deposited in the National Sound Archive (ace no. practice provision have been charted and kindness reported that they had become ‘a 1 C648/01-73 Oral History of illustrated using oral evidence. If, however, wee bit harder … less tolerant’ with patients General Practice c. 193 5-52). we listen to the voices of practitioners,2 this who fail to keep appointments. 2. Grele RJ. Listen to Their known history is confirmed and we gain Voices: Two Case Studies in the new insights into the qualitative changes in If time is the ‘real currency of general Interpretation of Oral History the relationships between doctors and their practice’6 then it is the currency of a token Interviews. In: Grele RJ. patients. economy, with practitioners historically Envelopes of Sound: the Art of valuing their time as precious. The GP Oral History. New York: Praeger, Older retired GPs in the Paisley study3 often narratives suggest that patient behaviour 1991: 212-241. 3. The project was based in the enthusiastically talk about home visiting in requires moderating by rewarding or Department of General Practice in the 1950s that once was central to the denying patients their doctors’ time. Glasgow and was funded under doctor’s day, and just as often are However, by insisting that general practice the Wellcome Trust’s History of significantly silent about the work they is more efficient if patients are provided Medicine programme. carried out in their surgeries at that time. with appointments to attend surgeries and 4. Smith G, Nicolson M. An oral Partly, this is because these doctors wish to clinics, GPs have increased their daytime history of everyday general emphasise their belief that the subsequent workloads and decreased the time between practice 10: Therapies and decline in house calls was a significant loss consultations. Diagnosis. Br J Gen Pract, (forthcoming). to general practice. But it also seems that 5. Ferguson R, Smith G. An oral seeing patients in their home environment The doctor who listens to non-medical history of everyday general was quite different from the demands of a problems remains a valuable resource to practice 4: Changing practice: surgery full of patients in a time before patients, according to a number of the Towards the practice team. Br J appointments, and with only limited access Paisley GPs who were interviewed. In doing Gen Pract, 2002; 52: 780-781. to diagnostic tools and therapies.4 Similarly, so, parallels were drawn between the 6. Hart JT. Going to the doctor. In: older GPs often describe their involvement pastoral role that was once filled by Cooter R, Pickstone J (eds). in obstetrics in positive terms. In these organised religion and their own work as Medicine in the Twentieth narratives doctors are appreciated for being GPs. Many of the GPs expressed a strong Century. Amsterdam: HAP, 2000; 543-557. on hand and for at least being potentially sense of egalitarianism in their descriptions 7. GPP 13. useful. Disappointingly for these of the doctor–patient relationship and some 8. GPP 15. practitioners, and in the space of a few of the younger doctors stressed that they 9. GPP 10 years, the several hundreds of home births maintained a sense of patient advocacy that 10. GPP 19. that partners in a medium size practice had been more of a feature in the work of 11. GPP 28. could find themselves involved with were the older generation. 12. GPP 9. all but ended and hospital medicine had 13. GPP 11. taken over a task that they believed had The oral evidence also suggests that even in 14. Smith G. An oral history of everyday general practice 7: been central to family doctoring. a town such as Paisley, with deep Outside interests. Br J Gen Pract deprivation, some practices were much 2002; 52: 1038-1039. The pleasant drives in a relatively traffic- more likely to have a patient population that 15. GPP 02. free town to call on reasonably was drawn from the poorest sections of the 16. GPP 28. undemanding patients’ in their homes had population. Indeed, the majority of working 17. GPP 07. given way during the 1960s to an escalation practitioners were keen to stress the value of 18. GPP 14 in house calls, fuelled at least in part by the having a patient population that was 19. GPP 25. growing numbers of patients with access to socially mixed. And while there was an telephones. Some of the GPs point out that acute awareness of the depths of deprivation they felt obliged to respond to this demand, in Paisley, there was little sense of rather than risk patients’ complaints, agreement about how general practice regardless of whether a visit was clinically could, or even should, tackle such poverty. indicated or not. Those who entered practice Some of this ambiguity seems to have from the mid-1970s onwards experienced a arisen as a result of the rise of a patient- reduction in the number of house calls. centeredness and emergence of ‘mass Home visiting was also increasingly medicine’,7 which appears to be more easily believed by doctors to be a waste of their practised with ‘mixed’ rather than paisley docs 8 time and, it was argued, more patients could ‘deprived’ populations.

76 The British Journal of General Practice, January 2003 The oral evidence house calls depending on summer or winter, hassle and trouble … It was a very [pause] and 30 people in the evening. You got to deprived part of the town … Took quite a few Hector M entered practice in the 1940s. learn to consult very quickly. … Well, as I of them off their hands and then he took on say, the old adage “I saw thirty people a partner. They have both retired and there’s ‘There was a lot less trivia in these days. today”. Nobody ever says, “I saw and two or three new people there whose names People only went to see the doctor if they examined thirty people today”.’10 I don’t know at all.’17 had to and home visits were done on a regular basis… return visits to chronically Fiona T: ‘The days of monthly home visits to For a number of years Dr Wasim B and his ill people were done once a month… “I'll elderly people at home — I wasn’t ever quite two colleagues have served the most just look in and see you next month”, so you sure why I went back, I left some deprived area in Argyll and Clyde. In 1999 did. It was much more friendly and you knew prescriptions, you know that kind of visit the practice was unique in Paisley in your patients.’7 [laughs]’.11 offering patients appointment free daily sessions. Two decades on, Donald W joined another David D: ‘At the end of the day doing house Paisley partnership. calls is just an extremely time-consuming ‘In the long run the patients are you know, way of seeing patients.’12 quite good. I mean they can be tamed, or ‘I mean the demands for house calls in the they can be civilised through certain aims. 60s hugely outweigh anything that we get The decline in home visiting has not always Because we treat them like human beings — now … and a vast amount of that would be been straightforward as this GP recalls. some of them — that doesn't mean it’s a just trivia. And while it’s important in general principle. Some of them like getting to know the background of people, if ‘Patients are less demanding because they alcohol, drugs ... We had a lot of difficulty in you’ve got a lot of calls to do there’s too are now being conditioned. Now I think for convincing them that some of the drugs are much pressure on you to actually appreciate a couple of years before we came into the harmful to your health. You know an that.’8 practice in 1975 they had been using the individual who used to come to consult us deputising service. Shortly after we came and they were forcing us to prescribe some In the late 1950s Charles McC joined his into the practice I got a call one night from of the drugs and there were some bitter father and older brother in practice. a patient, “Oh, it’s you doctor, Oh, I thought relations between the patient and the it was the emergency doctor that was on, doctor.’18 ‘Home births was where you got to know the Oh, I’ll wait till the morning”.’13 patient. You sat up with the patient and you Others share his enthusiasm. delivered the baby. You’d had a cup of coffee The commercial deputising service was and a smoke. I smoked in those early days ... replaced by an out-of-hours co-operative in Andrew K: ‘We were the second most It was exciting ... When you’re young in the 1990s.14 deprived practice in Paisley …We have medicine you like excitement ... You had to more than our share of social class V … I be kind to people that weren’t all that Christopher J: ‘The difference the [out-of- enjoyed working here, because … your own capable of defending themselves. It is easy hours] system has made is that people background is relevant in a situation like to beat someone who has got no defences. phoning on a regular basis get the same this. I could identify very strongly with the My old man used to make the comment, message about when you should or shouldn’t people in the practice … solid working-class “Never oppress the poor”. And the call the doctor out and whether its people. So I have a great empathy with them oppression of the poor was quite an appropriate or not and our house calls have … I had no difficulty eh, transferring into interesting concept, because it went through fallen. People have been educated ...’15 this environment because it’s something that a lot of things. For example if some old I was used to … Because you have so much buddy [resident of Paisley] offers you a cup Most of Paisley’s practices attract patents power in that situation, you have to be of tea. It’s a kind of miserable looking cup. across the social spectrum. careful that you don’t become superior, You don’t particularly want the tea, but you because the patients are vulnerable anyway. damn well sit down and have that cup of tea, Fiona T: ‘It’s a lovely [practice] population So I think you have a bigger responsibility because you are otherwise offending the of two, three at least, generations of treating people from the lower social class. person who is offering you hospitality … families. They stay very, very loyal to the … I would say I do feel happier dealing with you had to respect people’s dignity …’9 practice …Very much spread across the this section of the community, because it is town … the geographical spread and the worthwhile. Having said that I wouldn’t like Other GPs who entered practice in the late social class spread of the practice … I think to be working in a very deprived area and 1970s to early 1980s found that their time it’s nice not having an imbalance. I think it’s nothing else but that but having a, what we was limited and that home visits were good to have a variety of folk.’16 have is quite good. increasingly difficult to justify to themselves. Robert E recalled one of the first ‘… You could lose your humanity towards practitioners to establish a practice outside people, because your treating them less than Damian S: ‘At the time it seemed quite fair, of the town centre. yourself and when you start doing that your but on hindsight … it was bloody unfair. It own values begin to go and you start looking was shocking in fact. So for the first year or ‘And a lot of the doctors in Paisley were down on people …’19 two of Mondays [circa 1978] you were quite pleased, because they got rid of a lot of seeing 30 people in the morning, ten or 15 patients who had been giving them a lot of Graham Smith

