MARY MACARTHY WWW.MARY-MACCARTHY.CO.UK
THIS WEEK
EDITORIALS
PRIMARY CARE
WHODUNIT
1279 Self experimentation and the Nuremberg Code
1298 A modest proposal
1319 The rise and fall of celebrity pathology
1300 NHS acronyms and abbreviations
1322 Dr Watson: a regular BMJ reader
1280 The private finance initiative: the gift that goes on taking
1301 Are there too many referral forms?
1324 Agatha Christie’s doctors
1281 Strategies for coping with information overload
RESEARCH 1284 Effect on gastric function and symptoms of drinking wine, black tea, or schnapps with a Swiss cheese fondue: randomised controlled crossover trial 1286 Testing the validity of the Danish urban myth that alcohol can be absorbed through feet: open labelled self experimental study 1287 Beauty sleep: experimental study on the perceived health and attractiveness of sleep deprived people 1289 Can he fix it? Yes, he can!
THE LIVES OF DOCTORS 1290 Junior doctors’ urine output on an intensive care unit: case-control study 1292 Phantom vibration syndrome among medical staff 1294 The barrier method as a new tool to assist in career selection: covert observational study 1296 Bicycle weight and commuting time: randomised trial
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1302 Reflections of Father Christmas’s GP
HISTORY
SURGERY
1326 Medical identification of Henri IV
1304 Red for danger? The effects of red hair in surgical practice
1328 Mozart’s 140 causes of death and 27 mental disorders
1306 Middle ear instrument nomenclature
1330 A shopping list of doctors
1308 The IKEA pencil: a surprising find in the NHS
1332 Short and stout physicians’ friends 1334 Acting on evidence 1336 “In consequence of enemy action”
READING BETWEEN THE LINES 1309 How the growth of denialism undermines public health 1312 Integrative medicine and the point of credulity 1314 On the impossibility of being expert 1316 A dose by any other name would not sell as sweet 1317 A Christmas tree cataract 1318 Pie sharing in complex clinical collaborations
1338 New Zealand’s medical first XV
EDITOR’S CHOICE
Welcome to our feast of fools
M
“For most of the year it preached solemnity, order, restraint, fellowship, earnestness, a love of God, and sexual decorum—and then, at New Year’s, it unleashed the festum fatuorum, the feast of fools, and for several days the world was upside down. Clergy played dice on the altar, brayed like donkeys instead of saying ‘Amen,’ had drinking competitions in the nave, farted to the Ave Maria, and delivered spoof sermons based on parodies of the Gospels .... After drinking tankards of ale, they held their holy books upside down, burned excrement instead of incense, and urinated out of bell towers. They tried to marry donkeys, tied giant woolen penises to their vestments, and held boozy orgies on the altar.”
This sacred parody wasn’t just a joke, argued de Botton, but to ensure that things would be the right way up for the rest of the year. “If you really think that the Christmas issue is an example of festum fatuorum,” commented a colleague, “it’s a pretty tame one.” And yet.
CARNIVALISE
edieval Christianity understood the debt that goodness, faith, and sweetness owe to their opposites, explained Alain de Botton in an article in Harper’s Magazine earlier this year.
Anon captures the feast’s antiauthoritarian tone by liberating the NHS’s abbreviations and acronyms (p 1300). We don’t have priests urinating out of bell towers, but we have intensive care doctors micturating into wide mouthed plastic measuring jugs, unaided by the nursing staff (spoilsports) (p 1290). “A modest proposal” (p 1298) and “Pie sharing in complex clinical collaborations” (p 1318) parody the modern day gospels on the primacy of primary care and the worthiness of multidisciplinary collaborations. John McLachlan’s hoaxing of the scientific committee of an international conference on integrative medicine covers with wonderful economy spoof sermons, farting to the Ave Maria, and burning excrement instead of incense (p 1312). Readers of the article in the
Too much information and not enough time?
