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BOOKS • CD ROMS • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS
Irecently read George Bernard Shaw’s
The Doctor’s Dilemma and experienced
an unexpected sense of insult on behalf
of my profession. In this celebrated play (see
also Editor’s choice, BMJ 2 September 2006
(doi:10.1136/bmj.333.7566.0-f)), Shaw seri-
ally indicts various kinds of late 19th century
doctor
—
the hypocrite, the self publicist, and
(most dangerous of all) the blinkered zealot.
While I admired the plot construction, I sus-
pected that Shaw had created such character
extremes for comic effect. However, having
read David Wootton’s Bad Medicine,Iam
now no longer insulted and, on behalf of my
profession, feel somewhat grateful to Shaw
for his restraint. For, as Wootton painstak-
ingly argues in this short but undoubtedly
explosive new book, the history of medicine
has been nothing less than a failure and
doctors have been the culprits.
Although Bad Medicine is short, Wootton
has written “three books in one.” In the first
part he surveys a tradition of therapy that
survived for 2300 years, from Hippocrates
until the early 20th century. In the second,
he describes an important phase stretching
from the mid-16th to the mid-19th century
“in which medical knowledge progressed,
but in which that knowledge had little or no
significance for therapy.” In the final section,
he considers the emergence of medical
knowledge in the mid-19th century that
went on to establish “a positive feedback
loop with medical therapy” so that progress
in knowledge led to progress in therapy and
consequently more investment in research.
This is our current medical era and
Wootton’s important book informs us in
such a way as to infer possibilities regarding
our future progress. These are either good
or bad and our choice of either route
depends on our understanding of medi-
cine’s history.
Wootton explains that Hippocrates (who
possibly never existed) introduced “an
entirely new approach to medicine” that still
permeates current thinking. So, from him
we have the notion that disease has a natural
(as opposed to a supernatural) origin and
that its impact must be carefully observed.
The two fundamental Hippocratic branches
of medicine
—
one involving hands-on
manipulation and the other being con-
cerned with the inner workings of the
body
—
instigated a divergence between arti-
san based surgery and university controlled
medicine. This was consolidated in northern
Europe from the 13th century and still per-
tains with the “mister-doctor” division. It was
perhaps encouraging to note that most
medical innovations arose from unbiased
artisans and away from the centres of excel-
lence (and tradition).
However, despite its important innova-
tions, Hippocratic and (its successor)
Galenic medicine developed a stranglehold
on medical innovation that suffocated
progress for over 2000 years. Their trade-
mark “therapies” of bloodletting, purges,
and emetics were “almost totally ineffectual,
indeed positively deleterious,” except in so
far as they mobilised the placebo effect. Yet
even as late as 1875, the medical historian W
Mitchell Clarke noted that colleagues
looked forward to a time when they might
“employ” their lancets again.
In the second phase of his book,
Wootton stresses the brilliance of a few pio-
neers (Vesalius the anatomist, Leeuwenhoek
the microscopist, and Schwann the micro-
biologist) who experienced frustrating indif-
ference from a medical world that was
stagnantly comfortable. Instead, mainstream
medical science focused on comparative
physiology, often developed by increasingly
cruel and pointless vivisection. In particular,
Wootton argues, the possible benefits of
simple microscopy were shamefully ignored,
leading to an unnecessary 150 year delay in
the development of germ theory (and the
loss of countless lives).
It was only in 1865, in Glasgow, when
Joseph Lister (Wootton’s pre-eminent hero
in this tale) discovered what he called “the
germ theory of putrefaction” and the
striking benefits of antiseptic surgery, that
“modern medical science began.” Wootton’s
consideration of this era brilliantly revises
previous versions of medical history that
have been underpinned by a baton passing
concept of medical progress, routinely plac-
ing Pasteur before Lister. Wootton sees it the
other way round and argues that it was only
because of Lister’s multidisciplinary interests
that he was able to connect disparate discov-
eries (especially Schwann’s crucial experi-
ment of 1837 demonstrating that heat could
prevent putrefaction).
Wootton also covers other key areas
—
John Snow’s brilliant epidemiological work
in Broad Street, the somewhat sluggish
development of penicillin, and Doll and
Bradford Hill’s discovery of the inter-
relationship of smoking and lung cancer.
This latter endeavour gets Wootton’s full
commendation. For once he has a good
word to say, not just about exceptional doc-
tors, but about the profession as a whole and
so ends his fascinating journey with a
message of hope that the institution of
medicine, though ancient, can facilitate
progress.