The British Journal of General Practice, January 2003 77 References 1. Declaration of the Stockholm Medicine and the Holocaust - lessons for present and future physician International Forum on the Holocaust http://www.holocaustforum.gov.se /pdfandforms/deklarat 2. Willis BM, Levy BS. Recognizing ‘It is all about our conscience’ So far we have identified five major areas from the public health impact of genocide. which conclusions can be drawn for present JAMA 2000; 284: 612-614. LMOST 60 years after the end of World and future physicians. 3. Sofair AN, Kaldjian LC. Eugenic War II, interest in the Holocaust, sterilization and a qualified Nazi Aparadoxically, seems to be growing. Firstly, and most obviously, there are lessons analogy: the United States and There is still a need for contemplation. Leaders for present and future medical ethics, well Germany, 1930-1945. Ann Intern Med of 50 nations assembled in Stockholm in the documented in the literature.3,5,6 With 2000; 132: 312-319. year 2000 and declared that ‘the Holocaust 4. Barondess JA. Care of the medical scientific progress in genetic testing, the ethos: reflections on social (Shoah) fundamentally challenged the human genome project and other interventions Darwinism, racial hygiene and the foundations of civilisation … With humanity on the horizon, eugenics is again rising to Holocaust. Ann Intern Med 1988; still scarred by genocide, ethnic cleansing, prominence.7 Health care policy issues, such 129: 891-898. racism, anti-Semitism and xenophobia, the as resource rationing and dual/triple 5. Angetter D. Anatomical science at international community shares a solemn accountability, once again bring the conflict of the University of Vienna.1938-1945. responsibility to fight those evils … We pledge individual versus public welfare to the fore. Lancet 2000; 355: 1454-1457. to … promote education, remembrance and Clinical dilemmas surrounding euthanasia, 6. Seidelman WE. Nuremberg research about the Holocaust …’1 lamentation: for the forgotten victims abortion, transplantation, and establishing of medical science. BMJ 1996; 313: death are a constant reality. Research 1463-1467. It is not surprising that today there is more dilemmas exist around clinical trials, human 7. Caplan AL, McGee G, Magnus D. interest in the Holocaust than in 1945. Many subject experimentation and the like. Our days What is immoral about eugenics? feel that at the dawn of the third millennium, abound with questions that can be informed by BMJ 1999; 319: 1284-1285. the memory of the Holocaust is an essential studying the Holocaust.8 8. Silove D. Doctors and the State: component of human identity. Because of this, lessons from the Biko case. Soc Sci many commemorative and educational A second, perhaps more personal lesson, is that Med 1990; 30: 417-429. activities worldwide aim to remember the 9 Lifton BJ. The king of children. The of surviving and functioning when faced with life and death of Janusz Korczak. New spectre of the Holocaust. extreme situations and impossible choices. York: St Martin’s Press, 1997. The list of physicians who committed 10. Helman Z. Medical dilemmas in For health professionals, there are distinct atrocities is complemented by that of the the ghetto, according to the play: messages. The Holocaust raises many physicians who stayed true to their humanity Underground, by J Sobol. Harefuah 2-4 questions for medical ethicists. The and vocation. (in Hebrew) 2000; 138: 895-901. submission of the medical profession to a 11. Roland C. An underground murderous ideology led directly to the Dr Janusz Korczak, for example,9 a medical school in Warsaw ghetto, Nuremberg Code (the first code on human 1941-1942. Med Hist 1989; 33: 399- paediatrician turned director of a Warsaw subject experimentation). 419. orphanage, led his 200 protégés to their deaths 12. Biderman A, Carl R. The patient in Treblinka and refused the offer to save In this paper we wish to illuminate, as who is a Holocaust survivor. Harefuah himself. Weinryb, in Ghetto Vilna, organised a (in Hebrew) 1992; 122: 258-261. comprehensively as possible, lessons derived 13. Peleg R, Biderman A. The scars of fake ward to protect the lives of typhoid from the Holocaust, that can inform today’s 10 the Jewish Holocaust. BMJ 2000; health practitioners. Our observations are epidemic victims; Milikovski and Falk 320: 473. based on personal experience as practitioners continued to practise, research, and teach in 11 14. Steier T S. Attitudes of physicians and educators, combined with academic study the ghettos and camps. and the medical system in Israel to the of the subject. Holocaust. Harefuah (in Hebrew) A play by Israeli playwright Joshua Sobol, 2000; 139: 395-399. Underground,10 portrays the terrible 15. Charny IW. Psychology of For three years, Shmuel Reis lived and worked genocide. In: Encyclopedia of in Lohamei Haghetaot, a kibbutz in northern circumstances ghetto physicians had to genocide. Santa Barbara, CA: ABC- Israel. Lohamei Haghetaot is Hebrew for ‘the confront. Jewish physicians in the ghetto CLIO. Inc.,1999: 477-486. ghetto fighters’, and indeed, survivors of the faced terrible dilemmas: births were forbidden 16. Lifton RJ. The Nazi doctors. New Warsaw ghetto uprising of April 1944 founded and even their scarce medications had to be York: Basic Books, 2000. it in 1948. About one hundred of his patients in rationed. Individual care versus danger to the 17. Sacks J. Interview in The the kibbutz are survivors, now in their 70s and public was a constant conflict. The physician Guardian, 27 August 2002, was required to choose between the sick and 18. Gabriel R. From: 80s. A major physical presence in the Arbeitsmaterialien zum Thema: community is that of the Ghetto Fighters the healthy, the rich and the poor, the old and Euthanesie — Verbrechen im House (GFH), a museum and study centre the young on both medical and administrative National-Sozialismus. commemorating the Holocaust. issues, while facing the same fate: ultimate Landeswohlfahrtsverband Hessen. destruction. Inner struggles were a constant 1995; 21-26. His main practice, based in a health centre in reality: should one take personal risks in order 19. Luthar SS, Cicchetti D, Becker B. central Galilee, has about 6500 patients. to care for patients? Stay behind or attempt to The construct of resilience: a critical save one’s own life? Forge medical documents evaluation and guidelines for future During a typical working day, seeing between work. Child Dev 2000; 71: 543-562. 40 to 50 patients, the subject of the Holocaust or destroy records? Ghetto and camp life also 20. Sigal JJ. Long-term effects of the will usually come up several times. Such eradicated all traces of any former higher Holocaust: empirical evidence for figures are quite typical of many general status. resilience in the first, second and third practices in Israel. generation. Psychol Rev 1998; 85: Guilt, insanity, criminal behaviour, along with 579-585. We also teach medical students, family heroism, kindness and generosity — all of 21. Baron L, Eisman H, Scuelo M, et medicine residents, and practising physicians. these are potential reactions to such terrible al. Stress resilience, locus of control, and religion in children of Holocaust During one of the small group discussions, a choices. This is a case of living in an abnormal victims. J Psychol 1996; 133: 513- student said: ‘It all has to do with our reality and creating an alternative whereby the 525. conscience as future physicians’. This was a abnormal becomes routine. Can you imagine 22. Frankel VE. Man’s search for moment that gave meaning to our efforts. yourself in a situation where circumstances meaning. New York: Washington Since 1999 study days have been held on dictate that the world as you know it has

the levant Square Press, 1963. Holocaust Memorial Day each year. perished? You cannot choose life for yourself