masterclasses.bmj.com BMJ | 18-25 DECEMBER 2010 | VOLUME 341
print journal even get a moderately proportioned latex penis (rather than a giant woollen one) thrown in for good measure. And as happens in each year’s Christmas issue, booze is just about everywhere—if not in the nave or on the altar, then on the table (p 1284) and underfoot (p 1286). By contrast there’s nothing remotely foolish about three entries from last year’s competition for the most interesting use of the journal’s online archive. Although they didn’t win, they seemed too good not to share. Learn about the teapot’s occasional, but fascinating, appearances in BMJs over the years (p 1332), how BMJs of a hundred years ago were cannibalised for the plot of Casualty 1909 (p 1334), and how the archives facilitated a meeting between Sherlock Holmes, Dr Watson, and their creator (p 1322). Given the wave of creativity that last year’s competition unleashed, we were tempted to run another one this year. The working title was “How to reorganise the NHS,” and the plan was for entrants to submit their answers on the back of an envelope. From our experience last year, however, it was clear that many entrants would have spent more time drawing up their plans than the coalition
government has. It didn’t seem fair to waste their time. With so much information crying out for our attention (pp 1281, 1314) we have to spend our time wisely. One timesaver is to stop speculating on the nature of the illnesses of the illustrious dead. The fatuity of these efforts is pointed up by Lucien Karhausen’s totting up of Mozart’s suggested causes of death (140) and psychiatric states (27). As he points out, Mozart died only once: “some causes are plausible, only few—maybe one, or maybe none of them—can be true, so most if not all of them are false” (p 1328). His article allows us to draw a line, once and for all, under such speculative contributions. Far better use of your time is to support our charity this year, Save the Children (www. savethechildren.org.uk/bmj), and to nominate worthy contenders (or even yourself) for next year’s BMJ Group Awards (http:// groupawards.bmj.com). The deadline is 24 January—by which time the world should be the right way up again, always excepting the private finance initiative (p 1280). Tony Delamothe, deputy editor, BMJ
[email protected] Cite this as: BMJ 2010;341:c7228
EDITORIALS Self experimentation and the Nuremberg Code Ethics review is needed only when other people are subjects too
RESEARCH, p 1286 THE LIVES OF DOCTORS, pp 1290, 1296
George J Annas professor and chair, Department of Health Law, Bioethics and Human Rights, Boston University School of Public Health, Boston, MA 02118, USA
[email protected] Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2010;341:c7103
doi: 10.1136/bmj.c7103
Editorials represent the opinions of the authors and not necessarily those of the BMJ or BMA For the full versions of these articles see bmj.com
The Nuremberg Code is the cornerstone of human experimentation law and ethics.1 Nonetheless, the suggested exception of self experimentation in its article 5 has never been persuasive: no experiment should be conducted if there is an a priori reason to believe that death or disabling injury will occur, except, perhaps, in experiments where the experimental physicians also serve as subjects. The judges should have stopped at the word “occur.” Why is the exception there, and is it justifiable to put the lives of others at risk because the investigator is willing to risk his or her own life? The answer is that the prosecution at Nuremberg (and apparently the judges as well) thought that this exception was necessary to prevent the Nazi doctors from arguing that previous US government military experiments—most notably the Walter Reed yellow fever experiment—had also knowingly risked the lives of subjects. This explanation is supported by the originally suggested wording of article 5 by each of the two principal doctors who worked for the prosecution at Nuremberg, Leo Alexander and Andrew Ivy. Alexander suggested adding yet another clause: “such as was done in the case of Walter Reed’s yellow fever experiments.”2 Ivy would have replaced the existing clause with: “except in such experiments as those on yellow fever where the experimenters serve as subjects along with non-scientific personnel.”3 As Alexander and Ivy had anticipated, the 1900-1 yellow fever experiments did come up in the cross examination of Andrew Ivy. Ultimately, however, the studies did not play a crucial role because Ivy testified that he could not recall their details. Instead, he made a different point, that unlike the Nazi experiments, these were not performed under government or military orders. Because of the common equation of Walter Reed with self experimentation, it is of interest that Walter Reed himself, unlike his research team, was not a subject in the experiments. Similarly, although the yellow fever experiments made an appearance at Nuremberg, nothing in the testimony suggested that the willingness of an investigator to be a subject could serve as an ethical justification to put other humans at risk of death. Neither of these historical footnotes has much relevance today, not least because few, if any, contemporary researchers are willing to risk their own lives to prove the value or safety of their research.4 In the rare contemporary cases of self experimentation, today’s problem is whether self experimentation (an experiment done by the investigator on himself or herself only) must be reviewed and approved by an ethics committee before it is conducted.4 Three linked articles help clarify the ethics review question.
