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![][1] Quarterly journal of the Men's Health Forum Personal subscription: UK £30; overseas £45. Institutional subscription: UK £75, overseas £90 For further details, telephone 01279 714510 Rating: ![Graphic][1] ![Graphic][1] ![Graphic][1] Considering the power and influence wielded by men in both medicine and politics it is odd that, unlike women, they have ignored the clear adverse health profiles of their own gender. In the first issue of the Men's Health Journal , public health minister Yvette Cooper considers the fact that, on average, men die five years younger than women to be “one of the starkest health inequalities we face.” … [1]: pending:yes
Considering the power and influence
wielded by men in both medicine
and politics it is odd that, unlike
women, they have ignored the clear adverse
health profiles of their own gender.In the first
issue of the Men’s Health Journal, public health
minister Yvette Cooper considers the fact
that, on average, men die five years younger
than women to be “one of the starkest health
inequalities we face.” She concedes that
traditional health promotion campaigns have
not been a great success with men and that
NHS services are often perceived as being
geared more towards women.
However, it is more complex than that.
The “absent male” is a feature of a variety of
therapeutic settings and men are unlikely to
be the first to seek help when there are mari-
tal or child care problems. In general practice,
men are more prepared to see a registrar or a
locum than women and seem to place less
store on the doctor-patient relationship than
women. At one accident and emergency
department, 57% of attendees were male
(Journal of Accident and Emergency Medicine
1999;16:425-7). This may well be because
they sustain more injuries, but factors like
access, availability, and the doctor-patient
relationship need to be studied.
Wilson has noted that the impact of
general practice on lifestyle is limited, with
few practices running effective screening
and treatment programmes for hyper-
tension in men (In O’Dowd, T, Jewell, D,
Men’s Health, Oxford University Press, 1998).
Preventive services in the workplace seem to
have greater acceptability to men than those
in conventional primary care, as shown
when health visitors offered health promo-
tion from a caravan on two industrial sites
(Health Visitor 1991;64:265-6).
Healthcare professionals are increas-
ingly interested in men’s health but it is not
yet clear that men themselves are interested
in their own health. Indeed, men’s insouci-
ance about their health conflicts with a
healthcare system that is determined to
improve their health. Most healthcare
systems have considerable experience in
dealing with women’s health and a paternal-
istic model has evolved that has created a
dependence that has extended considerably
over the years. In the management of HIV/
AIDS men have often developed models of
self reliance with medical input being
accepted on a technical level only. Men’s
apparent unwillingness to look after them-
selves may be partly a resistance to our
attempts to make them dependent on the
healthcare professions.
The Men’s Health Forum, which pub-
lishes the Men’s Health Journal for primary
care professionals, is careful to point out that
it does not begrudge the achievements of
the women’s health movement but laments
the sparsity of men’s health initiatives.Let us
hope that the Men’s Health Journal will be an
important vector in reporting on male
Tom O’Dowd professor of general practice, Trinity
College, Dublin, Ireland
Hype, hope, or healing? Comple-
mentary and alternative medicine
is becoming increasingly popular
in the United Kingdom, with a fifth of the
population using it. Britons spend £1.6bn a
year on complementary medicine (in the
United States the figure is £21bn) and there
are now 49 000 practitioners.
Complementary medicine adopts a dif-
ferent philosophy to conventional medicine.
The idea is that a healthy body is a system in
balance and treating imbalance can help dis-
ease. Many sceptics state that it is the placebo
enhanced by the lengthy consultation
and the often pleasant treatment
that causes
positive results in complementary medicine.
However, for most of medical history,
compassion, attention, and emotional
all major contributors to the pla-
cebo effect
were all that doctors had to offer.
With the advent of modern medicine and the
advances in science and technology doctors
have to a great extent lost the traditional and
historical role of healer.
So does complementary medicine actu-
ally work? Which types are the most
effective? Is it possible to integrate comple-
mentary medicine into mainstream on-
cology care? Within orthodox oncology
care settings complementary medicine
approaches are usually provided to relieve
physical symptoms and ease emotional
reactions to illness. These benefits are well
founded, but what of the claims of
prolonged survival and cure? This excellent
book attempts to make sense and order of
an often confused and controversial field. It
is a mixture of evidence based, scientific
research and personal viewpoint, both from
patient and practitioner.