78 The British Journal of General Practice, January 2003 ns

or your patients. You lack the resources to persecution; and the dynamics of heal, even when the know-how and skills are rationalisation (‘they deserve it’) and that of Example there. You must act against your will, beliefs, the bystanders who watch and ignore the cries ethical codes, and medical oath. You are left to for help.15 Many of these precursors are based Albert, a 73-year-old male frequently appeared your own devices, facing your God and your on prejudice*, imprinted and fixed in people’s at the clinic, often with scraps of paper, along conscience. minds through propaganda — a basic tool of with lists of questions, making his doctor quite totalitarian regimes.18 uneasy. On the brink of losing his sense of A third area of concern is medical care of the compassion, the physician found out about his survivors and their families, wherever they Is this information effective? We cannot Holocaust history. live in the world.12-14 One cannot care provide you with any evidence on the matter. holistically for this community without However, ‘Not because of basic evil, but as He was 10 years old when the Germans knowledge of the history, names, places and part of human nature, we tend to obey blindly, occupied his hometown and he was deported possible consequences of surviving World War to be intoxicated by power when in charge of to the ghetto at age 12. One by one his father, II, or growing up in a home where one or both others, to continue our routine and justify the older brother, then his baby brother and parents are survivors. It calls for appropriate establishment, to project on minorities our mother died of hunger. He and his younger listening and communication skills. It calls for own feelings of inferiority and frustration, to brother became streetwise kids, learned how specific therapeutic interventions, all requiring become ecstatic in a rallying mass, especially to get food and how to come and go across imagination. It calls for you to put yourself in behind a flag, to deny the wrong that our own the barbed wire. They broke out of the ghetto, your patient’s place (see the example nation and we ourselves are committing to a looking for relatives. They stayed with one, opposite). minority we oppress’.15 then moved on to another. They became vagabonds, with only their clothes on their The fourth dimension is one that we are more Is it not our duty as human beings and as backs. When the snowy winter began, his hesitant to bring up, yet it may be the most professionals to take pains to study, remember younger brother fell ill and died. He was left important. It refers to the potential murderer in and teach these facts even if we do not yet alone, roaming southern Poland. He stayed on each and every one of us, the need to be aware have evidence of the effectiveness of such farms and when he sensed danger, he moved of it and suppress it. teaching? on, like a hunted animal. He crossed borders into Hungary and Slovakia, without realising it, Numerous experiments, experiences, and The fifth dimension is that of resilience,19-21 ‘a then tried to cross back. He became a partisan studies point to the fact that, given the right construct connoting the maintenance of at the age of 15. He was wounded when his circumstances, we are all prone to cruelty, positive adaptation by individuals despite unit was attacked. He barely escaped and blind following of a powerful evil, and experiences of significant adversity’.18 It is found himself on the road once again. In racism.15 Being caring physicians and model, now fairly extensively dealt with in the post- March 1945, he stumbled into a Russian unit. religious family men did not protect many traumatic stress disorder and child When sailing in an illegal vessel, he was Nazi doctors from committing the most development literature. It is an attempt to caught by the British and deported to Cyprus. abhorrent acts within the scope of their document, explain, and eventually intervene in He finally reached Israel in the latter part of profession.16 order to promote resilience in extreme 1947. He fought in the War of Independence situations. Some of this research is done with and then joined a kibbutz. We all know that, looking at world history Holocaust survivors and their offspring, the since 1945, numerous examples of ‘ethnic most remarkable example, probably, of human How can one not be compassionate towards cleansing’ and genocide (for example, in the resilience (and its lack) in recent history. What Albert? After reading his life story, the former Yugoslavia and Rwanda) show that the enabled so many survivors to reclaim their patient–doctor relationship completely lessons which should have been learnt from lives, and lead a normal life after the changed. Over the next two years he visited the Holocaust have not been. Holocaust, while a minority succumbed to the clinic relatively rarely. He had major psychiatric morbidity of various degrees? medical interventions, which went remarkably We are aware that some people think of Victor Frankl22 is probably the best known well, both physically and emotionally. Palestine in this context. To equate a war on scholar of this issue, teaching us the central terrorism with genocide is a gross distortion of role of purpose and meaning as protective a very complex situation. At the same time, against adversity. Many scientific problems most Jews agree with the British Chief Rabbi still limit the practical application16 of this Jonathan Sacks when he said that ‘there are construct, yet its study and contemplation things that happen [in Israel] which make me seem worthwhile. feel very uncomfortable as a Jew’.17 We also know that many Muslims feel very We have tried to share with you five domains Lessons for today’s health practitioners uncomfortable as Muslims about some events of lessons to be drawn from the Holocaust in from the study of medicine and the of the Intifada. If only for pragmatic reasons, order to enhance the field of medicine and Holocaust: much will have to change on both sides to turn serve both present and future physicians. We hatred into goodwill, and so to peace. have described our initial efforts at • the impact on professional ethics today implementing these lessons at one medical • the practice of medicine in impossible Israel Charny, a professor of psychology at the education institute in Haifa, Israel. circumstances universities of Tel Aviv and Jerusalem, is a • the care of survivors and their offspring scholar in this field. He lists the following as It is all about our conscience. • the suppression of the destructive potential some of the precursors of decent people in all of us becoming evil: obedience to authority; the • the capacity (or lack of) to withstand severe power of the mass and the leader; stress and Shmuel Reis adverse life circumstances (resilience) anxiety reducing quality of power; ideology; Tomi Spenser

*The Concise Oxford English Dictionary defines prejudice as ‘a preconceived opinion that is not based on This article is based on a lecture delivered at the reason or actual experience; unjust behaviour formed on such a basis’. WONCA-Europe conference Vienna, Austria, 2000.

The British Journal of General Practice, January 2003 79 War, peace, and the ‘relaxing pill’

RANQUILLISERS and hypnotics are in Several massacres took place during the relatively high use, and have resulted fifteen years of war; most notably at the Tin serious health problems in several Sabra and Shatila refugee camps, two camps parts of the world. In France and Italy, 13% inhabited mainly by Palestinian refugees. to 25% of the general adult population are occasional or regular users of these The war period, which ended in 1990, was medications.1,2 Lebanon witnessed a marked characterised by absence of legislative increase in the use of tranquillisers after the power, total chaos, and over-the-counter end of the wars in 1990. What follows is a dispensing of almost all medications. brief summary about the conditions in Lebanon between 1975 and 1999, which are In 1999, nine years after the cessation of the thought to have a direct bearing on the sharp Lebanese wars, more than 1 600 000 packs rise in the use of tranquillisers in the post- of anxiolytics and hypnotics were war years. dispensed, compared with fewer than 800 000 packs during the ninth year of war3 Lebanon covers an area of 10 452 km2 and (Figure 1). The increase in consumption of has a population of around four million. anxiolytics and hypnotics is thought to be Eighty per cent of the Lebanese live in urban owing to several factors, which include war- areas. In 1998, the ratio of physicians and related factors and the ease with which these pharmacists per 10 000 populations were 21 medicines could be obtained. We refer to and five, respectively. these anxiolytics and hypnotics as the ‘relaxing pills’ — that is how they are Between 1975 and 1990 the country perceived by the Lebanese people. witnessed a series of wars among several factions. In 1976, a peace-keeping force, War-related factors mainly consisting of Syrian troops, Socioeconomic succeeded in enforcing peace for few years, After 1990, the economic situation started to after which these troops were involved in deteriorate. The Lebanese had to cope with direct and fierce clashes with several an increasing daily cost of living and a Lebanese factions and Israel. In 1978, Israel decreasing income. In 1995, 28% of invaded the South of Lebanon and in 1982 Lebanese families were living below the the Israeli army invaded large territories of absolute poverty line, which is defined as Lebanon, including the capital, Beirut. extreme deprivation of basic human needs,

Figure 1. Rate of consumption of anxiolytics and hypnotics during the Lebanese wars.

