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Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double spaced
Changing relationship between the public and the medical profession
Sir Donald Irvine (April 2001 JRSM, pp. 162±169) gives two causes for the crisis in the National Health Service (NHS). His ®rst cause is the `cultural ¯aws in the medical profession'. Top of his list is excessive paternalism. He is impressed by the information revolution and gives an example of the change that has occurred. He speaks of a `¯avour' of recent improvement, a less pejorative word than anecdote: `Holly' has been transferred by her parents from one teaching hospital to another. Her parents are calling the shotsÐ`not doctors or managers'. Sir Donald's attack is really on eÂlitism. He doubts whether a lone doctor who has spent his life studying a subject will have the knowledge to advise wisely on treatment. In the place of judgment that might be faulty, treatment should be based on team decisions, protocols, guidelines, accepted good practice and `evidence-based medicine', all leading eventually to directives where responsibility is taken from the doctor, and the medical profession becomes a middlegrade civil service. Ward rounds where a consultant with small team and sister would make decisions on twenty patients in two hours have been replaced by the case conference: the notes without the patient are now studied by a group of doctors, nurses, social workers, physiotherapists, occupational therapists, home ®nders, dietitians and managers lasting two hours and often coming to no decision. Professor Anthony Smith, President of Magdalen College, points out that Britain has become uncomfortable with the idea that, in a democratic age, there can exist eÂlites and eÂlite institutions. We are more at ease with `excellence', which has acquired `a kind of bureaucratized status in all sorts of contexts, partly because excellence sounds not so much as something to be striven for as something that can be handed out in egalitarian rations'. Sir Donald writes: `The principle of quality improvement is that quality is achieved across a broad front by a process of incremental improvement and that, rather than inspecting our defects, one gets things right ®rst time'. If this statement means anything at all, it suggests that we should ignore defects but somehow achieve improvement, whatever one means by improvement. He then deals with assessment and the need for revalidation. Mistakes occur through tiredness, carelessness and other human failings but only rarely through ignorance. Would Lykoudis1, the forgotten discoverer that peptic ulcers are caused by bacteria, have had his revalidation refused until he accepted that the bacteria at the ¯oor of peptic ulcers were the result and not the cause of the disease? Sir Donald only touches on
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Shipman, the medical murderer, but cannot resist using the Bristol `scandal' to further castigate doctors who have not yet had the controls which he proposes to impose. George Orwell would have been proud to have produced the newspeak found in this article, and Sir Donald's new world could have been devised by Jonathan Swift. Gulliver in his travels to Laputa found that neither Prince nor people appeared to be curious in any part of knowledge except mathematics and music. If eÂlitism is expelled from medicine, so much the worse for the NHS. P B S Fowler 152 Harley Street, London W1N 1HH, UK
REFERENCE
1 Rigas B, Feretis C, Papassiliou ED. Lykoudis: an unappreciated discoverer of the cause and treatment of peptic ulcer disease. Lancet 1999;354:1634±5
Carbon monoxide poisoning and the eye
In his review of carbon monoxide poisoning (June 2001 JRSM, pp. 270±272) Dr Blumenthal draws attention to the confusing array of non-speci®c symptoms and signs which may characterize this potentially fatal condition. It should be noted, however, that the often neglected examination of ophthalmoscopy may reveal valuable clues to the diagnosis. Blumenthal comments that retinal haemorrhages are rarely seen. This may re¯ect more on the thoroughness of examination than on the actual prevalence of this sign. Ophthalmoscopy is many a physician's `blind spot', and poor equipment and the avoidance of mydriatics in an emergency may exacerbate this. Indeed in one case-series retinal haemorrhages were found in all patients with carbon monoxide exposure of more than 12 hours (comprising about half of the patients in that series)1. Case studies and series suggest that the retinal haemorrhages may occur super®cially or deeper in the nerve ®bre layer (¯ame haemorrhages), with a tendency to be peripapillary. Venous changes include engorgement and tortuosity, whilst oedema of the optic disc may also be noted. In general terms these changes re¯ect the extent of the hypoxic insult to the retina2. Electrodiagnostic tests can detect subtle changes in visual function associated with carbon monoxide poisoning. These changes are typical of optic neuropathy and suggest that this toxic neuropathy shares aetiological mechanisms with tobacco amblyopia3. Interestingly, smokers appear to be particularly vulnerable to additional environmental carbon monoxide, with adverse effects on dark adaptation and light sensitivity4. Whilst such electrodiagnostic tests are not available in an emergency, careful ophthalmoscopy may
LETTERS TO THE EDITOR
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greatly assist diagnosis of this insidious and life-threatening condition. Alastair Denniston Department of Ophthalmology, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK
REFERENCES
1 Kelley JS, Sophocleus GJ. Retinal haemorrhages in subacute carbon monoxide poisoning. Exposures in homes with blocked furnace ¯ues. JAMA 1978;239:1515±17 2 Ferguson LS, Burke MJ, Choromokos EA. Carbon monoxide retinopathy. Arch Ophthalmol 1985;103:66±7 3 Simmons IG, Good PA. Carbon monoxide poisoning causes optic neuropathy. Eye 1998;12:809±14 4 von Restorff W, Hebisch S. Dark adaptation of the eye during carbon monoxide exposure in smokers and non-smokers. Aviat Space Environ Med 1988;59:928±31
Why doctors get angry in Crown Courts
The adversary system is even more unjust than Mr John Kirkham (March 2001 JRSM, p. 157) imagines. It is de®ned as a system controlled by lawyers, not judges. Geoffrey Robertson QC says it is a game and shouldn't be. Arthur
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Applbaum, Professor of Ethics at Harvard, says `lawyers might accurately be described as serial liars because they repeatedly try to induce others to believe in the truth of propositions, or in the validity of arguments, that they believe to be false'. (Hence my forthcoming work: Serial Liars: The Musical.) A US jurist, Murray L Schwartz, says: `. . . a lawyer is neither legally, professionally, nor morally accountable for the means used or the ends achieved' on behalf of clients. In the opinion of a Sydney psychiatrist, Dr Elizabeth O'Brien, this remark sounds like psychopathy. The adversary system may thus be rede®ned as a game controlled by serial liars trained by legal academics to act as if they are psychopaths. I therefore trust that the British medical profession will support M Lionel Jospin's 1 June call for a common criminal justice system throughout the European Union. That will mean the beginning of the end for the adversary game and acceptance of the truth-based and (trained) judge-controlled system which was rejected nearly 800 years ago by a dozen or so probably corrupt London judges and lawyers. Evan Whitton 14/26 Cook Street, Glebe, NSW 2037, Australia E-mail:
[email protected]
