Statistics don't bleed; it is ... don't.â No doubt that was the Science Muse- um's aim when it unveiled its new ... could, they didn't stop to think whether they should.
Views & reviews
Personal views Our brilliant careers Trisha Greenhalgh
Isn’t it time you updated your curriculum vitae? It is a truth universally acknowledged that these documents—literally, the timetables of our lives—will indicate whether we are capable of doing a particular job, and, indeed, that the information therein can be used to discriminate between the different candidates for a post. While the former assumption often approximates to the truth, the latter could not be further from it. The CVs of applicants for a house officer post will reveal that they all went to nice schools, obtained a clutch of top grade A levels, played rugby or a musical instrument at medical school, and emerged (or will shortly emerge) with a degree. The CVs of the applicants for a chair of surgery
Managing gastric cancer in Britain: a Japanese experience Takeshi Sano When the endoscopist drew the scope out of her patientQs stomach without taking a picture I was speechless. She was talking to the patient, “Well done, Mr Smith. Your stomach is normal.” OK, I thought to myself, but who can prove it without pictures? I whispered to the endoscopist, “If he is found to have an advanced gastric cancer 12 months from now how can you prove that his stomach looked normal today?” This question was not meant to sound malicious. I was genuinely concerned that an early gastric cancer could have been overlooked. Japanese surgeons have published countless papers on the early detection of gastric cancer, the high curability, the low morbidity and mortality, the high survival 382
will all document 15 years’ experience in the operating theatre, an impressive list of publications in places like the British Journal of Surgery, and a track record of attracting large sums of money into impoverished institutions. What distinguishes between the candidates, of course, are things you usually only find out after you appoint one of them. Do they elbow you out of the best slots in the holiday rota? Does their work regularly find its way into your in tray? Can you tolerate their spouse at your dinner table? Do they fart in unventilated seminar rooms? At the end of the day, do you actually like this person? Not long ago a London estate agent made a million by changing his marketing strategy. He abandoned descriptions like “compact and charming pied a terre with original architectural features, conveniently situated for transport links,” and replaced them with, for example, “extremely small bedsit, last renovated 1921, backing on to railway line,” on the basis that people would rather be told these things up front than have to discover them for themselves. If the medical profession as a whole agreed to a similar amnesty what items of bald truth would you append to the squeaky clean and accomplished individual currently portrayed in your CV?
Trisha Greenhalgh, general practitioner, London
rates, and the benefits of radical lymphadenectomy. The data diverge so markedly from those of Western countries that many people (on both sides) can hardly believe that they are discussing the same disease. Several British surgeons have visited the National Cancer Center Hospital in Tokyo to convince themselves that the Japanese data are not fabricated. During one professor’s three week stay he observed 20 gastrectomies with various extent of lymphadenectomy, attended the weekly preoperative and postoperative conferences (conducted in English), and attended the daily rounds of senior surgeons. He made detailed inquiries about our surgical techniques, their importance, and the results obtained. We devoted considerable time to answering his complex questions. Well convinced, the professor established an exchange programme between the hospital and British gastrointestinal specialists, and this is supported by the British Council in Tokyo. I spent June and July of
1995 in Britain as the first surgeon in this programme, supported financially by the Japanese government’s ten year strategy for cancer control. I visited the endoscopy suites of four teaching hospitals and found that the devices used were modern videoscopes but that each was equipped with only a photoprinter. A few pictures were taken only to record abnormal findings. Whenever we do endoscopy in Japan we take at least 20 exposures, per patient, using 16mm film. In this way the entire inner surface of the stomach can be documented even if there are no apparent pathological lesions. I realised later, much to my surprise, that the 16mm film recorders for videoscopes are not available in Britain. Taking numerous pictures is a characteristic not only of Japanese tourists but also Japanese endoscopists. When we find a gastric tumour we photograph it from every angle with various volumes of intragastric air. Indigocarmine is used to enhance
Here, for a kick off, are my own top three. Firstly, I eat on the job. Since lunch times are invariably sacrificed to either sport or an overbooked work schedule, I maintain my blood sugar level by grazing through bananas, peanut butter sandwiches, and chocolate biscuits on virtually all occasions when I am not consulting with patients or examining students. Worse, I am blind to crumbs, disdainful of nutritional advice, and indifferent to the attempts of colleagues to stick rigidly to calorie controlled diets. Secondly, I have an irrational and unshakeable phobia of lifts, which dates from being shut in a drawer by my brother at the age of 3. I have missed more meetings and lectures through inability to find the stairs than through disinterest or disorganisation, and have been known to hyperventilate in the presence of important visitors when asked to “please take Professor X up to the chief ’s office.” Thirdly, remember that medicine is only my day job, and, like all hacks, I am perpetually on the lookout for a good story. Beware, fellow workers, if I am standing behind you in the photocopier queue, discussing an anonymous case, or making copious notes on your academic presentation. In a few weeks’ time you might recognise yourself in print.