Chronology of significant events: 1: Israel invades Beirut; Syria withdraws from the capital; Sabra & Chatila Massacres. 2: Syrian troops enter Beirut. 3: End of Civil War. the levant

80 The British Journal of General Practice, January 2003 including food, safe water, sewerage, health and convenient alternative. care, education and shelter. The symptomatic improvement of the With the beginning of peace, the patient is a ‘good’ reason for the doctor to government resumed tax collection. provide a refill on an ongoing basis. Residential rents rose by 64% between 1994 and 1996. The bill for utility services and the The physician’s role in allowing people to price of fuel also increased substantially. become habituated to psychotropic Concomitantly, unemployment rose from medication is well documented. Sleath et al, 8.1% in 1970 to 10.4% in 1987, and then to for example, found that, although patients 20% in 1999. The real GDP dropped from initiated 42% of psychotropic prescriptions, US$ 6880 in 1985 to US$ 4161 in 1993. the majority of medications were previously prescribed by a physician.6 The effect of the rapidly deteriorating economic situation on the psychological Uncontrolled dispensing by pharmacists wellbeing of the Lebanese individual is not For several years, medications could be to be underestimated. To make ends meet, obtained from pharmacies in Lebanon people tend to work more and socialise less. without a prescription. Self medication was Hence, social support is diminished and the observed in 53% of adults admitted to a stress is more pronounced. The ‘relaxing Lebanese hospital for drug-related illnesses; References pill’ may provide an easy way to cope with hypnotics and sedatives were the second 1. Pelissolo A, Boyer P, Lepine JP, Bisserbe JC. the situation. It is known that periods of most commonly used group in self- Epidemiology of the use of anxiolytic and political and economic transitions are medication.7 hypnotic drugs in France and in the world. associated with an increase in psychological Encephale 1996; 22(3): 187-196. morbidity and mortality.4 During the Lebanese wars, the existing laws 2. Turrina C, Zimmermann-Tansella C, Micciolo restricting the purchase of certain R, Siciliani O. A community survey of Psychological medications could not be enforced, and psychotropic drug consumption in South Verona: prevalence and associated variables. Soc During the Lebanese wars many people there was no control over patient access to Psychiatry Psychiatr Epidemiol 1993; 28(1): 40- were uprooted from their homes and forced psychotropic medications. 44. to move out. Many had to move more than 3. Chbaro H. Pharmaceutical market analysis in once, in search of a safe haven for them and This problem persisted after the wars ended Lebanon, 2000. Beirut: Bureau de Consultations their families. In addition to the feeling of and was compounded by the financial Pharmaceutiques a Beirut, 2001. insecurity and instability, the Lebanese motivation for pharmacists to encourage 4. Kaasik T, Andersson R, Horte LG. The effects individual had to deal with disrupted unlimited sales of these medications. of political and economic transitions on health sleeping patterns and struggled to ensure the Between 1975 and 1998 the number of and safety in Estonia: an Estonian-Swedish basic needs for self and family amid the registered pharmacies increased by tenfold. comparative study. Soc Sci Med 1998; 47: 1589- 1599. multiple challenges of everyday life (closure 5. Yabroudi P, Karam EG, Chami A, et al. of schools, power failures, interruption of Recommendations Gender dual diagnosis of psychiatric illness and water supply, rationing of food). The It may be difficult to control the economic substance abuse. In: Shehadeh LR (ed). Women ‘relaxing pill’ was a convenient and hardship of a country with few natural and war in Lebanon. Gainsville, FL: The comforting escape. resources that has witnessed complete University Press of Florida, 1999. destruction of its infrastructure and a 6. Sleath B, Svarstad B, Roter D. Physicians vs. The children of the 1970s became the draining of its financial and human patient initiation of psychotropic prescribing in adolescents and adults of the 1990s. resources. Yet, reduction in the use of primary care settings:A content analysis of audio-tapes. Soc Sci Med 1997; 44(4): 541-548. Mothers exposed to war-related events are anxiolytics and hypnotics may be possible, 7. Major S, Badr S, Bahlawan L, et al. Drug more likely to develop psychological by putting into action the following: related hospitalization at a tertiary teaching problems, and symptoms of depression center in Lebanon: incidence, associations, and among mothers are associated with • Promoting the skills of physicians in relation to self-medicating behavior. Clin increased morbidity among their children. different stress management techniques Pharmacol Ther 1998; 64(4): 450-61. Yabroudi et al demonstrated that Lebanese that may help with managing anxiety 8. Hamm RM, Hicks RJ, Bemben DA. adolescents whose parents take symptoms, without the need to resort to Antibiotics and respiratory infections: are tranquillisers are more likely themselves to medications. patients more satisfied when expectations are become users of the ‘relaxing pill’.5 This • Educating and training physicians about met? J Fam Pract 1996; 43: 56-62. 9. Freeman GK, Horder JP, Howie JGR, Hungin observation may explain the increased use sleep hygiene and the management of AP. Evolving general practice consultation in of anxiolytics and hypnotics at present in sleep disorder. Britain: issues of length and context. BMJ 2002; Lebanon. • Reducing the common practice of over- 324: 880-882. prescribing by educating caregivers that Access to medication patient satisfaction correlates directly The physician factor with the time spent with the physician and Lebanese physicians tend to prescribe improved understanding of the disease, anxiolytics to alleviate their patients’ not with receiving a medication.8,9 distressing non-specific anxiety-related • Making sure that anxiolytics and symptoms. The physician often finds hypnotics are not dispensed without a himself pressured by the patient to provide a prescription. Acknowledgement rescue remedy or a relaxing pill. Also, lack of knowledge of sleep hygiene and the Bassem Roberto Saab We would like to thank Dr Husni Chbaro different stress management techniques, or Namir Damluji from the Bureau de Consultation, the limited time allocated for a medical Najla Lakkis Pharmaceutique à Beirut for information provided. consultation, make prescribing a pill a quick Jinan Usta

The British Journal of General Practice, January 2003 81 Using information and communication technology in healthcare — Stuart Tyrrell (Radcliffe Medicine and the Internet (3rd edition) — Bruce C McKenzie (OUP, 2002, PB, 296pp, £14.99 Evidence-based medicine toolkit — Douglas Badenoch, Carl Heneghan (BMJ 2002, PB, 64p

‘ HE creation of the PC is the best thing health sector to harness health information that ever happened’, said Bill Gates at confidently and effectively.’ To cut to the Ta conference on the digital divide in chase, Mr Tyrrell fails to achieve this aim. In 2000. Well he would say that, wouldn’t he? the main, clinicians (and a good many others) But there is no denying that computers, and do not want to know how their computer goes especially the Internet, are providing about its machinations, but would be challenges and opportunities in equal interested in knowing the best treatment for measure and at an unprecedented pace to Mrs Smith’s sick child. While the book does boot. At the heart of the challenges and the offer some useful overviews, it will not light opportunities is the ease with which it is fires in the minds of medics hoping to become possible to generate and exchange IT-savvy. The book is far too general to information. Information is the lifeblood of warrant the word ‘healthcare’ in the title and health care, so it is not surprising that will be of limited use to clinicians needing information technology (IT) is seen as the advice on how to make better use of IT in Next Big Thing in healthcare. That IT has their practice. been the Next Big Thing for years shows how difficult it is to realise this potential. The For that, Bruce McKenzie’s book would be a British government has showed renewed better choice. Many things compete for a seriousness by recently earmarking £12 clinician’s time; patients and paperwork but billion over five years to improve the also the telly and family. Richard Smith, National Health Service’s IT infrastructure. editor of the BMJ, has said that those providing health information should make it These three books, each in its own way, aim sexier if people are to divert themselves from, to help clinicians make better use of well, everything else. ‘Medicine and the information and the technologies that provide Internet’ nods in this direction by having short it. Stuart Tyrrell aims ‘to assist staff in the chapters and visual cues to help the reader

Physician, heal thyself: the NHS needs a voice of its own Duncan Smith (Spokesman Books, 2002, Socialist Renewal Series - 1, Pamphlet, 40pp, £4.00

