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Richard Smith

Richard Smith: Misunderstanding conflict of interest

18 Jul, 14 | by BMJ

richard_smith2In Britain we have had a row over whether a judge, Elizabeth Butler Sloss, should chair an inquiry into child abuse. Everybody agrees that she has the necessary skills and unquestionable integrity, but she has a conflict of interest: her long dead brother was in the government and may have been involved in covering up child abuse. The case has exposed deep misunderstanding on the nature of conflict of interest.

The country is in the grip of a moral panic over historical cases of child sexual abuse, with well known entertainers going to prison for abuses they committed 50 years ago. Every day we hear rumours of which “national treasure” (a British cliché) will be next. So the government had to react quickly to the possibility that politicians themselves had covered up abuses. In the rush to appoint a chair to the inquiry, the government probably overlooked Butler Sloss’s conflict of interest, and so she was appointed. more…

Richard Smith: Three myths blocking progress against NCD

16 Jul, 14 | by BMJ

richard_smith2The church at the House of St Barnabas was standing room only to hear Professor Robert Lustig, a paediatric endocrinologist from San Francisco, castigate our current attempts to counter the global pandemic of NCD. (I judge that we’ve reached the stage where NCD, like AIDS, no longer needs to be spelt out.)

Lustig, who has a YouTube video that has been viewed 4.9 million times and who has been interviewed by The BMJ, is clearly somebody who loves his high profile and his capacity to bewitch an audience. Although I’d heard a professor I admire dismiss him as “wholly wrong,” he didn’t encounter much dissent at the meeting organised by C3 Collaborating for Health. He spoke without notes and a PowerPoint presentation, the modern way.

Lustig built his talk around the three myths that he thinks are blocking progress on reducing the burden of NCD. For 30 years, he said, we’ve been concentrating on reducing total calories and fat but made little or no progress. Thinking has been based on bad science. more…

Richard Smith: The best doctors and their errors

26 Jun, 14 | by BMJ

richard_smith2I’m listening to Sandy Ruddles (not her real name), an ordinary general physician who does some rheumatology, present a case, and I’m feeling some regret at having given up the sacred calling of being a clinician. Oddly, the case Sandy is presenting was disastrous, a catalogue of errors.

What impressed me was not Sandy’s knowledge and technical skills, which are no doubt considerable, but her humanity. When it finally became apparent that her patient was going to die, Sandy went and told the patient and her family, and faced the anger and bitterness they felt. She described to them how the doctors, herself, but also the pathologists, dermatologists, and radiologists, had missed the diagnosis a year previously despite it being obvious in retrospect. more…

Richard Smith: A book of poems for medical graduates

23 Jun, 14 | by BMJ

richard_smith2What should you give doctors when they graduate? An expensive stethoscope, a Ferrari, a lifetime subscription to The BMJ, a ticket to India, or a pet canary? The answer of “the medical community” in Scotland is a book of poems called Tools of the Trade. A copy will be given to every doctor graduating in Scotland this year, and I can’t think of anything more precious to give them.

The poems have been selected by Lesley Morrison, a GP; John Gillies, chair of the Royal College of General Practitioners in Scotland (and a friend of mine); Ali Newell, associate chaplain in the Edinburgh University Chaplaincy; and Lilias Fraser of the Scottish Poetry Library. The book is a tribute to Morrison’s partner in a practice in Hawick, Pat Manson, who died in 2012 and was noted for his compassion, teaching, and love of poetry.

There is an understandable bias in the collection to doctor poets and Scottish poets, but I didn’t find any dud poems, and several of them bewitched me as the best poems should. Some are in Gaelic, with translations, and some in Scots. The poems deal with birth, pain, sickness, suffering, death, and the privilege and challenge of being a doctor. Some are funny, as doctoring often is. more…

Richard Smith: Where is the value in medical care?

5 Jun, 14 | by BMJ

richard_smith2We have an old dog we love, and my wife and I have been debating whether to take him to the vet. Will it be worth it, asks my wife. The dog is coming up to 13 (91 in “human years”). He has a large lipoma. Some of his teeth are bad. He may be a little deaf, and he doesn’t see well. He may have arthritis in his back legs, and we wonder if he’s demented.
We’ve shortened his walks. He sleeps most of the day and still enjoys his dinner.