Having been thoroughly impressed by
this book’s arguments, I began to wonder
—
what are we, as doctors, doing to ensure that
our profession remains the vehicle of
progress and not its obstacle? One concern
must be that medical history is not routinely
taught in medical schools. It is a well under-
stood maxim, that to discover where you
want to go, you need to know where you are.
To truly know where you are, I would argue,
you need to understand how you got there.
Wootton’s book should be standard issue for
every first year medic.
Iain McClure consultant child and adolescent
psychiatrist, Vale of Leven Hospital, Alexandria
imcclure@nhs.net
Bad Medicine: Doctors
Doing Harm Since
Hippocrates
David Wootton
Oxford University Press,
£16.99, pp 320
ISBN-10: 0 19 280355 7
ISBN-13: 978 0 19 280355 9
Rating: ★★★★
Items reviewed are rated on a 4 star scale
(4=excellent)
Did the ancients suffocate medical progress
for over 2000 years?
DETAIL FROM MS LAT6823F.IV. HIPPOCRATESAND GALEN. BIB NAT/CHARMET/BAL
606 BMJ VOLUME 333 16 SEPTEMBER 2006 bmj.com
This book
—
painstakingly researched
and compiled over four years by an
assistant professor in information
management in Victoria, New Zealand
—
is a
laudable attempt to capture thoroughly the
bewildering array of global health informa-
tion available on the internet and to
elucidate how the internet has changed the
way in which healthcare consumers and
providers communicate. Inevitably, given
the time it took to write, some of the
information is not up to date
—
access to
bmj.com is not universally free any more, for
example.
The author argues that a paradigm shift
has taken place as the internet has
fundamentally changed the relationship
between providers and consumers of health
care. It has done this by providing access to
clinical information for both groups, thus
potentially enabling consumers to question
as well as challenge providers, participate in
decisions, make informed choices, and influ-
ence outcomes. Cullen begins by looking at
where and how health information is found
on the web, and who provides it (educational
establishments, government initiatives, pri-
vate companies, etc). She also examines bar-
riers to using the internet (such as access
problems, a lack of familiarity with search
techniques, or a lack of culturally relevant
content) and the factors that motivate infor-
mation providers (which can range from
making profits to networking to facilitating
academic excellence). There has been
substantial investment, and online health-
care information has some unique charac-
teristics that affect its production and use.
These include issues of regulation and qual-
ity (control), ease of dissemination, possible
access from anywhere and at any time, as
well as the searchable and accessible format
of this information.
Examining the structure of knowledge
in the health sciences (including an interest-
ing discussion on evidence based medicine),
the author highlights the differences in the
format and content of print and web media.
Web information may be as costly to
produce as printed matter, but its dissemina-
tion incurs no cost to the provider. However,
web content has necessitated new marketing
ventures to increase advertising revenue and
has required a rethink of subscription and
reprint rates as a result of losing print
subscriptions. Web content is not limited to
the printed word; it can include interactive
features, soundbites, videos, podcasts, online
surveys, and additional data sets, and thus
altogether helps the web user to become a
participant, rather than just a reader.
Cullen concludes that people from
many different disciplines
—
such as librar-
ians, information managers, web developers,
health informatics specialists, healthcare
practitioners
—
will have to pull together and
become involved in making this new
technology effective and useful in improving
health care through collaboration, training,
and evaluation.
The book’s main shortcoming, however,
is that it is anything but a rollicking good
read
—
it takes discipline and application to
plough through, and its academic style, pep-
pered with lots of citations and quotes,
makes it hard to recall what you have just
read, even when you have only just reached
the end of a chapter. That said, it is
incredibly informative, and its eight clearly
labelled chapters with tables and figures,
plus 22 pages of bibliography, and a
carefully compiled index make it easy to for
readers to locate whichever bit of informa-
tion they are after.
Birte Twisselmann assistant editor (web),BMJ
btwisselmann@bmj.com
Losing It
ITV1, 13 September at 9 pm
Rating: ★★★★
Actor Martin Clunes is Phil Mac-
Naughtan, an advertising executive
who discovers he has testicular can-
cer, and we’re supposed to see the funny
side? Well, yes. The essence of Britishness is
the stiff upper lip
—
Churchill, Dunkirk, and
the rest. There is deep humour in adversity,
even with cancer. Humour sidesteps senti-
mentality to address difficult issues, espe-
cially with emotionally dim men types.
After discovering a lump Clunes visits
his general practitioner, who spends most of
the time gazing at his computer screen
—
no
doubt looking up his QOF points (quality
and outcomes framework points) and
wondering whether it would be inappropri-
ate to check Clunes’s blood pressure and
cholesterol. Clunes’s urologist is as func-
tional as a kitchen chair and just as wooden.