The first section explores the back-
ground of holistic health care, which views
health and illness as the result of interacting
influences of mind, body, spirit, and the envi-
ronment. It reviews the scientific evidence
underpinning such approaches. The second
section focuses on specific therapies such as
acupuncture, nutrition, homoeopathy, hyp-
nosis, guided imagery, and psychospiritual
approaches. These chapters are written by
experienced practitioners (including con-
sultants) and comprehensively discuss the
historical background, philosophy, scientific
evidence base, clinical application, and often
patients’ experiences of each therapy. The
third section, which includes chapters about
delivery of therapies within a variety of
healthcare disciplines and settings, was
slightly repetitive.
This book should be essential reading
for all those involved in oncology, both
healthcare practitioners and patients alike.
Those who are sceptical about complemen-
tary medicine, and those who despise and
disparage it, should also read this.
Susannah Baron specialist registrar in
dermatology, Leeds General Infirmary
Men’s Health Journal
Quarterly journal of the Men’s Health
Personal subscription: UK
£30; overseas £45.
Institutional subscription: UK
£75, overseas £90
For further details, telephone
01279 714510
Rating: ★★★
Integrated Cancer Care:
Holistic, Complementary
and Creative Approaches
Ed Jennifer Barraclough
Oxford University Press,
£29.95, pp 312
ISBN 0 19 263095 4
Rating: ★★★★
1432 BMJ VOLUME 323 15 DECEMBER 2001
This book provides a most informative
guide to how drastic funding cuts
have affected healthcare delivery. It
looks at how cuts have changed both the
ethos behind healthcare delivery and the
suitability of the traditional contract and tort
doctrines as mechanisms of legal account-
ability. The book focuses on the legal and
practical implications of resource shortages
and it highlights the transition from an age
of “if it may help, try it” to one of “don’t do it
unless it definitely will help.” In this sense its
interest to British readers is obvious, even
though it is written on the basis of the US
experience since the 1950s.
However, obvious interest does not
mean obvious significance. Some chapters
deal with contractual liability in the context
of health plans. Such liability is of only
limited practical significance in this country
given that most health care is still delivered
through the NHS. This is not to say that the
contractual rights of the large and growing
number of British citizens who now have
some form of private healthcare cover are
unimportant. Rather it means that, in this
country at least, any discussion about
effective healthcare accountability must
extend beyond the narrow confines of
contract and tort actions.
Public law accountability
for example,
judicial review of policy decisions concern-
ing area wide healthcare provision
far greater potential for ensuring the
provision of high quality health care than
private law actions against specific individu-
als ever can. While the occasional litigant
may secure an award in damages from a
careless individual (or from his employer) in
a negligence or malpractice action, such
actions alone can do little if anything to
ensure sound policy formulation. Morreim
recognises this when she concedes that “tort
seems inadequately equipped to look
beyond the needs and circumstances of
individual litigants” (p 43).
On the other hand, it is perhaps
understandable that she concerns herself
purely with private law given that the
context of her study is the United States
where there have been two malpractice
crises in recent times: one in the early 1970s;
another in the mid 1980s. But this is not my
central point. Rather, it is that her account is
an insufficient one for the purposes of
presenting a picture of healthcare account-
ability in Britain.
Much more worthwhile is Morreim’s
account of how traditional tort doctrines,
formulated in an age in which economics
was not a major concern, have since lost
touch with the economic realities of health-
care provision (on both sides of the
Atlantic). She describes how providers com-
monly try to avert legal action by declaring
that an intervention is not medically
necessary rather than saying that it “may
have some value, but isn’t worth the money.
Anyone who takes medical malpractice
seriously should read Morreim’s arguments
about recognising the full potential of negli-
gence law
which is intimately connected
with the exercise of skill, knowledge, and
care. This is especially so given the way in
which the debate about the negligence
liability of resource capped public bodies
has recently resurfaced so markedly. In par-
ticular, Morreim’s suggestion (p 141) that
the courts must “invoke a conceptual
expertise versus resources
is not currently built into the language of
adjudication” warrants serious attention.
