Domhnall MacAuley: Of mice and real people

Domhnall MacauleyDo you dither with your mouse? Who would have thought there could be any new angles on consultation analysis! Simon de Lusignan (St Georges, University of London) had some new insights in his keynote address at NAPCRG (North American Primary Care Research Group). Linking three way video and computer activity he showed that some doctors, at critical phases in the consultation, were busy moving their mouse but there was no computer screen activity- it was simply a ploy to buy some time to think. Analysing current systems, he feels that some of the major weakness are because they apply a biomedical framework to a human process; we think in narratives but computers think in codes. But, other parts of the communication industry are more advanced in the science of relationships. Surprised that the drug rep remembered your wife’s name and was able to talk fishing? Their company may use a much more sophisticated consultation recording system than you.

What will become of us when we are old? Running scared of ageism, doctors follow guidelines to the letter, racking up multiple medications in older patients. Dee Mangin (University of Otago), said that patients were more afraid of the mode of death than death itself. And we are in danger of making their lives miserable too. Citing the PROSPER trial, which is the only one that includes patients over 70 years of age, she pointed out that, while cardiovascular mortality was reduced, all cause mortality was not. We simply replace one illness with another. But, more than that, we make healthy older people into patients. Our unwritten contract for treating patients who present with illness does not apply when we apply preventive therapies that can cause harm. We need to think beyond all cause mortality- we need to think of all cause morbidity.

Do clinician researchers have a future? Only doctors embedded in practice have a real understanding of the implications of some of these trial findings in real patients. But, the days of the clinician researcher look soon to pass. There are exceptions and some countries, notably the Netherlands, have combined MD/PhD programmes. There are few mid career clinical research opportunities, however. One exception is the Community Based Clinical Investigator programme that David Adams (University of British Columbia) described. This enables mid career researchers to follow up their own research ideas, develop projects and publish their work. Some of their research was discussed at the conference, including studies on the health of prisoners, a mobile falls prevention programme, and screening for Chlamydia in seasonal workers. Work with an impact in real people. It is a worry that the future of this programme could be threatened by the shrinking investments of their funding agencies. Another potential casualty of the economic downturn.

Domhnall MacAuley is primary care editor, BMJ