The oncologist has the charisma of said
kitchen chair and has clearly decided that if
he cannot carry a scythe at work he will at
least dress Grim Reaper style in grey polyes-
ter. For a moment I was convinced that this
was a fly on the wall production.
Clunes, in Monty Pythonesque madness,
decides to go straight back to work. He has
important business, as he is leading a bid to
win a large contract to sell power tools, and
so he has radiotherapy first thing every
morning before work. The utter insensitivity
of his boss and the vacuous consumerist
nature of advertising is the backdrop to
Clunes’s life threatening illness.
His family struggles on. Clunes, con-
sumed by his own illness and his work, is
blind to the impact of his cancer on the rest of
his family.His wife cries quietly, his young son
becomes goggled eyed through video
therapy, and his mute teenage daughter hides
away at friends’ houses. His widowed stepfa-
ther, an emotional Neanderthal, merely lurks
ineffectually in the corner of rooms.
In the end, it is the teenage daughter
who gives Clunes the doubled barrelled
emotional blast straight to the chest
—
the
cancer is affecting the whole family, not just
him. Tears all round
—
they nearly even got
me. Clunes wins the advertising contact but
gets sacked none the less. But that’s no mat-
ter, as he now appreciates what is
important
—
his wife and children.
Will Losing It raise the profile of testicu-
lar cancer and screening? I doubt it, and
anyway men’s attitude to health care has
spared us the intrusive screening that afflicts
the lives of women. But Losing It is funny and
moving
—
or, as my daughter might say, it’s
the bollocks.
Des Spence general practitioner, Glasgow
destwo@yahoo.co.uk
Health Information on the
Internet: A Study of
Providers, Quality, and
Users
Rowena Cullen
Praeger £16.99/$29.95,
pp 272
ISBN 0 86569 322 6
www.praeger.com
Rating: ★★★>
The funny side of testicular cancer?
CLERKENWELL FILMS/ITV
reviews
607BMJ VOLUME 333 16 SEPTEMBER 2006 bmj.com
PERSONAL VIEWS
One NHS reorganisation too many: time to
move on
Most British doctors are not affected
by NHS reorganisations. They
manage to concentrate on caring
for their patients, despite the surrounding
upheaval. Many GPs and consultants don’t
know what the current NHS structure is or
what a primary care trust or strategic health
authority does, and to them it probably
doesn’t matter. It is different for public
health doctors: they are invariably affected
and are often required to move into a new
organisation. Many years ago a wise medical
director told me that as a “punishment for
joining NHS management” public health
doctors have to regularly reapply for their
jobs.
I was a director of public health in three
health authorities, none of which now exist.
I always believed that the value of public
health skills and knowledge,
once recognised, would
guarantee that boards and
colleagues embrace and
implement good public
health practice. Doing so
became harder and harder
over the past 10 years.
In 2002 we imple-
mented the proposals in the NHS’s Shifting
the Balance of Power policy in response to
concerns that patients, the public, and front-
line clinicians had too little influence over
NHS decision making. Health authorities
were abolished, along with some very sound
commissioning arrangements that engaged
clinicians and the public in planning
services. Within nine months we had created
five times the number of organisations,
including new primary care trusts, strategic
health authorities, and public health teams
in the Government Offices of the Regions,
and we moved all our communicable disease
control teams into the newly formed Health
Protection Agency. These new organisations
appointed boards, moved into new
premises, and established their new roles.
Primary care trusts got on with the busi-
ness of engaging new local partners,
assessing local health needs, improving
primary care, and influencing the local
determinants of health. However,they didn’t
really get to grips with commissioning.
The public health teams at the Govern-
ment Offices of the Regions made progress
in influencing the regional assemblies to
address health issues. The Health Protection
Agency got its local and regional teams to
re-engage with trusts. Strategic health
authorities, never intended to have any pub-
lic health presence, appointed directors of
public health who, with an ambiguous role
in a complex public health system, suc-
ceeded in getting public health on the
agenda and also contributed to improving
health through the performance manage-
ment of national targets.
From 2002 to 2004 there was an
unprecedented increase in NHS funding.
More patients got treated sooner, hospitals
were cleaner, many new staff were recruited,
and targets were achieved. Lack of waiting
times lowered thresholds for care. New
treatments were introduced, and national
service frameworks and models of service
delivery, along with new professional roles,
led to a more patient centred service.