Although Morreim’s book is narrower in
focus than its title suggests, it is nevertheless
a welcome addition to the already extensive
literature. It is certainly recommended.
John Murphy senior lecturer in law,
University of Manchester
Signs of Life
BBC Radio 4, Wednesdays at 9 pm,
5 to 19 December
Each of the three programmes in this
short series of drama documentaries
explores a different medical condition.
The voices of patients and their doctors
documentary part
are interwoven with a
radio drama. These voiceovers serve as a
commentary on the drama, which in turn
serves as a metaphor for the pathology, the
symptoms, and their emotional impact. A tall
order, for a 30 minute programme. Did it
work? The short answer (at least with the first
two programmes made available for review)
is no. Yet the series still provided moments of
dramatic power.
The first programme, “The Drowning,
dealt with cystic fibrosis. In the drama,the sole
survivor of a tragic shipwreck mixed memo-
ries of the events around the sinking,
including a vision he had of a beautiful and
mysterious woman. Unfortunately, the drama
totally disordered
and distracted from
documentary, which was trying to explain the
condition and its treatment and tell the story
of a real patient, Jo,delicately reported by her
father. The main problem was the abstruse-
ness of the dramatic metaphor. Granted, a
patient with cystic fibrosis can experience
something like drowning, but the hero of this
drama spent most of his lines musing on how
and why he had not drowned (although, at
the end, he did die, but without any obvious
explanation). I struggled to see why the
drama was about him at all.
The second programme, “Battle Cry”
(on Parkinson’s disease), presented a more
convincing dramatic metaphor. Two strate-
gists were planning war moves in a secret
nerve centre. I understood the metaphorical
connection of neural nexus with military
machine. In the drama, telephoned military
orders were mutinously ignored and a neu-
rologist’s commentary likened this to neuro-
transmitters not ringing their receptors.
However, this programme’s success was par-
tial. For example,the documentary’s real life
patient (a middle-aged mother) explained
her distress at developing a mask like face
and how it reduced her range of possible
emotional contact with her children. Crassly,
the drama then featured a military com-
mander talking about putting on a brave
face when spinning bad news in a propa-
ganda broadcast. The drama had missed the
point of the documentary’s message. It
wasn’t about hiding inner feelings; it was
about being trapped in a disordered body
that could not display them.
What struck me about this series was that
powerful drama was, paradoxically, only to be
found in the documentary element.
Thus, in the first programme on cystic
fibrosis, we heard the father of Jo, the
patient, perfectly encapsulate both the
pathology and his pain, when he said, “If you
kissed her, she tasted salty.”We heard that Jo
had had a lung transplant and her doctor
then said, ‘There are days you come off the
ward and you could use some really foul
language to describe CF . .. it’s a pig of a dis-
ease and we hate it.” The father’s simple “Jo
died,” spoken in a faltering voice, was the
next that we heard. I silently cursed when
the actors returned, breaking the spell.
Signs of Life is a bold experiment, which,
these days, only radio would dare to
broadcast. Unfortunately, it tries to do too
much with too little time, and mixes its two
genres clumsily, sometimes incomprehensi-
bly.However, its disease is intriguing and the
doctor in me can’t resist listening to the last
programme (on alcohol dependence syn-
drome) just in case the metaphor dramati-
cally cures the message.
Iain McClure consultant child and adolescent
psychiatrist, Vale of Leven Hospital, Alexandr ia
Holding Health Care
Accountable: Law and the
New Medical Marketplace
E Haavi Morreim
Oxford University Press,
£39.50, pp 320
ISBN 0 19 514132 6
Rating: ★★★
Items reviewed are rated on a 4 star scale
1433BMJ VOLUME 323 15 DECEMBER 2001
Vincent’s bandage
The art of selling a drug for
bipolar disorder
Over the past few months the British
Journal of Psychiatry has contained
a striking image of Vincent Van
Gogh. The BMJ has also carried the image.
