|Home | About | Journals | Submit | Contact Us | Français|
Leo Rosten, in his book The Joys of Yiddish uses stories to illustrate words where the definitions are elusive. For instance, the entry on ‘chutzpa’ includes: ‘Chutzpa is that quality enshrined in a man who, having killed his mother and father, throws himself on the mercy of the court because he is an orphan’. But for ‘mensch’ there are no stories (or I would have quoted them instead); only a definition and his own memory. ‘As a child, I often heard it said: the finest thing you can say about a man is that he is a mensch!’ The article on page 976 explores some definitions, and suggests that the notion of virtue, respect and dignity that it enshrines should be used as a guiding principle in medical education.
The personal account of one doctor's work on page 982 shows such a (female) mensch setting the very highest standards for herself under difficult conditions. Such virtues have a decidedly old-fashioned ring to them, but it is hard to imagine good medical practice without them. Here in the UK there is tension between managerial and professional decisions, and it is mostly the professionals deciding which bits of some directive are implemented (page 918). There is a reminder on page 945 of the need to respect the values of patients coming from different cultures.
Promoting the idea of professionalism requires care, since it comes with a lot of unattractive baggage. For a start, like ‘clinical freedom’, it has acted in the past as a cloak for inadequate standards of care. This month there is a depressing account of GPs' beliefs in the efficacy of modern hypnotic drugs (page 964), mercifully counterbalanced by a study into peripheral vascular disease where the positive predictive value of GPs' diagnoses, verified by ankle brachial index was a highly creditable 48%. There is also the long history of professionals hiding their activities behind obscure language and keeping patients ignorant, now thankfully impossible. The study on page 911, another using a discrete choice experiment method, explores patients' preferences for self-care when dealing with minor illness. While self-care come out clearly on top, the next best choice was advice from a community pharmacist or GP; the desire for professional authority has not yet vanished. However this paper also seems to suggest that for such minor problems willingness to pay is traded against willingness to wait, so that in practical terms putting some delay into the system encourages self-care, and takingit out(thatis, making GPs more easily accessible) would discourage it. The two policy imperatives in the UK of improving access and encouraging self-care may be pulling in opposite directions. The leader on page 907 discusses the burgeoning market in self-care materials, but also warns of the need to back up the results with professional expertise.
The ways in which doctors used to exclude patients from the inner mysteries of medicine are sometimes reproduced in the uneasy tension between primary and secondary care doctors. The habit of using language as much to exclude as to communicate dies hard, as the letter dealing with acronyms in ophthalmology shows (page 968). The authors on page 938 seem to feel let down by their colleagues: ‘A primary care treatment regimen based on the consensus among urologists does not improve effectiveness’. In contrast, the leader on page 908 argues that recent changes in the UK aim to shift the responsibility for managing patients with chronic kidney disease towards primary care. The public still finds generalism difficult to believe. The young adults on page 924 found it hard to credit GPs with expertise in mental health as well as physical problems.
The world of fiction is, after all, much simpler. Marjory Greig pays homage to The Archers on page 973, but her list of medical events is incomplete. We have had, in no particular order, Chris Carter's cleft lip, Jack Woolley's dementia, Daniel Hebden-Lloyd's juvenile arthritis, Peggy Archer's polymyalgia rheumatica, Brian Aldridge's post-traumatic epilepsy, Helen Archer's anorexia, Phil Archer's hip replacement, his wife Jill's hypothyroidism, Joe Grundy's farmer's lung, and Someone (was it Neil Carter?) got tetanus from a puncture wound. There has been much violent death: John Archer (tractor accident), Mark Hebden (car accident) and for those whose memories go that far back, Grace Archer (fire — to spike the first night of ITV transmission in 1955). My own view is that, with its small population, Ambridge is far and away the most unhealthy place in the UK, and recent events (Betty Tucker's untimely death from heart disease, Ed Grundy's cocaine habit, and Hayley Tucker's incipient infertility) have done nothing to shake it. Since Tim Hathaway eloped with the vicar they haven't even had their own doctor. Perhaps the Borsetshire PCT should consider inviting a private company to set up an EMS surgery there (see page 974).