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Groves studied his bicycle riding and only his bicycle riding, and he has no plans to conduct bicycle riding research. He justifies not having his “n=1” bicycle riding study reviewed because he is the “sole investigator and subject” of the study and that it was “conducted . . . using his normal mode of transport.”5 This misses the central point. Groves was not doing research at all—he was not seeking generalisable knowledge by testing a hypothesis. He was simply trying to decide which of two bicycles to ride to work. The fact that he wrote up his “findings” in the form of a journal article does not make his decision making process a research project. It is a single anecdote that makes interesting reading, but it is much more suited to a cycling magazine or the newspapers than to a medical journal.6 Of course ethics review committees do not and should not review consumer product choice procedures (although someone might caution Groves about the dangers of cycling in the rain and snow). The Danish research team doesn’t say why it didn’t seek ethics committee review for its study on whether alcohol can be absorbed through the feet, although it was probably because all three investigators were physicians in good health, they understood the study, and they reasonably believed that it carried no risk, except perhaps of embarrassment.7 This is responsible. But it is also responsible for an institution (and a medical journal) to require that the “no risk” determination be made by an ethics committee. As the Danish team acknowledges, a slight modification to the protocol, such as including “eyeball drinking,” could radically alter the risks of the research.7 The PARCHED investigators did seek and obtain ethics committee approval for their investigator subject study. This is appropriate because their group contained more than one investigator subject (no plural exists for self experimentation), and because they recognised the risk of death posed by compromises to renal function.8 The ethics committee was overly cautious in its requirement of a data monitoring committee, but it curiously did not require documentation of fluid intake by the subjects, suggesting a cursory review at best. The investigators properly note this failure as a limitation of their study, but this simply makes their recommendation to drink more water while on shift all the more puzzling. Where does this leave us? The reasonable conclusion is that, contrary to article 5 of the Nuremberg Code, for life threatening research the participation of the researcher as a subject adds nothing to the ethical analysis of whether the research can be justified at all. The Walter Reed studies should have been characterised as unethical at Nuremberg (because they predictably would cause the 1279
EDITORIALS
deaths of non-investigator subjects), rather than weakly defended, and they certainly provide no ethical basis for their repetition today. Informed consent is a necessary, but not sufficient, condition of ethical experimentation. Self experimentation is neither necessary nor sufficient. Even where risks are minimal, prior ethics committee review of research in which investigators are subjects should be sought, if only to confirm the reasonableness of the risk assessment. If, on the other hand, an investigator proposes to experiment only on him or herself, that activity is not properly categorised as research at all, but as self indulgence (or, some may say, self abuse). Nuremburg continues to teach us serious ethical lessons. Trivial interventions masquerading as research studies are primarily a source of amusement.
1 2 3
4 5 6 7 8
Annas GJ, Grodin MA. The Nazi doctors and the Nuremberg Code: human rights in human experimentation. Oxford University Press, 1992. Schmidt U. Justice at Nuremberg: Leo Alexander and the Nazi doctors’ trial. Palgrave Macmillan, 2004:204. Ivy A. Report on war crimes of a medical nature committed in Germany and elsewhere on German nationals and the national of occupied countries by the Nazi regime during world war II (undated report to the prosecution, 1947). Altman LK. Who goes first? The story of self-experimentation in medicine. University of California Press, 1986. Groves J. Bicycle weight and commuting time: randomised trial. BMJ 2010;341:c6801. Kolata G. Fell off my bike, and vowed never to get back on. New York Times 2010 November 29. www.nytimes.com/2010/11/30/health/ nutrition/30best.html. Hansen CS, Færch LH, Kristensen PL. Testing the validity of the Danish urban myth that alcohol can be absorbed through feet: open labelled self experimental study. BMJ 2010;341:c6812. Solomon AW, Kirwan CJ, Alexander NDE, Nimako K, Jurukov A, Forth RJ, et al; on behalf of the Prospective Analysis of Renal Compensation for Hypohydration in Exhausted Doctors (PARCHED) Investigators. Urine output on an intensive care unit: case-control study. BMJ 2010;341:c6761.