HE author of this book became Chief was further compounded in the Thatcher era, Training Officer of the National Health where the internal market was developed as TService in 1967, having spent his active the catchphrase but where patients did not working life in nationalised industries. He have freedom to choose — some market! And documents, in easily understood and vivid where the provision of care was not matched language, how the politicians have walked by quality control! And yet in Northern like ‘elephants in the jungle’, trampling the Ireland Health Boards such provision was goodwill of a service industry, where the already in place, bringing together health, wisdom of those working within it has been social service, and local authority provision. I systematically ignored. observed at first hand this successful model when seconded to the clinical standards His main thesis is that within this large advisory board in 1997 and also saw first organisation there has been a systematic class organisational audit working across attempt to develop a culture of active boundaries at the general practice level. learning, and successive governments have ignored feedback from those who serve. A He makes a powerful plea for the good physician listens, observes, investigates establishment of a staff college, able to if necessary, and then makes a decision to act. discuss and formulate recommendations from To monitor the success or failure of the those working within the health and social process in reflective practice is axiomatic. services, and informing the health executive For the service as a whole the task then of areas where a change in public policy becomes to provide a constitutional method needs to be implemented. In other words, a to ‘take the temperature of the service’ and to ‘bottom-up’ approach to communication with implement change in a dynamic and organic staff, as well as informed leadership. He is overheard in way. scathing about initiatives such as the New Orleans... private/public partnership and the failure to He proposes that, whereas health requires an plan for the staff levels required in the A presentation at the North integrative and co-operative working development of a modern service. Is it too American Primary Care Research relationship between health, community and late to return to co-operation and the Group Conference on a small study social service provision, separatism has been distillation of excellence, where those who on medical error in Cincinnati. built into successive reorganisations. He serve the NHS do so with a sense of service Eight or so practices involved ... recommended, while Chief Training Officer, and pride, rather than defensiveness and ‘None of these practices have electronic records ... [pause] This is the development of a ‘staff college’. This did overload, generated by a ‘top-down’ Cincinnati. Of which Mark Twain not progress after Keith Joseph, then management deluge? He points out that there wrote that he would like to be there Secretary of State for Health and Social has been reorganisation after reorganisation, when the world ends, because Services, found that other major departments in which management consultants — with far everything comes to Cincinnati ten concerned with health wanted the same less experience than the providers — work

digest years later.’ mechanism. Problems of integrated working with politicians eager to make their names

82 The British Journal of General Practice, January 2003 2002, PB, 156pp £19.95, 1 85775469 7) 1421: The year China discovered the , 0 19851063 2) world — Gavin Menzies p £9.95, 0 72791601 7) Bantam Press, November 2002 HB, 389pp, £20.00, 0 59305078 9

reach content quickly. There is plenty on how AVIN Menzies is a retired Royal Navy the Internet could help you with your clinical submarine commander and enthusiast practice and research but relatively little Gfor ancient maps. He noticed about the technology, which, frankly, most something odd about a map drawn in 1424 by people don’t care about. Website addresses a Venetian cartographer, Zuane Pizzigano. come in spades, which can sometimes be The map showed four islands in the Western irritating, but the book is about the Internet so Atlantic with towns marked on them, and suggesting where to look is perhaps the whole unknown names. After allowing for errors in point. Finding the evidence upon which to calculating longitude and comparing it with base your evidence-based practice is often a other charts he became convinced that the problem, so Andrew Booth’s chapter on islands named Antilia and Satanaze on the accessing the evidence is particularly map were in fact the Caribbean islands of welcome. It makes a good starting point for Puerto Rico and Guadeloupe. He concluded anyone at a bit of loss as to how the Internet that someone had accurately surveyed them might actually help them become a better seventy or more years before Columbus What’s in a font size? doctor. One point though: the full Cochrane reached the Caribbean. It's interesting, I think, to see Library is now available free in many 1 2 countries, including England. Writing a book This was the starting point for a fascinating A GPSCI and a GPWsi quest to discover who could have been Then there's a GPwsi3 , and about the Internet is doomed to be out-of-date 4 while the ink is still drying. responsible. He uncovered maps of Patagonia GPwSI to lend a hand and the Andes dating from a century before The last of this trio is a bit different, since it is Europeans visited them, and accurate charts Is this a crisis in I.D. not about information technology, just of Antarctica, Australia, the Arctic, and the Or id? information. Or rather, how to make the best Pacific and Atlantic coasts of North and An oversight? use of information. It is small enough to stuff South America centuries before Europeans I shall argue for insight in a shirt pocket and is easy to read. Dip in arrived. The cartographers would clearly between walking the dog and Friends. have had to be skilled navigators and seamen, Be sure, the font is writ with good intent and the extent of their exploration suggested The emphasis is surely meant that large resources, including many ships, To show 0 85124667 2) had been used. Yet this massive achievement The way each author's wind does blow appeared to have been completely forgotten and to change service provision, by by history. The GP Wsi must be a generalist It is the WITH that time will test. revolution rather than evolution. In the Menzies describes events in the reign of the process the management costs have increased third Ming emperor of China, Zhu Di who SI shows a new departure …. to 5% of health service costs in 1980, and to built a vast fleet of ships, including 400-foot- 12% in 1997! But weren't our patients interesting long, nine masted ‘treasure ships’. On 8 (and special) heretofore? March 1421 a fleet of more than 100 ships set In the UK the population still largely supports sail from Southern China under the command The C denotes a claim to competition — the health service, even though the NHS of the eunuch admiral Zheng He, to chart the receives only two-thirds of the income of our Consultant after all has such a start oceans and bring the entire world into And it is clinical acumen that we mark here European partners. He draws attention to the China’s sphere of influence. * need to see human health as a co-operative (Otherwise, why not E and R , which do not seem to figure). venture between medicine, community Two years later, less than a tenth returned, facilities, and social services, and that your bringing stories of having visited ‘3000 Perhaps its GPwsi that knows the score health is directly affected by your income if countries’. During that time a series of GP comes first in all, and non-disputed you are in the poorest quarter of the disasters had struck China, including the But it is in the rest that strife is mooted. population. He makes a plea for a return to destruction of the newly built Forbidden City rehabilitation and, where possible, at Beijing by fire, and political collapse. The So let GP stand out, the rest is an aside resettlement of older people in their own records of the voyages, the plans of the ships It is the big GP homes, and sees the possibility that the new and the shipyards themselves were destroyed. That makes a case primary care trusts may begin to plan a more China turned in on itself and avoided contact For pride. appropriate service. He finds it strange that with the outside world. the local authorities are not represented as a voting representative on the new boards. And Menzies presents evidence from his Amanda Howe where is the public? In school governing knowledge of navigation, from accounts of Venetian travellers, and from anthropology, References bodies we see how important a contribution 1. Jones R, Bartholomew J. General practitioners the general public can provide. archaeology and horticulture, to support his with special clinical interests: a cross-sectional hypothesis that Zheng He’s subdivided fleets survey. Br J Gen Pract 2002; 52: 833-834. Duncan Smith offers us a comprehensive and charted the greater part of the world. He 2. Gerada C, Wright N, Keen J. The GP with vivid portrait of political short-termism, and argues that there are traces of Chinese special interest: new opportunities or the end of solutions that the government might be well influence throughout America and even in the the generalist practitioner? Br J Gen Pract 2002; advised to develop as policy. stories of Australian Aborigines. His main 52: 796-798. weakness is that his enthusiasm for his theory 3. Kacker R. From no interest to special interest: a personal reflection on the RCGP certificate in As a general practitioner who retired early leads him into not considering alternative explanations for some of the evidence he substance misuse? Br J Gen Pract 2002; 52: because of the increasing bureaucratic control 866-867. and difficulty in practising the craft I love, I presents. But that is a small complaint against 4. RCGP. Implementing a scheme for GPs with recommend this astute analysis. a compelling and thought provoking book special clinical interests. (College Viewpoint.) and I thoroughly recommend it. London: RCGP, September 2001. David L Beales Toby Lipman *E&R = education and research