Those who attended the annual general
meeting of the Royal College of Psychiatrists
in July 2001 encountered the same image in
a lofty, softly lit hall,a shrine to the pharma-
ceutical industry. The image
consisting of
renditions of one of Van Gogh’s self
portraits against psychedelically coloured
backgrounds, echoing Andy Warhol’s
formed a devotional icon to the
drug valproate semisodium. But this is a
Vincent with a difference. A large dressing
covers his left ear, held in place by two strips
of adhesive dressing. What are we to make of
this? What is really being said here?
It is well known that Vincent Van Gogh
removed part of his left ear. In October 1888
Paul Gaugin visited him in Arles. The two had
previously met in Paris, and had much in
common. Van Gogh hoped that together
they could start a school of artists in the
south, in contrast to “those decadent and rot-
ten Parisian boulevardiers.” Things didn’t
work out. Gauguin was short tempered, and
they quarrelled, some-
times violently, until
Gauguin decided that
he had had enough
and returned to Paris.
At this point Van Gogh
became agitated, and
on Sunday 23 Decem-
ber removed part of his
left ear with a razor. He
was admitted to the
asylum at Saint-Remy.
Although he was in and
out of hospital after
this, the last 18 months
of his life were marked
by a burst of creative
energy, as he painted
some of his greatest
works, 60 paintings
alone between May and
July 1889.
The advert for val-
proate semisodium
shows Van Gogh with
his left ear bandaged. At least the advertising
agency got its facts right, which is more than
we can say for poor Vincent. In one of his
most famous paintings, the Self-Portrait with
Bandaged Ear of 1889, he shows himself with
his right ear bandaged. He had painted him-
self from his image reflected in a mirror,
which reversed right and left. So the first
message is that we can rely on the drug
company’s facts, in contrast to these
temperamental artists.
But there is more. We are presented with
four identical images of Vincent, each with a
different coloured background, scarlet red,
blue, green, and purple. Does this mean that
Vincent was a fragmented human being?
Perhaps he had multiple personality dis-
order. But no, the message becomes clear if
we examine the text that accompanies these
images in the medical journals: “First Line
Mood Stabiliser” above the images and
“Proven across a spectrum of today’s bipolar
patients” below. So the truth is that Vincent
suffered from bipolar disorder, his extremes
of mood implied by the violently clashing
colour backgrounds out of which his
mutilated face emerges. The adverts also
have helpful little coloured bullets to guide
our interpretation of this revelation, each
annotated and linked to reliable drug
company references, scarlet red for mania,
blue for rapidly cycling bipolar disorder,
purple for mixed mania (sic), green for
lithium non-responders.
Surely, then, there can be no doubt
about the facts. Valproate semisodium is the
best thing for fast, consistent mood stabilisa-
tion. If only Vincent had taken this he
wouldn’t have needed the bandage. With
mood suitably stabilised he would not have
hacked away at his left ear to still his
tormenting voices. He would never have
found his way into Saint-Remy, and the
world would never have had its breath taken
away by Starr y Night, or any of those other
great canvases in his last 18 months.
And it can work for us too, in an age that
has no use for anxiety, in which we lie ether-
ised like Prufrock, sedated, becalmed, and
tranquil, neither high nor low. No suffering,
no soul, no art. Yes, if Vincent had been on
valproate he might still have painted. If he
were alive today and on valproate Vincent
would be driving around in a white transit
van, painting houses battleship grey. But
then at least the bandage wouldn’t be neces-
sary. Madness is okay, as long as it’s kept in its
place, on the canvas, in the asylum but, either
way, under drugs.
Philip Thomas, Pat Bracken consultant
psychiatrists, Bradford Community Health Trust
The information gap was launched last week to bridge the divide
between knowledge rich developed countries and the knowledge poor
developing world. Sponsored by the journals Nature and Science, the site was
created on the premise that “those who stand to benefit most from modern
science and technology tend to be those who have least access to information.”
