BMJ 16 Jun 2007 Vol 334

Diagnostic studies are abundant, but I continue to be amazed that senior researchers often write about things like “specificity” and “sensitivity” as if they are not context-dependent.There is a world of difference between me in primary care ruling out peripheral vascular disease because I can’t feel the foot pulses in a woman who gets calf pain while walking around town, and a vascular surgeon wanting to know where the lesion lies in an old smoker who can’t go fifty metres. This systematic review identified 107 studies and my conclusion is that ultrasound is probably good enough for most purposes I require, while the vascular surgeon should opt for magnetic resonance angiography.

Does “primary care medicine” mean the same thing in all developed countries? Obviously the strict answer has to be no, but this study of diagnostic clustering in three countries – the USA, Australia, and New Zealand – shows remarkable similarities. The paper is followed by a nice little filler describing the enriching effect of a GP exchange between England and Canada. Sabbaticals and swaps remain the best way to combat primary care fatigue.

Thirty years ago, GPs saw a lot of acute coronary syndromes and often tried to manage them at home, knowing that patients sent to hospital generally fared worse. Now both the incidence and the mortality of these syndromes has fallen dramatically, and GPs are happy to be by-passed in the interests of rapid diagnosis and intervention. But ACS without ST-elevation remains a dilemma. It is easy to detect the cases with myocardial damage ten hours later, when the troponins have risen, but in the meantime the window for treatment has gone. Here is a good clear review of the problem.

When he was eight years old, little Mieczysław Horszowski was acclaimed as the greatest living player of Chopin, and so he remained for the next 90 years. For several of these decades he taught in America, where his pupils were frustrated by his refusal to explain fingering and his gentle insistence on demonstrating passages as real music. One of them finally gave up and splashed out an approximate imitation of the master. “Good,” smiled Horszowski, “but we should also try to play the notes.” In this Personal View piece about a man dying from heart failure, Communication is seen as the “forgotten palliative care emergency”, and I would entirely agree. But the authors also ensured his good death by managing to deactivate his implanted defibrillator. We should also try to find the magnet.