Despite the increase in funding, the
NHS seemed unable to control costs, and a
large financial deficit was predicted for the
end of 2005-6. Primary care trusts’ failure to
commission effectively was used as a reason
to reorganise the NHS again, and in 2005
we were requested to “create a patient led
NHS.” We set about to
design a structure that
would halve management
costs, and after a rather
token consultation process
we ended up with about a
fifth of the number of NHS
organisations. Four in five
directors of public health in
primary care trusts would lose their jobs,
and 37 directors at the “intermediate tier”
would compete for nine posts.
I became increasingly disillusioned with
public health leaders, as our specialty became
increasingly distanced from both medicine
and management. The rushed reorganisation
meant that none of the good things achieved
in the previous four years could be consoli-
dated. I was concerned that my profession
and my specialty would not embrace the
policy of choice for patients and that the
potential for the independent and voluntary
sectors to accelerate change and provide
services free at the point of use to NHS
patients would be lost. Contestability
confronted professional protectionism. As
an advocate of public health and reduc-
ing inequalities, I had seen in three years
huge improvements in access for people
from deprived communities to cataract
and joint replacement surgery. This resulted
from the NHS’s effort to invest in and
increase elective capacity, including the
procurement of overseas clinical services
and independent sector treatment centres.
However, everyone in public health and most
consultants considered the focus on reducing
waiting times and on developing plurality of
provision to be increasing inequality in
health, taking resources from the NHS, and
preventing investment in public health.
In March 2006, after 27 years in the
NHS, I decided that it was a good time to
look for a new job, possibly outside the NHS.
I was determined to make the absolute com-
mitment to my ideological beliefs by
applying for a job with a large independent
sector healthcare provider. On 10 May I
accepted a job as medical director, and on
20 May I resigned from the NHS.
I know that my public health skills, clini-
cal knowledge, and NHS experience can still
be used to design and deliver high quality
care to NHS patients. I face risks and many
challenges, and I will require boundless
energy and enthusiasm to build new
networks. I think it is an exciting and brave
career move. Others in the sector say that
working in it is liberating, if hard, and that
expectations are high. The rewards will be
great if it works out: new colleagues, new
ideas, and new perspectives. I am sure it will
prove to have been one of the wisest
decisions I ever made.
Sarah Wilson medical director, Netcare UK,
London
sarah.wilson@netcareuk.co.uk
Contestability
confronted
professional
protectionism
Has increased patient choice in areas such as cataract surgery ruffled some public health feathers?
ANTONIA REEVE/SPL
reviews
608 BMJ VOLUME 333 16 SEPTEMBER 2006 bmj.com
Wombless in Maharashtra
Hysterectomy is the commonest sur-
gical procedure performed on
women today in the United States.
In almost 60% of these women (at
least 3.5 million women in the past
20 years, and possibly as many as double
that figure, according to Carla Dionne,
author of Sex,Lies and the Truth about Uterine
Fibroids (2001)) the procedure has been
done to treat relatively benign diseases such
as uterine fibroids. Only about 3% of
fibroids turn cancerous. However, they can
cause a range of symptoms, and in about
25% of women these can lead to serious,
full blown illness. Although a range of
treatment options
—
conventional and
complementary
—
are available for fibroids,
these are never brought to the attention
of most women, and certainly not by
doctors.
Contrast this with the fact that in men
with an enlarged prostate gland almost 10%
of glands do contain can-
cerous tissue. Yet surgery is
not done or even suggested
to men as a preventive
measure (most men would
never allow such an opera-
tion to be done). Further-
more, each year nearly
360 000 women in the US
have their ovaries removed
to prevent ovarian cancer,
even though the lifetime
risk for cancer is only 1.8%.
A study in Obstetrics and
Gynecology (2000;95:199-
205) showed that almost
70% of hysterectomies were recommended
inappropriately and that about 76% of
these did not meet the guidelines on hyster-
ectomy specified by the American College
of Obstetricians and Gynecologists. Educa-
tion and social class are important factors
in whether a woman is forced into
hysterectomy, as discussed in Achieving
Best Practices in the Use of Hysterectomy,a
2001 report of the Ontario Women’s
Health Council (available at www.
womenshealthcouncil.on.ca).This report
shows that more hysterectomies are done in
poor, rural areas where the overall level of
education is low than in other areas. A doc-
tor working in rural Maharashtra, India,
reported in the Indian Express a few years
ago that certain areas there had now
become “womb-free zones.” In the US the
rate of hysterectomies done is highest in the
southern states.