Over the past few years there has been increasing recognition of impact of
the knowledge gap on developing countries. To this end free access to medical
research published by the BMJ has been possible via since 1995. All
23 specialist journals published by the BMJ Publishing Group are currently
available free of charge to 44 low income nations and there are plans to extend
this access to 34 lower middle income countries. Earlier this year six of the
world’s leading medical publishers signed a “statement of intent” to provide
free access to scientific information for more than 100 of the poorest countries
in the world (BMJ 2001;323:65).
Against this background, is now the first website dedicated to the
needs of the developing world. It reports and discusses aspects of science and
technology that are relevant to sustainable development and specific to the
needs of developing countries. Each week up to four full length research
articles from each of the journals Science and Nature are posted on the site.
There is also a news section on development related scientific and policy issues,
and in depth dossiers are being created on topics such as gene cloning, climate
change, and malaria.
The site
funded by UK, Swedish, and Canadian development
also advertises job opportunities and international meetings. Links
are available to funding agencies, and other development agencies. Overall the
site gives the feel of being a forum where connections are made, ideas
exchanged, and information shared. Together with the changes in publishing, it
shows how the electronic revolution could help to abolish the information gap.
Alex Vass
If only Van Gogh had been on valproate semisodium . . .
1434 BMJ VOLUME 323 15 DECEMBER 2001
In praise of books
Occupied as we are with electronic
databases, information on the
internet, and full text journals on
the web, do we not sometimes overlook the
value of information in current textbooks?
I have gone through my file of reference
inquiries over the past six months and
looked at those questions where clients
insisted on a search on Medline, other elec-
tronic databases, or the internet. I would
think that more than 60% of the questions
were actually so general and unspecific that
relevant information could have been found
with ease in a current
textbook or other printed
I refer to questions such
as “Where do I find every-
thing [sometimes the word
“something” is used] on:
diabetes in pregnancy? sec-
tioning under the Mental
Health Act? how to write a research paper?
crisis intervention? screening for prostate
cancer? hepatitis C? the principles of
evidence based medicine? preceptorship?
priority setting in the NHS?”
In each case the attempt to get more
information from the reader in order to
develop a specific, focused question (only
those can generally be searched on, for
instance, Medline or the internet) has failed.
Sometimes clients react with remarks sug-
gesting that I am prevaricating and conde-
scendingly preventing access to current
information. Sometimes people say: “My
tutor/lecturer has said that I should do a
search on the web.
I am aware of the dictum that “half of
what we learn in medical
school will be outdated by
the time you start practis-
ing: we just don’t know
which half.” I also know of
studies that indicate that it
takes five or more years for
new research findings to fil-
ter through into medical
textbooks (JAMA 1992;268:240-8).
I believe such statements and research
findings are instances of hard cases leading
to bad laws and I offer the following
xIn everyday practice, it is possible to find
in current textbooks valid answers to
questions such as those above. Textbooks
put the subject in context, investigate
background, describe current practice, and
highlight problems. Typically, articles on
Medline deal with specialised aspects of a
xIt is worrying that during facilitated
searches (a search conducted with the help
of the librarian) clients are unwilling to scan,
say,40 references to pick five that are directly
relevant. Even the minor effort to scan is
considered too time consuming.
xFocusing a database search to retrieve
general overviews is difficult. Scanning a
table of contents or the index of a printed
source is easy.One doesn’t even have to scan
a table of contents or indices: in my
experience you can find the introduction to
the subject on pages 1-18, with pages I-IV or
the dedication note giving background on
the enthusiasm, dedication, and sometimes
human costs involved in producing the
book. It is here that authors mention
instances of spouse and
child neglect, and also,
sometimes, the help of a
xIt appears to me that
results of Medline searches
tend to confirm the preju-
dice that scientific medicine
deals only with body parts
while books tend to give a holistic view of
the disease and patients affected by it.
xI suspect that among reasons for this
decontexualised approach to medical
this reluctance to use books
evidence based medicine’s stance that only
the most current and validated information
should be used. This is true only for focused
questions derived from clinical settings where
valid information may age quickly.
xTaking this point a bit further, I would
suggest that “electronic information” is to
“information in context in books” what “evi-
dence based medicine” is to “narrative medi-
cine.”As the patient’s narrative forms part of
good clinical practice, so should a book or
printed source be part of the information
gathering process for find-
ing the external evidence.
xMedicine, an art based on
science (sorry), thrives on
more than just “valid infor-
mation.” It depends on
“knowing,” which is charac-
terised “by the fact that we
know more than we can
impart” (Lancet 2001;358:397-400). I would
claim “that what cannot be imparted” is more
easily found in a book than a number of arti-
cles found on Medline or a site on the web.