“What will the vet do if we take him,” wonders my wife. “If we get one of those young useless ones they’ll want to X ray him, do blood tests, and anaesthetise him to look at his teeth and possibly remove his lipoma. They’ll find other things, and before we know it, we’ll have spent £2000 and have a proposal for £5000 more. It isn’t worth it. Maybe we could take him to the old vet and simply ask if there’s anything that might make him more comfortable, but he doesn’t seem that uncomfortable. Let’s not bother.” Doesn’t the same go for human beings? more…

Richard Smith: Rebranding and telling stories about NCD

3 Jun, 14 | by BMJ

richard_smith2I was delighted to be asked to organise this series of events on non-communicable diseases, but I had a problem—I had no idea what NCDs are or were. So Kate Hoyland from UCL’s Grand Challenge of Global Health introduced an evening entitled “The NCD Makeover Show.”

We who live in the NCD ghetto don’t know how to get our message across. The person in the street has never heard of NCD and so will not demand global action or change their own lives. We can’t even agree on our name. We don’t like being defined by what we are not so we don’t like “non-communicable disease”; and we’ve abandoned the term chronic disease. So we’ve homed in on the acronym of NCD—but sometimes it’s NCDs and sometimes NCD.

So how can we do better? “Recognise,” said Fred Hersch from NCDFree, “that the solutions lie outside traditional thinking.” Thus we heard about branding and storytelling. more…

Richard Smith: The polypill reaches the plateau of productivity

15 May, 14 | by BMJ

Richard Smith“I’m outraged,” said Robert Beaglehole, former director at WHO responsible for non communicable disease, at the end of the second polypill summit in Melbourne recently. He’s outraged because the world is failing to respond adequately to the “global public health crisis” of non communicable disease (NCD) that is destroying lives in low and middle income countries as people die from preventable diseases. In particular, said Salim Yusuf, incoming president of the World Heart Federation, only about 3% of people in the world with established cardiovascular disease are getting the four evidence based treatments of aspirin, beta-blockers, an ACE inhibitor, and a statin. We have it in our power to change that dramatically, particularly through the use of the polypill, and yet regulatory, commercial, and cultural barriers are blocking progress. more…

Richard Smith: Talking eugenics in Germany

6 May, 14 | by BMJ

Richard SmithThe other day I heard a wildly optimistic account of how our understanding of genetics would allow us to eradicate many diseases, potentially create better people, and reduce health costs. I’m sceptical about all of these claims, but I was taken back to a strange meeting I attended in Germany perhaps 20 years ago.

David Weatherall, Britain’s “top doc,” invited me to attend a meeting in a schloss in Germany that had belonged to one of Queen Victoria’s many nephews. I couldn’t think at the time why he invited me, but older as I am now I guess that he had to come up with somebody at short notice—and I’d just crossed his horizon at a meeting on genetics. more…

Richard Smith: Why doesn’t the obvious happen?

1 May, 14 | by BMJ

Richard SmithIt’s obvious to me that all scientific research should be available free to everybody everywhere, the polypill to prevent heart attacks and strokes should be offered to all those over 55, and patients not health institutions should control their records. Why don’t these obvious things happen?

The core arguments for making all research free are that most of it is funded with public money and that ideas unlike physical objects can be shared infinitely, increasing their value and the chance they can be exploited. Something like 20% of scientific studies are now available free to everybody, but most are not. Vested interest is the main barrier: the profits of many organisations, many of them scientific societies ironically, and the jobs of many individuals depend on the present limited access model. As Maynard Keynes observed, it’s impossible to convince somebody of the value of an innovation if his or her job depends on not being convinced. more…

Richard Smith: Do sexual abuse of children and research misconduct have something in common?

29 Apr, 14 | by BMJ

Richard SmithEvery so often I hear stories of people prominent in medical research who are suspected of research misconduct—or research fraud, as it was once more bluntly called. Could the stories possibly be true?

Some prominent people have been found guilty of misconduct, and we know that research misconduct is not rare. A systematic review found that about 2% of researchers reported that they themselves had been guilty of serious misconduct and that 14% of their colleagues had been. (The King James Bible tells us “Thou hypocrite, first cast out the beam out of thine own eye; and then shalt thou see clearly to cast out the mote out of thy brother’s eye,” but we are better at seeing motes in others’ eyes than beams in our own.) And people who do multicentre trials expect that about 1% of the centres may falsify data. Retraction Watch now does a marvellous job of highlighting dozens of studies being retracted every year because of misconduct, but all the data suggest that most misconduct goes unidentified,  unreported, and uncorrected. more…

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