Gynaecologists, in their desire to per-
form hysterectomies, have traditionally
downplayed the risks associated with the
operation and its many lasting conse-
quences, which include hot flushes, depres-
sion, anxiety, osteoporosis, generalised
fatigue, stress and urge incontinence,
masculinisation, insomnia, bowel dysfunc-
tion, and mood swings.
The removal of the uterus and ovaries
can lead to loss of sexual desire, diminished
orgasmic response, and pain with inter-
course. Sexual functioning is discussed with
men before they undergo surgery for
prostate cancer but among women is not
considered important enough an issue to
be talked about. Many women find it
difficult to raise this issue with their doctors.
Doctors often assume that after reproduc-
tion and as women age they automatically
lose interest in sex, and if they don’t they are
made to feel terrible. Removal of ovaries is
also associated with loss of libido. In
Tiruvananthapuram, Kerala, India, a coun-
selling centre set up by a local college has
found that women are raising a range of
family related problems associated with
their hysterectomies.
The medical route that most gynaecolo-
gists seem to take is to
remove the uterus and pos-
sibly the ovaries and then
manage any surgical meno-
pause with hormone
replacement therapy and
calcium supplements. (The
side effects of hormone
replacement therapy are
ignored, for the most part.)
They make further referrals
to their friends in psychia-
try to “manage” any aches,
pains, and depression. So
there’s another round of
drugs. The crucial question
here is: who benefits from creating a condi-
tion in the first place that needs to be man-
aged? I leave my highly educated readers to
answer that for themselves.
Doctors in India have managed to get
away with a lot. It is important that women
as consumers become more vigilant. It is
only women’s collective voice that will lead
to more research into why more and more
young women are getting fibroids these
days. And it is only through our vigilance
that the results of such studies will be
examined and criticised. Carla Dionne’s
book cites Stanley West, a New York
physician and surgeon, who believes that
nine out of 10 hysterectomies are absolutely
unnecessary. Dr West points out that it was
when women refused to have disfiguring
operations performed on them that doctors
suddenly found out that if they wished to
remain in practice they needed to listen
to their patients. He is convinced that
women’s views will prevail and that they will
force the medical profession to listen to
them.
Asha Gopinathan neuroscientist, GenSci-e-Tech,
India
dend_15@yahoo.com
A doctor in
Maharashtra,
India, reported
that certain areas
there have now
become
“womb-free
zones”
SOUNDINGS
Totally transforming
Auchendreich
Here in Auchendreich we deplore the
ravages of market driven healthcare
reform even in England, but are not
averse to learning from the remarkable
skills and insights engendered by the
rigours of commerce. Thus we have the
best of both worlds: revitalising our daily
work with the latest thinking while still
retaining the uniquely dynamic ethos of
the traditional Scottish public sector.
So, at the August summit of the
pan-Auchendreich Clinical Leadership
Forum, a powerful team from Total
Logistics Corporation of Waco, Texas,
brought us the most dazzling PowerPoint
presentation ever seen in the Greater
Auchendreich Health Board area. It
covered every detail of an impressive
plan: from the selection of
transformational leaders to the
culmination of the entire task
—
the
embedding of a healthcare culture of
permanent excellence.
In only three years the £30m (€23m;
$16m) consultancy would cascade out
TLC’s 4As
—
awareness, analysis, action,
and achievement
—
and thus totally
transform all our organisational and
clinical settings: from the troubled board
headquarters now at Inverdreich, to our
most remote psychogeriatric day hospital
in Upper Dreichmuir.
A public health doctor asked if this
methodology had brought equity and
efficiency to health care in the United
States. The chairman disallowed the
question to save time for discussion of
local issues. A tanned and crew-cut
urologist, an army reservist, asked if the
company had done any healthcare work
outside the United States. The TLC lead
speaker cited ongoing billion dollar
projects in a prominent Middle Eastern
country which, for reasons of
commercial confidentiality, he could not
identify. The urologist stated that he had
served in Iraq, and so thought TLC
might be far too busy there to help in
Auchendreich for the foreseeable future.
Eventually a psychotherapist tried to
restore civility by complimenting the
main speaker on his presentation. This
brought the urologist to his feet again.
He had heard that US commanders in
Iraq had banned PowerPoint from all
briefings, because its use in the Pentagon
had convinced politicians that the war
was already won. The chairman thanked
him for his contributions and closed the
meeting at 9 27 pm: sadly, with no
consensus reached.
Colin Douglas doctor and novelist, Edinburgh
reviews
609BMJ VOLUME 333 16 SEPTEMBER 2006 bmj.com