The British Journal of General Practice, January 2003 83 4TheBritishJournalofGeneralPractice,January2003 84 reflection Durham wineshop. he sentbackacorkedbottlein estimation bythepoisewithwhich of Bergen, Norway, whogrew inour general practitionerand My co-facilitatoris Atle Klovning, Acknowledgement bon viveur years, andknowitallanyway. This isdone they’ve beendoingthissortofstuff for effectively subvertgroupsbyassertingthat academics, andmanagerscanalso people, notstatistics’.Seniorclinicians, self-righteously proclaimthat‘wetreat from anythinginvolvingmathematics,and facilitators. They diverttheagendaaway hijack thegroupfromhapless stories aboutGPsusingtheirgroupskillsto sentence isnotaparadox)fullofdark thing —mythologyandEBMinthesame EBM workshopfacilitation(thereissucha behaved impeccably, butthe mythologyof fair, mostGPsIhaveworkedwith notorious forthiskindofbehaviour. To be report this,butitseemsthatsomeGPsare comfort zones.Itgivesmenopleasureto avoid angstbykeepingintheirprofessional accounts ofgroupsthathavemanagedto The truthofthatisborneoutbyanecdotal prefer, noperformingwithoutstorming. there isnogainwithoutpain—orifyou to breakoutthenextday. The moralisthat (i.e. apparentlyperforming)onlyforastorm cracking pacebythesecondorthirdsession groups thathavebeengoingalongata necessarily inthatorder. Ihavebeenin form, storm,normandperform—not The secondthingisthatgroupsreallydo will saythattheywouldhavelikeditearlier. If yougiveitoutwhentheyregister to readandtherewasnopointinsendingit. workshop, theywillsaytherewastoomuch you sendouttheresourcepackbefore participants foraworkshopwillbewrong.If whatever youdotoprepareprospective learned athingortwo. The firstthingisthat small groupsatEBMworkshops. We have around sixmonthsofourlivesfacilitating Between us,myco-tutorandIhavespent year. ruminating onwhywedothisyearafter evoked awearychordinmeandmuch and someofShakespeare’s words. They which included Walton’s musicfor listened totheLastNightofProms, relaxation. SoIturnedontheradioand facilitating mysearchforwell-deserved teenagers whoweren’t exactlycommittedto together foraweek.Myhousewasfullof are outoftheircomfortzoneandthrown that happeninsmallgroupsofstrangerswho appraisal, oddsratios,andtheusualthings small groupinitsstrugglewithcritical shattered. Ihadspentaweekfacilitating T si muove... round theSun,andwasthereforenot atthecentreofuniverse,heissaidtohavemurmured‘ *After Galileo,underpressurefrom thechurch,hadrecantedhisclaimin1632thatEarthmoved Once moreuntothebreach,dearfriends... Based Practice Workshop I was Northern and Yorkshire Evidence- he dayaftermyreturnfromtheFourth —‘andyetitmoves...’. ’ Henry V worked outOKagain. become leadersandwewonderhowit joy whenthepenniesdrop,diffident So that’s whywedoit—forthemomentsof themselves sotalented. are surprisedanddelightedtofind wonderful, polishedlearningsessions,and rabbits caughtinacar’s headlamps,lead are thosewho,havingbehavedatfirstlike specificity, andlikelihoodratios. Orthere time) reallyunderstandsensitivity, confidence intervalsor(oftenforthefirst numerophobia andmerrilycalculateNNTs, when participantscrossthebarrierof happened therearemomentsofpurejoy their fearofstatistics.Oncethishas and canbejunked!);(c)begintolose truly impenetrabletheyarenotmuchuse writ norimpenetrable(andthatiftheyare learn thatscientificpapersareneitherholy confidence inaskingfocusedquestions;(b) whenthey:(a)develop individual ‘getsit’ yet’. As farasIcantell,agroupor or 3istheanxietythat‘theyhaven’t gotit regularthemebyday2 learning process. A toreflectonthegroup ‘buddy groups’ meet upregularlyduringworkshopsin Groups ofuptothreepairsfacilitators Eppur simuove a shock,andisnottoeveryone’s taste. reality ofself-directedlearningcancomeas that way, itishardlysurprising thatthe controlling professionaltraininginexactly maintained theirpowerandstatusby logy. Sinceprofessionshavetraditionally comprehensively aspre-Galileancosmo- set themexamsonitisbanishedas tell noviceswhattheyneedtoknowandthen that educationisaprocessinwhichexperts groups. Iffacilitationissuccessful,theidea horribly cleartothemembersofsuccessful first sessionortwo,becomesonlytoo such peoplefailtorealiseiswhat,withinthe because theydidn’t domuchteaching. What taught EBMandthefacilitatorswereuseless who complainsthatheorshecametobe Of course,yougettheoccasionalwhiner reassured thatthere’s nothingmuchtoEBM. already knowabout,andthenleavehappy, week discussingthingstheythink anything new, theymayhaveapleasant Even ifsuchflawedgroupsdon’t learn to learn. to persuadethemthatthereisanythingnew experienced facilitatorsmayfinditdifficult with suchself-confidencethateven *. Toby Lipman Eppur Master classes in primary care roger neighbour - behind the lines research no. 5: patient participation and ethical considerations On poetry Edited by Yvonne Carter, Sara Shaw ITH the possible exception of Henry ‘Naming of parts’ Reed, I don’t really do poetry. and C Thomas When I am informed by the late Lord Tennyson that ‘ “Tirra lirra” by the river Sang RCGP, 2000 WSir Lancelot’, none of the rejoinders which spring to my lips reflect well on either PB, £16.20, 0 85084 264 6 knight or poet, nor indeed on my own Plebeian self. I relate more to Nigel ‘the curse of st custards’ Molesworth, who, compelled to recite aloud, records the ensuing artistic treat thus:1 ATIENT participation in clinical research has too often been taken for granted by SIR THE BURIAL SIR OF SIR JOHN MOORE SIR AT CORUNNA SIR Presearchers who have assumed that a (A titter from 2B they are wet and i will tuough them up after.) duty existed for patients to volunteer for Notadrumwasheardnotafuneralnote clinical trials, although patients may receive shut up peason larffing no benefit themselves from participating and As his corse the possibility exists that they may actually As his corse suffer harm. However, there is growing what is a corse sir? Gosh is it awareness of the ethical problems to the rampart we carried engendered by medical research and the (whisper you did not kno your voice was so lovely) stated aim of this masterclass is to examine Not a soldier discharged his farewell shot. these issues in primary care research from a PING! patient perspective. I suspect it may also be Shut up peason i know sir he’s blowing peas at me designed as an awareness-raising exercise Oer the grave where our hero we buried. for many of those involved in such scientific enquiry. Frequently otherwise scientifically But now and again the occasional line does press some button, does jab one in the fleshy valid research is rejected because scant parts, does cause to flash before the mind’s eye some truth which, albeit less than clearly attention appears to have been given to the discerned, nevertheless cries undeniably for expression. I chanced recently upon this, from ethical considerations of such research. All T E Hulme’s Images: too often, the patient information provided and the consent form appear to have been Old houses were scaffolding once and workmen whistling. hurriedly prepared and poorly translated from a foreign language. Researchers appear The wretched thing’s persistent, won’t get out of my head. ‘Old houses were scaffolding to have poor understanding of legal and once and workmen whistling’: there’s a medical metaphor in there somewhere, I can smell ethical concepts, such as confidentiality and it. And while I don’t do poetry, I do do metaphor — which is odd, because they’re what constitutes adequate disclosure of essentially the same thing. To a prose-monger like me, metaphor is truth with wings, and information to ensure validity of the consent poetry just metaphor in fancy dress. Anyway, at risk of showing myself up for the process. It is noted that the latter is unreconstructed fuddy-duddy which at heart I probably am (and which we are all destined particularly difficult to achieve in primary to become), I’m driven to try and unpack Hulme’s metaphor. care, where the investigator is often the Is he simply saying, ‘What’s now old was once new’? I guess not; a poet couldn’t be that potential subject’s GP, making a decision to blindingly obvious. ‘Even the most enduring of our institutions emerged from the mud and participate less likely to be truly free. confusion of a building site’? That perhaps comes closer. Then again — since I’m from a Interestingly, it has become standard practice generation to whom age in a house suggests character and craftsmanship rather than dry rot in trials sponsored by the pharmaceutical and noisy plumbing — Hulme could be reminding us that ‘what now looks out-of-date and industry to declare that the doctor will be irrelevant was once created with skill and dedication, and should be respected for it’. Is the reimbursed for their involvement, but the poet warning the young not to belittle their heritage? Or the old not to laud it over the new advice here stops short of suggesting that kids on the block, nor hold their inexperience against them? Yes. And no. That’s poetry for patients should be made aware of the extent you. Ambiguous. of the financial benefit to their doctor. I look around the urban skyline of my own professional habitat. Backlit by a setting sun are The contributions include several examples silhouetted some of the structures that have given my working life a sense of place and of ‘best practice’, that do not merely pay lip purpose. Vocational training, which is intended to give young GPs the time — and, more service to the concept of patient importantly, the permission and the freedom — to explore their own curiosity. The Balint involvement. Importantly, these cover advice movement, and all the creative interest in the doctor–patient relationship and the on dealing with potentially vulnerable consultation process that flowed from it. All the local variations on one fundamental groups, such as children, or where the architectural design, that places the resources of the individual doctor at the service of the capacity to consent may be impaired or needs of the individual patient. Old buildings these may be; but I’ve in my turn put up a fluctuating. Organisations such as CERES few scaffolding poles and done a fair bit of whistling, and I’m fond of them. So while I have already made a valuable contribution in understand that new ways of doing medicine need new homes and premises, I do wish this area, but there is little doubt that such ‘development’ wasn’t so inescapably a euphemism for demolition. resources deserve wider publicity, as many researchers still appear to be ignorant of their The JCBs and ball-hammers are at work on the brown-field building site that is to become existence. Apart from helping investigators the New General Practice. And what does the architect’s model promise? A patchwork to fulfil their ethical obligations, the estate, some of it mock Georgian, the rest a mix of the jerry-built and the trompe l’oeil. masterclass also makes it clear that there are And who is to live in Newtown-Blair? A dwindling generation of cash-strapped, target- many pragmatic benefits to be gained from driven, protocol-worshipping, initiative-purged young doctors, too busy to notice where patient involvement in the research process. they’re living and too stressed to care much. I would suggest that this book provides a Gosh. Maybe there’s something in this poetry malarkey after all. I feel a New Year’s readable and comprehensive resource for resolution coming on: look more carefully for the poetical in practice. I might even attempt members of local research ethics the odd line of my own. In fact, I’ll start right now by reworking Hulme. committees, multi-centre research ethics committees, and for all those either New houses are scaffolding still and builders bickering. contemplating or already involved in research. Reference Niall Cameron 1.Willans G, Searle R. The compleet Molesworth: How to be topp in English. London: Pavilion Books, 1984.

