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Jenny kissed me when we met
Jumping from the chair she sat in;
Time, you thief, who love to get
Sweets into your list, put that in:
Say I'm weary, say I'm sad,
Say that health and wealth have missed me
Say I'm growing old, but add,
Jenny kissed me.
Leigh Hunt (1784–1859)
Leigh Hunt was immortalised by Dickens as Harold Skimpole in Bleak House. The Jenny in the poem was Jenny Carlyle, who kissed him out of delight at seeing him recovered from illness. On page 80 Dougal Jeffries writes in homage to the value of touch as a diagnostic aid. As he points out, we all recognise it; it is second nature to experienced doctors, although I suspect it is, like other skills, something we have learnt and use every day without entirely understanding how it works. Another such is the dimension of time, also central to the practice of medicine. For a start we rely on the efforts of our predecessors, and should properly have some understanding of the history of medicine.
On page 70, Andrew N. Williams describes Thomas Willis' work as a GP in rural Oxfordshire. For me, the account illustrates how time worked in Willis' favour — how he sometimes was called in late in the course of an illness, when the picture was clearer, and how he was blessed on occasion by a modicum of good fortune. History teaches us how rapidly medicine can change. In one editorial this month we are warned of the possibilities of developing deficiencies in micronutrients. The reason suggested is the increasingly sedentary nature of our lives that has dictated a significant drop in the overall food intake over the last few decades (page 3).
The other editorial this month describes the changing patterns in malaria, both improving in some parts of the world and worsening in others (page 4). History also teaches us how little some things change. In Mike Pringle's account of his participation in a reading of Bernard Shaw's The Doctor's Dilemma, he discerns some of the same problems confronting doctors in Victorian London as now (page 76).
We all construct our own narratives, and Kath Checkland shows how they affect the ways in which different practices adapt to change (page 56). Time, as for Leigh Hunt, can often appear as an enemy, and doctors discussing their management of patients with headache recognised time constraints as one of the factors that tended to encourage referral (page 29). Others included lack of confidence in dealing with uncertainty, a sense of technology undermining clinical medicine, and patients claiming their rights.
Time runs forwards as well as backwards, and these days we are most conscious of time when we are asked to try and predict the future. The study on page 40, using general practice records in a way that is admirable but all too rare, has found that those patients admitting in a questionnaire to having chest pain not declared to a doctor at the beginning of the study, were more likely to have heart disease and higher mortality among men over the next 7 years. The authors warn that most people with such chest pain will not present with heart disease or die from it.
It's useful to be confident when predicting that conditions, such as neck pain (page 23), tend to get better over the next year, whatever we do. GPs also turned out to be uncannily good at predicting the outcome for patients with low back pain (page 15), although this was another case where it wasn't clear exactly how they arrived at their conclusions. On the other hand, don't let yourselves get too confident when predicting the future: on page 79 Neville Goodman mocks the futurists' prognostications. Pity: I'd always rather fancied the idea of male pregnancy.