The private finance initiative: the gift that goes on taking Its genius is how it diverts public resources to private interests
Allyson M Pollock professor and director, Centre for International Public Health Policy, University of Edinburgh, Edinburgh EH8 9AG, UK
[email protected] David Price senior research fellow, Institute for Health Sciences, Barts and The London, Queen Mary’s College, University of London, London, UK Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2010;341:c7175
doi: 10.1136/bmj.c7175
bmj.com/archive ЖЖPFI: perfidious financial idiocy. A “free lunch” that could destroy the NHS (BMJ 1999;319:2) 1280
Perfidious financial idiocy was how the BMJ’s editor described the private finance initiative (PFI) in 1999.1 Under the policy, NHS hospitals and land are sold off and new hospitals built using private loans instead of public loans or grants. We argued at the time that this would result in bed closures because hospitals had not been funded to pay the full costs of the loans, which are paid back over the 30-60 year contract period.2 3 And that’s what happened: English NHS hospital capacity fell by 73 882 beds (almost a third) between 1992-3 and 2009-10, and occupancy rates rose to unsafe levels of more than 85% during the period when the PFI system of loan financing was introduced.4 5 In 2000, as controversy grew over PFI related bed reductions, the government’s National Bed Inquiry found that further acute sector closures were unlikely to be safely attainable without more intermediate and community service beds, and it recommended reversal of bed closures.6 The wasteful £4bn (€4.8bn; $6.3bn) independent sector treatment centre programme was introduced as a stop gap,7 and hospital reconfiguration continued. Last week the Public Accounts Committee revealed that PFI is even less affordable.8 Banks lending to PFI projects have increased their interest rates by 20-30% since the financial crisis. But, as Audit Scotland has shown, private finance interest rates were already 2.5-4% above public borrowing rates before the government bail out.9 Higher charges for interest rates mean higher annual repayments by the NHS, as much as £200m a year for every 0.01% to 0.03% increase in lending rate.10 The Public Accounts Committee calculates that the increased bank charges “added £1 billion to the contract price, payable over 30 years, for the 35 projects financed in 2009.”8 But the problem of higher interest rate charges is not confined to new PFI deals. The PFI’s annual charges rise each year because annual payments are linked to the retail price index. This policy requires large injections of taxpayers’ money to support it. The funding freeze and ring fenced PFI debt payments that are index linked provide the ingredients for a perfect economic storm. The scale of the problem for the UK is formidable. By
December 2009, 159 PFI projects, worth £13.2bn in terms of building costs, had been signed to the NHS, and total debt to be repaid had reached £43bn. This year alone (2010-11) all PFI payments across the public sector will reach £8.6bn. The commitment over the next 25 years is projected to be £210bn.8 What stands out is the disparity between the original cost of a building and the final bill—a consequence of higher interest and returns to investors. Is the bill worth it? The government says it is. It argues that we are buying cost efficiency and that contractors have an incentive to be more efficient because it is their own money, not taxpayers’ money, that is at risk. According to the treasury, when “risk transfer” of this kind is taken into account, private finance is no more expensive than public finance.11 The UK parliament has repeatedly questioned the lack of evidence in support of risk transfer and value for money claims. In July 2010, a National Audit Office paper to a House of Lords committee described value for money as “subjective judgements of risk, which can easily be adjusted to show private finance as cheaper.”12 The chairman of the Public Accounts Committee described PFI as “probably the most secure projects to which the banks could lend.”12 The committee previously expressed concern over high interest rates, returns that contractors earn from PFI projects, and the risks they actually bear.13 To restore confidence in the financial markets and to free up lending, the UK government increased public borrowing to support the banking sector. It is this increased borrowing that lies behind the austerity drive across the public sector. In 2008-9, the government recapitalised the Royal Bank of Scotland Group (RBS) and the Lloyds Banking Group at a total cost of £37bn to become the major shareholder in both banks, holding 70% of RBS shares and 43.5% of Lloyds shares.14 The government also agreed to protect RBS from losses on risky assets up to £282bn.15 The effect of government rescue is to transfer the risks, completely or in part, from the private sector back to the taxpayer. These same banks provide loans to and take equity shares BMJ | 18-25 DECEMBER 2010 | VOLUME 341
EDITORIALS