The British Journal of General Practice, January 2003 85 6TheBritishJournalofGeneralPractice,January2003 86 matters arising Iona Heath Chairman ofEthicsCommittee John Howard Committee Chairman ofInternational Mayur Lakhani Publishing Network Chairman ofCommunications& Amanda Howe Chairman ofResearch Group Steve Field Chairman ofEducationNetwork Joe Neary Projects Network Chairman ofClinicalandSpecial Valerie Wass Chairman ofExaminationBoard Has Joshi Chairman ofQualityNetwork Mrs EileenHutton Group (PPG) Chairman ofPatientPartnership Peter Colvin Committee Chairman ofNorthernIreland Mike Jeffries Chairman of Welsh Council Bill Reith Chairman ofScottishCouncil Maureen Baker Honorary Secretary Colin Hunter Assistant Honorary Treasurer Tony Mathie Honorary Treasurer Tina Ambury Vice-Chairman Professor DavidHaslam Chairman ofCouncil Professor DameLesleySouthgate President 2002–2003 President, Officers andChairs to discussthedraftbeforeCouncil met,but those facultieswhodidnothave thechance response tothisdocument. Apologies toall Council consideredthefinaldraft ofour Grade HouseOfficer ReformoftheSenior for the ConsultationDocumentonProposals Unfinished Business:DraftResponseto certification. new systemofdeathandcremation document exploringthedevelopmentofa The Inquiryhasalsoissuedaconsultation to theInquiry. December CECmeetingbeforeitissenton information wearetosubmitatthe providing. We shallbelookingatthe be includedintheinformationweare useful informationthatyoumighthave,to handed practice.Iwouldwelcomeany discipline, whistle-blowing,andsingle- phase are:monitoring,complaintsand College. The areasbeing covered inthis attending oneoftheseonbehalfthe seminars tobeheldinJanuaryandIwill enquiry, whichwillincludeaseries of Inquiry hasnowembarkedonPhase2ofits involvement intheShipmanInquiry. The developments regardingtheCollege’s I informedCouncilaboutthelatest Shipman Inquiry 2003 andthe AGM on14November2003. organised bytheSevernFaculty)on 6 April Bristol (aspartoftheSpringSymposium Our nextgeneralmeetingswillbeheldin Annual GeneralMeeting Brown, andDrGeorge Shirriffs. Dr Alastair Wright, DrJeremyDuncan Committee. The successful candidates were to fillthreeplacesontheFellowship We recentlyheldaballotofCollegeFellows Fellowship Committee Council meeting. Chief Executive,HilaryDeLyon’s, first chair thisnetwork. This wasalsoournew Publishing Network.DrMayurLakhaniwill create anewCommunicationsand merged PublishingandCommunicationsto list oftheappointments,wehavenow networks. As youwillseefromtheattached of Councilandchairscommittees Council electedourChairmanandOfficers As usual,atthefirstmeetingofyear, Chairs ofNetworksandCommittees Chairman andOfficersofCouncil, UK CouncilNovember consider howtheguidelinesthat existinthe Exercise (RAE). There isalsoaneedto in theacademicResearch Assessment NICE guidelinesnotreceiving recognition being developedtolookattheissue ofthese paperis they areactuallyimplemented. A ensure thatwhenguidelinesareproduced came outofthediscussionswasneedto PC. Oneofthemajorareasconcernthat Lakhani, whochairstheBoardofNCC- We discussedapaperfromDrMayur Primary Care (NCC-PC) National CollaboratingCentre for Regulations. currently takingplaceonthePMETB consultationis Secretary ofState. A be establishedinOctober2003bythe progressing. The BoardofthePMETBwill implementation ofthePMETBis and alsogaveabriefingonhowthe member ofthesteeringgrouponassessment training issues.DameLesleySouthgateisa on oneofthesteeringgroupslookingat developments withthePMETB.Steve sits Professor Steve Fieldupdated Councilon Training Board(PMETB) Postgraduate MedicalEducationand roposals_for_reform_sho_.asp http://www.rcgp.org.uk/rcgp/education/p our websiteandcanbefoundat The College’s responsehasbeenplacedon TheCollegegivesstrongsupport forthe • Thereshouldberealequivalence between • Theintroductionofa two-year • Thedocumentgivesscantregardto • The mainthemeswearestressingare: and themainissueswehavehighlighted. Overall, Councilwashappywiththedraft was neededinputtingthisdrafttogether. you willappreciatethatconsiderablework than time-basedtrainingandassessment. introduction ofcompetency-basedrather least intheimplementationofthisreview. general practiceandotherspecialties,not training isfiveyears. policy forspecialistgeneralpractice for generalpractice.CurrentCollege to reducetheperiodforspecialisttraining Foundation programmemustnotbeused implications forgeneralpractice. but withoutexplorationofthecostsand intending acareerinhospitalmedicine— experience gatheringfordoctors approvingly asavenueforteachingand general practice.Itismentioned neville goodman

