Alison Tonks speaks to Richard Lehman about writing research reviews and what he’ll be doing next
For 20 years, GP Richard Lehman reviewed the headline research papers in general medical journals for an increasingly grateful following of readers. For 12 of those years, his reviews appeared every week in The BMJ, but the post on 30 July was his last. Now a professor of shared understanding of medicine at the University of Birmingham, I asked him to how he did it, what he learned, and what he’ll be up to next.
His breezy column looks like it wrote itself most weeks. But such crafting is hard work, he reports, done at the weekends (mostly Saturdays, but latterly Sundays too), while “I spit coffee, I stomp about, I shout at the bookshelves, I write a few immoderate sentences, and then delete them.” His wife is an active partner in this enterprise, an editor in residence who checks for sense and “hates bad prose.”
Will he miss his column? A pause. He’ll miss having a birds’ eye view of medical developments, but not the deadlines. That bird’s eye view reveals a global research effort whose good intentions are failing to make much headway against prevailing academic cultures and vested interests that ignore the needs of patients.
“It’s becoming increasingly frustrating to see the continuing mismatch between real clinical need and promoting products for crowded disease areas. Some conditions are so poorly defined you can’t extrapolate to the patient in front of you”.
I sense a disappointment, sadness even at the slow pace of change.
“Most papers still don’t address clinical questions, and the quality of the literature hasn’t really improved despite all the metrics, bells, and whistles that have been added, partly through journal requirements. Of course pharma funded papers are written to an excellent standard, because these companies have large teams to make that happen. But the questions they address and the metrics that they use are still a long way from clinical practice. When billions are at stake, you get pretty good at designing trials that flatter products, and in some ways that’s got worse over the years.”
Is patient and public involvement the answer? Only partly: “Patient involvement in the prioritisation of research questions is one of the most important aspects of PPI, along with choice of outcomes that are important to patients. The James Lind Alliance has been a great success in making prioritisation a common effort between researchers, clinicians, and patients. But the biggest issue for medicine in the 21st century is how we get closer to making decisions that are patient specific and fit in to each patient’s physiology, preferences, and priorities.
Tailored care that’s flexible is required, but there are competing forces constantly subverting that progress. We need a better flow of patient relevant evidence, and a much better understanding of how people deal with acute illness, and also how they cope with living with an increasingly complex range of life limiting problems. These things should be at the very centre of the research agenda. But the whole architecture of research funding and planning works against them.”
He hopes to tackle these issues in his new role in the shared understanding of medicine
Richard Lehman’s columns are written with heart and a slow burning wit that turns casual readers in to regulars, and regular readers in to devotees. His twitter account has more than 10 000 followers. Chuckling while learning something useful is a rare experience in medicine, and it works for the writer too “I write this way because that’s the way my mind works but also because it’s entertaining for me”. Here he is entertaining himself with a culinary take on confusing nutritional advice on fish in 2006
“Should we eat fish? You betcha. Especially with large quantities of dairy-based sauces, in case people suspect you of being a health freak. Dover sole with béarnaise; skate in black butter; turbot with cream and sorrel; trout with buttered cèpes; Matjesfilets of salted raw herring with heaps of sour cream: the list is as wide as the ocean. Warning: may contain traces of methylmercury”
Perhaps it’s humour that has allowed him to remain largely unchallenged while taking the occasional and not so subtle swipe at pharma companies, publishers, journals, and anyone else whose priorities appear to be off kilter. While his self confessed rudeness got him in to mild altercations every couple of years, he reports having to “back off” just once—in response to a tap on the wrist, not a law suit.
Regular readers won’t be surprised to learn that Richard Lehman has a degree in English literature. He’s particularly fond of William Blake and early columns always ended with a quote. As the quotes became increasingly “bonkers” (the English poet and artist was considered insane by peers) he decided to abandon Blake and switch to a “plant of the week” for light relief instead. “I’ve always loved collecting plants, although they do tend to die from lack of attention” he says. “There’s a constant turnover in our small garden, but at least the choice is infinite. I’d never run out of plants of the week even if I continued the column for 100 years”. If only he would.
Richard Lehman’s journal reviews may be retired, but readers will continue to see both the author and the reviews on bmj.com. Does he have any tips for his successors? “Make it fun for yourself and it’ll be fun for your readers.”
Alison Tonks is editorials editor, The BMJ.