in many PFI schemes; it is ironical that they are currently using high PFI interest rates to rebuild their balance sheet after the financial collapse. In other words, the public sector is making PFI payments to banks it partially owns, at a higher cost of borrowing than traditional public borrowing. This means that investment risks have now been transferred back to the tax paying public, negating the rationale for the policy. The rewards to PFI investors and shareholders are shrouded in secrecy, but an analysis of the financial projections for three hospital projects at the time the contracts were signed has shown that pure equity investors expected to receive £168m for £0.5m of equity invested in the Royal Infirmary of Edinburgh, equity of £100 in Hairmyres PFI hospital was expected to generate £89.14m for investors, and for Hereford hospital equity of £1000 was expected to generate £55.7m.16 These high rewards are contractually protected and underwritten by government. The genius of PFI is the way it diverts public resources from public to private interests, providing guaranteed profits to its backers in a time of austerity. But the shiny “new builds” will be cold comfort for the thousands of NHS staff now being served “at risk of redundancy notices” and millions of patients who face withdrawal of much needed entitlements and public services. A public enquiry and full publication of all contracts are long overdue.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Smith R. PFI: perfidious financial idiocy. A “free lunch” that could destroy the NHS. BMJ 1999;319:2. Gaffney D, Pollock AM, Price D, Shaoul A. The private finance initiative: NHS capital expenditure and the private finance initiative—expansion or contraction? BMJ 1999;319:48. Pollock AM, Dunnigan MG, Gaffney D, Price D, Shaoul J. Planning the “new” NHS: downsizing for the 21st century. BMJ 1999;319:179-84. Department of Health. Hospital activity statistics, 2000-8. www. performance.doh.gov.uk/hospitalactivity/data_requests/beds_open_ overnight.htm. Department of Health. Beds open overnight, 2008-11. www.dh.gov.uk/en/ Publicationsandstatistics/Statistics/Performancedataandstatistics/Beds/ DH_083781. Pollock AM, Dunnigan M. Bed in the NHS. BMJ 2000;320:461. Pollock AM, Kirkwood G. Independent sector treatment centres: learning from a Scottish case study. BMJ 2009;338:1421. House of Commons. Financing PFI projects in the credit crisis and the treasury’s response. Report of the Public Accounts Committee. HMSO, 2010. Audit Scotland/Accounts Commission. Taking the initiative. Audit Scotland, 2002:58. Norman J. Hard times call for a new rebate on PFI deals. Financial Times 2010. www.ft.com/cms/s/0/b5a2d048-a968-11df-a6f2-00144feabdc0. html#axzz17irB8IFt. HM Treasury. PFI: meeting the investment challenge. HMSO, 2003. National Audit Office. Private finance projects. Paper for committee of economic affairs. NAO, 2010. House of Commons. PFI construction performance. Select Committee on Public Accounts. Stationery Office, 2002. HM Treasury. Budget 2009: building Britain’s future. HC 407. Stationery Office, 2009. HM Treasury. Pre-budget report. Securing the recovery: growth and opportunity. Cm 7747. Stationery Office, 2009. Cuthbert J, Cuthbert M. The implications of evidence released through freedom of information in the projected returns from the New Royal Infirmary of Edinburgh and certain other PFI schemes. Papers on the Scottish economy. 2008. www.cuthbert1.pwp.blueyonder.co.uk.
Strategies for coping with information overload You need a machine to help you
READING BETWEEN THE LINES, p 1314
Richard Smith chair, Patients Know Best, Cambridge CB4 0WS, UK
[email protected] Competing interests: The author has completed the Unified Competing Interest form at www. icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; RS is on the board of the Public Library of Science and chair of Patients Know Best, a company that uses technology to enhance patient-clinician relationships; RS was the editor of the BMJ and chief executive of the BMJ publishing Group. Provenance and peer review: Commissioned; not externally peer reviewed. Cite this as: BMJ 2010;341:c7126
doi: 10.1136/bmj.c7126
bmj.com/archive ЖЖThe knowledge disease (BMJ 1993;307:1578)
Fraser and Dunstan show that even within a narrow specialty it is impossible to keep up with published medical reports.1 Trainees in cardiac imaging reading 40 papers a day five days a week would take over 11 years to bring themselves up to date with the specialty. But by the time they had completed that task, another 82 000 relevant papers would have been published, requiring another eight years’ reading. And this analysis assumes that trainees need to know about cardiac imaging only, whereas they surely need to keep up with other areas of medicine and healthcare. The authors conclude that it is impossible to be an expert. This problem is not new. Dave Sackett, the “father” of evidence based medicine, found some 20 years ago that to keep up to date in internal medicine it was necessary to read 17 articles a day 365 days a year.2 He also found that the median time spent reading by newly graduated doctors was zero, while for senior consultants it was 30 minutes, with 40% reading nothing.2 Some 10 years ago I asked around 100 doctors how much of what they should read to do their job better they actually read. About 80% said less than 50%, and 10% said less than 1%.3 More than half felt guilty about this, and when asked to describe in one word how they felt about their information supply it was mostly negative (impossible, overwhelmed, crushed, despairing, depressed), with just a few answering “challenged.”3 One of the best known responses to information overload was the founding of the Cochrane Collaboration, named after the epidemiologist Archie Cochrane who called for a “critical
