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Richard Smith

Richard Smith: Is global health too medicalised?

16 Sep, 14 | by BMJ

richard_smith_2014When I teach young doctors in Amsterdam about responding to NCD (non-communicable disease) in low and middle income countries, I ask them how they would allocate 100 units of resource. I give them four buckets.

One bucket is for treating people with established disease: patients with heart attacks, strokes, cancer, and chronic obstructive pulmonary disease. The second bucket is for treating metabolic risk factors, such as hypertension, hyperlipidemia, and raised blood glucose. The third bucket is for acting on the four risk factors—tobacco use, poor diet, physical inactivity, and the harmful use of alcohol—recognising that many of the interventions will be political, actions like raising the price of tobacco. The fourth bucket is for working on social determinants, such as poverty, housing, globalisation, and urbanisation. I ask the doctors not only how they will distribute their resources, but what they will do with the resources. more…

Richard Smith: Simon Stevens, chief executive of NHS England, live

12 Sep, 14 | by BMJ

richard_smith_2014When Simon Stevens, chief executive of NHS England, was buying his Sunday papers a few weeks ago he encountered an elderly woman complaining that her newspaper didn’t contain the television section. It did, as the newsagent pointed out to her before asking her, “Would you like me to walk you home?” Stevens was struck that this was a “dementia friendly community” in action. He followed the story by emphasising that the traditional “factory model of health and social care” will not solve society’s problems, including the rise in dementia. Without a redesign of health and social care services, the NHS will not be sustainable. “We don’t exclusively own the problem or the solution,” he said. more…

Richard Smith: “Psoriasis is my health”

5 Sep, 14 | by BMJ

richard_smith_2014To most doctors psoriasis is a disease to be fought, contained, and even cured, but is this far too narrow a view? John Updike, one of the greatest writers in English of the past century, had psoriasis for almost all his life, and he writes in Self-Consciousness: “Psoriasis is my health. Its suppression constitutes a poisoning of the system, of my personal ecology,” and “psoriasis is normal, and its suppression abnormal.” How can doctors who study disease and a patient who sees deep inside himself have such different views? The patient comes first, and so it is the doctors who must learn. more…

Richard Smith: Why scientists should be held to a higher standard of honesty than the average person

2 Sep, 14 | by BMJ

richard_smith_2014Although it may seem harsh, I believe that scientists should be held to a higher standard of honesty than the average person. The consequence is that they will be punished more severely for dishonesty—for example, by being banned from research for life.

The main reason for this is that science depends wholly on trust. If, for example, The BMJ receives a paper describing a trial in 200 patients, the editors don’t ask to see pictures, signatures, records, and consent forms from the 200 patients. They trust that there were 200 patients in the study, and that the researchers did what they said they did and reported the outcomes honestly. Ideally, the researchers will also recognise the limitations of their studies, although often they don’t, but at least if everything is reported honestly then the editors and readers can see the limitations for themselves. more…

Richard Smith: I hate going to the doctor

4 Aug, 14 | by BMJ

richard_smith_2014I hate going to the doctor. Don’t you? My statement is unsurprising as I’m a man and a doctor (of sorts), two groups who are known to dislike going to the doctor.

Like most Londoners, I don’t have a doctor. I belong to a practice, but take pot luck on whom I see. Last time it was a locum who was mainly interested in global health; he did some general practice to provide some income. Neither he nor I were much interested in the consultation.

So far I’ve averaged a consultation rate of about once every five years. I wouldn’t dream of going to the doctor with a cough, a cold, a fever, or most aches and pains. Something has to persist for a while before I contemplate going, and even then I usually don’t—because I don’t expect much value from the consultation. The doctor usually says: “It might be this, or it might be that. Or it could be something else altogether. We might run some tests.” more…

Richard Smith: “All problems are ultimately linguistic problems”

31 Jul, 14 | by BMJ

richard_smith2“All problems are ultimately linguistic problems,” says Muir Gray, once NHS chief knowledge officer, misquoting the philosopher Ludwig Wittgenstein. But I don’t think that he misquoted him badly, and that Wittgenstein did say something along those lines.

I thought of Muir and Wittgenstein, a powerful couple, as I read a piece in the Guardian about whether there is such a thing as “just terrorism.” My immediate response was that if it’s possible to have a “just war,” then “just terrorism” must also be possible. But don’t terrorists kill civilians? Can that be just? But then in war these days more civilians than soldiers are killed. Oh dear, this is difficult. more…

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…

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