I promise myself to exercise at least once
every week a policy of benign refusal to
launch a full Medline or internet search and
insist on consulting a relevant printed
source first. If the client then uses that source
to reframe and focus a question, so much
the better. My subsequent facilitated search
or search tutorial on Medline will be more
enthusiastically executed, generate more
benefit for the client, and still highlight the
valuable, albeit old fashioned, source of
medical knowledge: the printed book.
Reinhard Wentz Imperial College Library Ser vice,
Chelsea and Westminster Hospital, London
Typically, articles
on Medline deal
with specialised
aspects of a
Books tend to give
a holistic view of
the disease and
patients affected
by it
Clients on diets
So we worry about frightful epidemics,
on television and in the newspapers,
about the Black Death coming back or
variola major rising from the dead,
forgetting, in the midst of our recent
preoccupations, about the deadliest
scourge of all, more lethal than
handguns and automobiles and anthrax
all put together. It is food, food,the stuff
that in the Hindu Kush we drop from
planes in yellow packages but that here
is a pathogen, causing this terrible
epidemic of obesity, of coronary heart
disease, of type 2 diabetes.
And so it came about, some 10 or
15 years ago (according to notes I found
in an old file, and that I had made for a
“Letter from . . . Chicago” that was
never written) that the phone rang while
I was in the middle of a busy outpatient
“It’s about my client for whom you
prescribed an 800 calorie diet.”
“You mean my patient,” I interjected.
“Well, we call them clients,” the voice
said. “I think 800 calories is too little for
my client.
Defensively I suggested that 1000
calories might be sufficient to keep
this 270 pound woman in metabolic
“No,” said the voice, “at 1000 calories
she will still need supplements; 1500
calories would be better.
“Would you please do as I asked
you?” I ventured.
“Oh no,” she said, “you do your
doctoring, and I do the diet counselling.”
By now I could have hit her, had she
not been at a safe distance. Instead I
asked for her name, saying I would speak
to her supervisor, whereupon she
slammed the phone in my ear, and I let
the matter go.
My feelings, moreover, were
compounded by a certain amount of
guilt, because somewhere in the dim past
I was taught that it was the doctor’s job
to counsel patients about their diet. But
things being as they are, I must also add
that I have always felt sorry for dietitians
because, despite their best efforts,
most patients will still eat whatever they
I also find that many dietitians
imagine indeed that we are in the Hindu
Kush, and are more worried about
starvation and deficiencies than about
obesity.But I have stopped arguing with
them. I now tell my overweight patients
to listen politely, but then to eat half of
what the dietitian prescribed.
George Dunea attending physician,
Cook County Hospital, Chicago,USA
1435BMJ VOLUME 323 15 DECEMBER 2001
Full-text available
Contemporary health policy increasingly positions responsibility for the management of health with the individual which reflects newer neo-liberal discourses of health. Such an approach can be seen as problematic in the context of men’s health, with men tending to be seen as largely ‘irresponsible’ towards their own health. This paper addresses this question by drawing on qualitative data on how men conceptualise responsibility for health. Whilst the desire to be responsible for health was borne by most of the men in the study, this was not always reflected in practice. There was also evidence of strategies that men adopted for either divesting themselves of responsibility for health or for legitimising lack of responsibility. In some instances, acting ‘irresponsibly’ was what defined participants as ‘real men’. The implications of these findings for men’s health policy are discussed with specific reference to the recent publication of Ireland’s National Men’s Health Policy.
ResearchGate has not been able to resolve any references for this publication.