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Richard Smith

Richard Smith: How to fill the void of evidence for everyday practice?

11 Aug, 15 | by BMJ

richard_smith_2014Some even most (depending on how you measure it) of what doctors do lacks strong evidence. Even when evidence exists it often doesn’t seem to be relevant to doctors—because their patients or their circumstances are so different from those in the trials that produce the evidence. This is especially true in low and middle income countries as most evidence is produced in high income countries. Understandably doctors grew wary of evidence from trials and make decisions on other grounds, particularly their experience. The result is that patients may suffer from not receiving effective treatment or receiving treatments that do more harm than good. Could this sad state of affairs be improved? A group of clinicians, researchers, evidence buffs, policy makers, and odds and sods (me) met in Bellagio in Italy last week to think about how. Most were from Africa. more…

Richard Smith: Science and journalism threatened in the high court

30 Jul, 15 | by BMJ Group

richard_smith_2014I wrote this piece some six weeks ago after giving evidence in a libel case reported by The BMJ and published on 30 July 2015 . I’ve had to wait until the case was over to post the blog.

I’ve just finished giving evidence for a day and a half in the high court in Toronto. I enjoyed the experience, despite being cross examined for five hours. Fulfilling his duty, the barrister tried to discredit me and my evidence. I don’t think he succeeded, but it’s for the jury not me to decide. It’s a 15 year story that led to me being in court, and I want to share that story, describe my experience in court, and reflect on important implications for science and medicine. more…

Richard Smith: Making patient data available—the risks are easy to understand, the benefits opaque

21 Jul, 15 | by BMJ

richard_smith_2014“We seem to spend all our time talking about the downside of making patient data available and little about the upside,” said a frustrated researcher at last week’s Sowerby eHealth Symposium organised by Imperial College’s Institute of Global Health Innovation. The problem seems to be that the downside—somebody’s health records being made public—is horrible, concrete, and easy to understand, whereas the upside remains vague, aspirational, and largely opaque to the public. more…

Richard Smith: Do dreams have meaning? The great divide

6 Jul, 15 | by BMJ

richard_smith_2014The other night in a dream I saw my father, who died 11 years ago. He was very clear, recently shaved, with his hair combed and in full colour. He was perhaps 60, although he was 81 when he died. Smiling, he hugged the person beside me (I don’t know who that was), and then he hugged me. I enjoyed the hug. Did this mean anything? Do our dreams mean anything?

I’m fascinated that we don’t know the meaning of something we all experience. I often ask people what they make of dreams. The morning after the dream of my father, I had breakfast in Dhaka opposite an Argentinian scientist. I asked her if she believed that dreams had meaning. more…

Richard Smith: Is informed consent impossible at the end of life?

22 Jun, 15 | by BMJ

richard_smith_2014Informed consent is impossible at the end of life, said a British palliative care physician last week at a conference on Heybeliada, one of the Prince’s Islands in the Sea of Marmara, close to Istanbul. Could he be right?

Before I reflect on the question, I want to say a little about what was an extraordinary conference. Although the conference was in Turkey, most of those attending were Greek. The conference was held in what was once an Orthodox Greek monastery and still is a holy place for Greeks. The conference was on dying of cancer. Most of the speakers and audience were oncologists, but we heard from priests, theologians, artists, musicians, and philosophers. The conference rightly took a broad view of death and dying. We met in a dark wood panelled room with pictures of priests from floor to ceiling and an altar covered in icons in a corner behind the translators’ box. Priests in black robes with long white beards sat in the front row. Bringing together the ancient and the modern, the whole conference was live streamed on the web. more…

Richard Smith: “Diagnose, treat, and cure” is largely dead

15 Jun, 15 | by BMJ

richard_smith_2014I don’t suppose that the people who taught me at medical school thought that they were promoting particular mental models. They were trying (and sadly failing) to make me the best doctor they could. But just like the man who didn’t know he’d been speaking prose all his life, they were promoting mental models. One was always wrong and one is no longer right.

One mental model was that doctors were scientists who used the natural sciences to solve people’s health problems. It still prevails and is still wrong. Some doctors are scientists, but most, as all doctors know, are not. A few months’ exposure to molecular biology and physiology does not make you a scientist. Scientists pose falsifiable hypotheses, design interpretable experiments, gather data, and mostly find that their hypothesis was wrong. That’s not how doctors work, and as a knowledgeable patient I wouldn’t want them to. Doctors work more like dressmakers or carpenters: they learn through apprenticeship and experience and work mostly by using familiar responses to familiar problems. more…

Richard Smith: Time for GPs to be leaders not victims

9 Jun, 15 | by BMJ

richard_smith_2014General practitioners are overworked, underappreciated, and perhaps underpaid. Politicians are unsympathetic to their plight and expecting more of them. Hospital doctors dump work on them. Nurses are after their jobs. Patients are demanding and ungrateful. Bureaucrats and regulators are making their professional lives a misery. General practitioners have replaced farmers as the profession that complains the most.

I have no sympathy for them. I want them to stop being victims and become leaders, people who solve problems rather than complain about them and expect others to solve them. I’ve preached this message to meetings of GPs several times in the past, which has not made me popular, but the current orgy of moaning has urged me to put finger to iPad. more…

Richard Smith: Time for a drive to register all global births and deaths

12 May, 15 | by BMJ

richard_smith_2014If your birth is not registered then you don’t exist, and yet a third of global births are not registered. If your death is not registered then your wife (or husband) may have poisoned you and not been caught, but two thirds of global deaths are not registered. Registration of births and deaths also allows the generation of health statistics and matters for education, human rights, justice, equality, and security. Yet civil registration and vital statistics (CRVS in the jargon) is poor in most low and middle income countries and sometimes weak in high income countries, a meeting organised by the Lancet was told this week. The Lancet also published a collection of articles on the subject, a follow up to its 2007 collectionmore…

Richard Smith: Keeping the NHS alive

6 May, 15 | by BMJ

richard_smith_2014The NHS has to change radically if it is to survive. All those who study the NHS closely know that, but I’m not sure that all those who work in the NHS know it. And the necessity for radical change—as opposed to more money—features hardly at all in our depressingly shallow election. But how do you change radically such a monolith, something so loved that every criticism can feel hurtful, and a service soaked in ideology? The current answer is “from the bottom not the top.” more…

Richard Smith: Australians fire an editor of the MJA for the fourth time

5 May, 15 | by BMJ

richard_smith_2014The Australian Medical Publishing Company (AMPCo), a creature of the Australian Medical Association, has just fired another editor of the Medical Journal Australia; that’s at least four (and probably more) in my professional lifetime. Over the same period the Canadian Medical Association has got rid of two, and the American Medical Association one. The British Medical Association has never fired one, although it’s come close.

Stephen Leeder, a friend of mine, was fired because he disagreed with AMPCo outsourcing production of the journal to Elsevier, the world’s largest scientific publisher and owners of the Lancet. Leeder is a former dean of Sydney University Medical School and one of Australia’s best known clinician scientists. Deputy editor Tania Janusic is also reported to have resigned along with several members, even most, of the editorial board. more…

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