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summary . . . adapted periodically, of all relevant randomised controlled trials.”4 He knew that most of the new information was of poor quality, and Brian Haynes showed later that less than 1% of studies in most medical journals reach stringent scientific standards.5 John Ioannidis has argued in the best read paper in PloS Medicine that most research findings are false.6 So it makes no sense for doctors to try and read everything: rather, argued Cochrane, they should rely on critical summaries. But 20 years after the launch of the Cochrane Collaboration a review has found progress to be poor.7 Around 75 clinical trials and 11 systematic reviews are published every day, with no sign of abating. Yet many clinical topics have no Cochrane Library systematic reviews, and perhaps three quarters of interventions lack a firm evidence base. We have what Muir Gray, once director of the National Library for Health, calls an information paradox—we are overwhelmed by new information yet have many unanswered questions. The average 10 minute consultation between a doctor and patient will throw up at least one question that cannot be answered.8 The box lists the possible strategies for dealing with the problem, but the only one that might bring success is to use a machine. Several years ago after conducting a semi-systematic review of the information needs of doctors I tried to identify the characteristics of the machine that would finally solve the seemingly impossible problem of answering all the questions that arise in medicine with the very latest research.8 Here are the characteristics: 1281
W HEATH ROBINSON
EDITORIALS
Strategies for dealing with information overload The ostrich strategy With this strategy doctors simply ignore the torrent of new information. If Sackett’s data are right, many doctors adopt this strategy, especially as they get older.9 The pigeon strategy Perhaps the most common strategy is to hang around with other doctors and pick up titbits of information. You attend grand rounds and the occasional postgraduate meeting, follow some guidelines, and rely on drug company representatives to tell you about new treatments. When you have a tricky question about a patient you consult a colleague—the most common way to get an answer.8 You sometimes flick through journals, but you learn more from the mass media. The most annoying way that you learn new things is from patients who bring newspaper clippings, garbled stories about something on the television, or long printouts from the internet.
The owl strategy Probably the rarest strategy is that proposed by the originators of evidence based medicine. You build your knowledge patient by patient by identifying questions that arise during interactions. You refine the questions to one that can be answered, search for all relevant evidence, and systematically analyse it, abandoning the large amount that is of poor quality and combining, preferably numerically, that of high quality. The advantage of this strategy is that your information relates directly to your patients. Unfortunately, almost nobody has the time and very few the skills to pursue such a strategy. The Jackdaw strategy Doctors who pursue this strategy follow the pigeon strategy but also regularly search for highly refined evidence— from perhaps the Cochrane Library, Clinical Evidence, guidelines, or other
• Part of the information system that doctors use as they see patients • Able to answer highly complex questions • Connected to a large valid database • Electronic • Fast (answers within five seconds) • Easy to use (as easy as a car) • Portable • Prompts doctors in a way that is helpful not demeaning • Connected to the patient record • Gives evidence related to individual patients • A servant of patients as well as doctors • Provides psychological support. Some of these characteristics may never be achieved. For example, it is impossible to give evidence related to individual patients because evidence is gathered on populations. It would also be hard for machines to provide psychological support, but many of the questions that doctors ask themselves, such as, “Did I do the right thing by that young woman who died of breast cancer last week?”, are really a request for psychological support.8 And will doctors be willing to use such machines? De Dombal showed that computers are better at diagnosing acute abdominal pain than doctors, but his strategies were never widely adopted.11 My father resented my mother buying a dishwasher because he feared it would replace his role, and 1282
sources of evidence based reviews. Unfortunately these sources are full of holes (because the evidence simply doesn’t exist), and the evidence is not useful—and may even be harmful—for patients with comorbidity (who now constitute most patients).10 The inhuman strategy John Fox, once director of the Advanced Computing Laboratory, said that practising medicine is an inhuman activity, meaning that it’s absurd for doctors to practise without the help of machines. Individual doctors have no chance of keeping up with new research, but teams of people can process new information and feed it into machines that doctors (and patients) can use. The most popular of these machines is UptoDate, which has 400 000 users, but there is also BMJ Point of Care, the Map of Medicine, and more.