Targets UST 25% of hospitals are reaching the target for treating heart attacks. There is Jonly one conclusion. Hospitals are failing heart attack victims. Clearly the doctors are rubbish and coronary care nurses are too busy seeing to their nail varnish. The Royal College of Physicians have painted an ‘alarming picture’. The country’s ‘heart tsar’, Dr Roger Boyle, reckons this audit has provided hospitals four home countries are co-ordinated with the information they need to meet the effectively. Mayur Lakhani will also push standards. According to my sources, the for the development of guidelines focusing heart tsar was appointed after long and on co-morbidity. rigorous interviews. Many cardiologists were considered, asked to submit their European Definition of General Practice solutions to the UK’s ‘number one killer’, We had an interesting discussion on how the and these solutions were pondered long and European Definition of General Practice, hard by a multidisciplinary team. Nothing from WONCA, could be used and less would do in this age of accountability. disseminated by the College. To help spread Except that apparently the appointee just the European Definition, Dr Justin Allen has happened to find himself on a train from kindly shared two PowerPoint presentations the North East one day with Alan Milburn, with us for use in explaining what it means. who sort of liked the cut of the chap’s jib, If you would like an electronic copy of the and appointed him. While the rest of us of the presentations, please contact struggle with Equal Opportunity forms and [email protected] who will be glad to rigorously conducted interviews after send them to you. which all notes are stored for 12 months in case of complaint, the ministers just pick a Child Protection buddy or two.1 You will recall, that Council discussed at its September meeting, the draft College How do we judge people who set standards position paper on child protection written by by which to judge a workforce? My Professor Yvonne Carter and Dr Michael conclusion from the RCP’s audit is that the Bannon. The document has now been standards were set far too high. Those who finalised and approved and will be available wrote the NSF for coronary disease need to on the College website shortly. The rethink their target of 30 minutes to document will be co-badged with the Royal thrombolysis, and Roger Boyle should be College of Paediatrics and Child Health, the apologising to the hundreds of staff who National Society for the Prevention of are now feeling victimised and Cruelty to Children, the British Association demoralised. Targets must be set bearing of Medical Managers, and the NHS local circumstances in mind; national Confederation. We also plan to publish the targets are an abstraction. This is not the document as a College position statement first NSF to fail so spectacularly, and I and also on our website. wonder how many were actually trialed after the great and the good sat around their Domestic Violence in Families with tables laying them down. As a rule of Children thumb, any target failed by more than 20% Council considered draft guidance for is unrealistic and has been set by people primary healthcare professionals on the who should have done their homework issue of domestic violence and the better. implications for children in these circumstances. The guidance, written by Dr I wonder what targets Jean-Pierre Garnier Judy Shakespeare and Lesley Davidson of has been set? He is chief executive of the National Perinatal Epidemiology Unit GlaxoSmithKline, one of the biggest of Big and was enthusiastically supported. The Pharma, and it is in trouble. Its profits and document was endorsed by Council and will share price are down; its R&D faltering. M. soon be appearing on our website. Garnier earned £7 million last year, but says he needs more money to keep him Council will next meet on Saturday 25 motivated. He wants one million share January 2003, commencing at 9.00 am at options (worth £12.5 million) plus 200 000 Princes Gate. free shares. Yes, I know there are footballers and pop stars who earn more, If you would like any further information on but something about Jean-Pierre makes me the matters discussed above or any other despair of humankind. issues we covered at Council then please do not hesitate to contact me via email at [email protected] [email protected] Reference 1. Cohen N. ‘Just like his pal Silvio’. New Maureen Baker Statesman 18 November 2002; 26-27.

The British Journal of General Practice, January 2003 87 our contributors saul miller

David Beales lives near Cirencester, Time to toe the line Gloucestershire. He has published widely, E are in the midst of a national advertising campaign about athlete’s foot. No, really, famously (with Nethercott) on the effects on it’s true: check your daily paper. Somewhere in there, between the early pages that health of closing a sausage factory Wmajor on adverts for cars, mortgages, and computers, and the later pages that carry Niall Cameron, newly M Phil’d, has promotions for corsets and other devices for those tired of cars, mortgages and computers, enlivened Bearsden dinner parties with ethical there will be one about corporal fungus. Not selling it of course. Rather, a public service quandaries for years now ... He practises in advertisement, warning darkly of the dangers of being a carrier. To be fair, the version I Govan, Glasgow keep coming across doesn’t actually spell out the dangers but it implies them well enough Namir Damluji is currently Associate as it alludes to the guilt I must feel should I turn out to be a Carrier Who Didn’t Seek Clincial Professor of Psychiatry at the Treatment. University of California, San Diego, California. Previously he was a full time Well, luckily I have the opportunity to confess here and now: I am a Carrier Who Didn’t faculty member at the American University Seek Treatment. Nor have I sought help yet. Recalcitrant is the word to describe my of Beirut Department of Psychiatry from shameful behaviour. But then, wait till you hear who is sponsoring the not-for-profit 1997–2000, and in 2000 was the chairman organisation that cares so deeply about my spore-ful infectiousness: a business that makes of the department and sells treatments for all manner of fungal afflictions. A symbiotic relationship perhaps? Amanda Howe chairs the RCGP Research How fortunate are such arrangements! Group. She is Professor of Primary Care at the School of Medicine, Health Policy & My imagination is stirred, as I take a pause from reading the lesser domestic news, by the Practice, University of East Anglia idea of a person (surely it can’t be a whole team) dedicating an entire career to the pursuit [email protected] of the war on fungus. Perhaps because it must take such a caring attitude and yet so much Najla Lakkis is chief resident, energy, I imagine this person as a woman, young and ambitious. I am intrigued with the Department of Family Medicine, American concept of what life must have been like for her, setting up a radical single issue campaign University of Beirut. organisation like that when all her friends, themselves still with the time to meet up at Toby Lipman is a GP in Newcastle. He coffee shops and chat, must have thought her mad. Did she have a partner? Was he can write a book review on almost anything supportive or was he another who believed athlete’s foot should be brushed under the in about fifteen minutes carpet? Orest Mulka practises in Leicester. He is the RCGP Ukrainian Fellow and author Imagine her struggle to make an impact from some sweaty armpit of a backroom office. All of the first ever textbook on general those letters of rejection from the many magazine editors to whom she submitted her practice written in Ukrainian proposal for a regular column. The family-friendly events she thought up along the way to Roger Neighbour recently delivered the raise the profile of her work but to which no-one came: the Dermatophyte Derby and the 21st George Swift Lecture to the RCGP Thrash Thrush Yoghurt Meet perhaps. And all along her parents still hoping to persuade her Wessex Faculty — full text at back towards the career in horticulture that had at one time appeared to be mushrooming. http://www.rcgp.org.uk/rcgp/faculties/ wessex/Swiftlecture2002.doc How did this person endure those years without any public recognition for her efforts? It Shmuel Reis as well as his wife were must take a strong woman to pursue such an apparently hopeless cause as that for so long born to Holocaust survivors. The Holocaust is without once faltering. Think too of the personal setbacks: finding that even she, with her ever present in their families. (Department of scrupulous hygiene, could harbour such evil germs from time to time must have been hard Medical Education, Rappaport Faculty of to swallow. Medicine, Bat Galim, Haifa, 31096, Israel. [email protected]) Against this background of struggle and rejection she won through, however. She managed Bassem Roberto Saab MD is to convince a large multinational of the purity of her struggle and, indeed, of their joint Associate Professor in the Department of interest. For the first time someone listened. How glad must have been her heart when they Family Medicine, American University of first agreed to fund a major advertising campaign to highlight her organisation, her Beirut, P.O. Box 113 – 6044, American message! University of Beirut [email protected] Now, reflecting like this as I turn the pages on towards the foreign news, I feel fortunate Graham Smith is a social historian now that this person chose to stay in Britain, to fight her fight here, to benefit us. I feel rueful based in Sheffield. His work on Paisley for all this time I have been harbouring the very germs she has dedicated her existence to doctors was carried out with Graham Watt fighting. I promise myself I will go for treatment at last. More, I will seek out all my and Malcolm Nicolson at the University of mouldy patients and persuade them of the true way. Glasgow Tomas Spenser was rescued from the That I ever hesitated, thinking of the adverts as a cynical ploy by the drug company to Holocaust at the age of 11 by a ‘Children’s stoke demand for its products, seems itself so shameful now. Transport’. His mother was gassed at Auschwitz; his father survived Auschwitz and died later. He qualified in St Andrews in 1950. Since 1966 he has lived in Israel, practicing and teaching as a rural GP until his retirement. Shaun Treweek has acquired a PhD and is presently working in Oslo [email protected] Jinan Usta is a Clinical Assistant Professor, Department of Family Medicine, American University of Beirut

All of our contributors can be contacted via the Journal office at [email protected]

88 The British Journal of General Practice, January 2003