perhaps doctors are worried that machines might precipitate the reformation, described so beautifully by Joanne Shaw, where priestly doctors with their Latin bibles will have to give way to plebeians speaking the vernacular.12 “Will we ever solve the problem of information overload?” I imagine myself asking God as I arrive in heaven. “Sure,” he’ll answer, “but not in my lifetime.” 1
Fraser AG, Dunstan FD. On the impossibility of being an expert. BMJ 2010;341:c6815. Sackett D. The need for EBM talk. www.cebm.net/index.aspx?o=1083. Smith R. Meeting health care challenges: what are the challenges and what is the role of e-health? http://learn.patientsknowbest.com/WikiEditor. im?doc=2010-12-25-Meeting-healthcare-challenges-what-are-thechallenges-and-what-is-the-role-of-e-health&pid=0. 4 Cochrane AL. 1931-1971: a critical review, with particular reference to the medical profession. In: Medicines for the year 2000. Office of Health Economics, 1979:1-11. 5 Haynes RB. Where’s the meat in clinical journals? ACP J Club 1993;119:A23-4. 6 Ioannidis JPA. Why most published research findings are false. PLoS Med 2005;2:e124. 7 Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Med 2010;9:e1000326. 8 Smith R. What clinical information do doctors need? BMJ 1996;313:1062-8. 9 Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Norcini JJ, et al. Changes over time in the knowledge base of practising internists. JAMA 1991;266:1103-7. 10 Tinetti ME, Bogardus ST, Agostini JV. Potential pitfalls of diseasespecific guidelines for patients with multiple conditions. N Engl J Med 2004;351:2870-4. 11 De Dombal T. Medical informatics: the essentials. Oxford University Press, 1993. 12 Shaw J. A reformation for our times. BMJ 2009;338:b1080. 2 3
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RESEARCH THIS WEEK’S RESEARCH QUESTIONS 1284 What should you drink with a cheese fondue—white wine or black tea, and is a shot of schnapps good for the digestion? 1286 Is the Danish belief that submerging your feet in alcohol can make you drunk merely an urban myth—or is there some truth in it? 1287 Can you tell just by looking at someone that they’re sleep deprived?
DUNCAN SMITH
1289 Which popular children’s toy provides symptomatic relief for ocular neuromyotonia, and why?
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1283
RESEARCH
Effect on gastric function and symptoms of drinking wine, black tea, or schnapps with a Swiss cheese fondue: randomised controlled crossover trial Henriette Heinrich,1 Oliver Goetze,1 Dieter Menne,2 Peter X Iten,3 Heiko Fruehauf,1 Stephan R Vavricka,1 Werner Schwizer,1 4 Michael Fried,1 4 Mark Fox1 4 EDITORIAL by Annas 1
Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland 2 Menne Biomed, Tuebingen, Germany 3 Division of Legal Medicine, University Zurich, Switzerland 4 Zurich Integrative Human Physiology Group, University of Zurich Correspondence to: M Fox, NIHR Biomedical Research Unit, Nottingham Digestive Diseases Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
[email protected] Cite this as: BMJ 2010;341:c6731 doi: 10.1136/bmj.c6731 This is a summary of a paper that was published on bmj.com as BMJ 2010;341:c6731
OBJECTIVE To compare the effects of drinking white wine or black tea with Swiss cheese fondue followed by a shot of cherry schnapps on gastric emptying, appetite, and abdominal symptoms. DESIGN Randomised controlled crossover study. PARTICIPANTS 20 healthy adults (14 men) aged 23-58. INTERVENTIONS Cheese fondue (3260 kJ, 32% fat) labelled with 150 mg sodium 13Carbon-octanoate was consumed with 300 ml of white wine (13%, 40 g alcohol) or black tea in randomised order, followed by 20 ml cherry schnapps (40%, 8 g alcohol) or water in randomised order. MAIN OUTCOME MEASURES Cumulative percentage dose of 13C substrate recovered over four hours (higher values indicate faster gastric emptying), and appetite and dyspeptic symptoms (visual analogue scales). RESULTS Gastric emptying was significantly faster when fondue was consumed with tea or water than with wine or schnapps (cumulative percentage dose of 13C recovered 18.1%, 95% confidence interval 15.2% to 20.9% v 7.4%, 4.6% to 10.3%; P