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Views & reviews visualisation of the minute mucosal structure. Film presentation is always the core of the clinical conference because the data obtained are the only means of convincing other endoscopists and surgeons that the assessment made is correct. We believe that sharing the data with other doctors is important for clinical and educational purposes. I visited the surgical division of four hospitals in which gastric cancer is a subject of special concern in Britain. The Northern General Hospital in Sheffield and the General Infirmary in Leeds were my bases, and I also visited the General Hospital in Newcastle upon Tyne and Fazakerley Hospital in Liverpool. The gastrectomy techniques employed were quite similar to those used in Japan. Operative morbidity and mortality were also comparable with those of Japanese series though the patients were apparently somewhat poorer candidates for major abdominal surgery: they tended to be more obese, were 10 years older, and more had cardiovascular disease than Japanese patients. In all four hospitals excellent surgical skills had been developed and maintained by one or two specialists. This is in sharp contrast to the position in Japan
where gastrectomy with systematic lymphadenectomy is a basic skill that all general surgeons are expected to master. During my stay I took part in 18 gastric operations. Of these, three (17%) had early gastric cancer, while four (22%) had non-curable tumours. There were no postoperative deaths in this group. Two patients (11%) had an abdominal abscess associated with minor pancreatic leakage after extended lymphadenectomy, which resolved with conservative management.
“Some doctors later acknowledged that they had not entirely believed the Japanese results.” What impressed me most was the delighted expressions on the patients’ faces when they were told that they could go home. In Japan the majority of patients are uneasy about being discharged. They ask to be allowed to stay in the hospital as long as possible because they are apprehensive about being at home on their own. This is one explanation for the difference in length
of hospital stay between the two countries. In Japan patients with gastric cancer are admitted for at least a week before surgery and stay for two to four weeks afterwards. This allows us sufficient time for preoperative assessment and postoperative management. The latter includes late initiation of soft meals which may even be supplemented with intravenous feeding. The 20th annual meeting of the British Stomach Cancer Group was held during my stay and I was invited to be the guest lecturer on early gastric cancer. I also gave lectures on the Japanese experience at three other hospitals. These were attended by endoscopists and pathologists as well as surgeons. I got the feeling that many people were sceptical about the data coming from Japan. Indeed, some doctors later acknowledged that they had not entirely believed the Japanese results. The English version of the Japanese gastric cancer classification was recently published with full illustrations. By providing a common language this will promote accurate data exchange and valid comparisons. Takeshi Sano, consultant surgeon, National Cancer Center Hospital in Tokyo
Medicine and the media I have often wondered what I would do if I had just been told that I had only a short time left to live. Perhaps I would spend all my savings in one last hedonistic fling. Or perhaps I would spend the time organising my affairs to ease the administrative burden on the executors of my will. I imagine that it is more likely that I would simply decline into despondency. All these are predictable responses. Far less expected is the response of a growing group of people who, when faced with this news, choose to offer their experience for public scrutiny by writing a personal account of their illness and publishing it in a newspaper or magazine. In the past year many of us will have read Clare Vaughan’s compelling Personal View in the BMJ in which she describes her response to having disseminated breast cancer (BMJ 1996;313:565). Martyn Harris’s “On the Sick” columns in the Spectator and the Daily Telegraph, which record his experiences of lymphoma, and Oscar Moore’s PWA column (person with AIDS) in the Guardian provide further examples of the genre. Writing about the experience of illness and dying could be seen as part of a growing trend of personal confessional-style articles about all aspects of life and death. What motivates a person to write about such an intimate experience as dying? Martyn Harris BMJ VOLUME 314
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wrote that all writing probably has its roots in “a heightened, even neurotic fear of extinction,” as if by leaving some powerful memorial he would not really die at all. Those who choose to write about their dying experiences in this way show us that there are many different ways in which an individual faces death. Guardian journalist Jill Tweedie responded with blind fury and fear while television writer Dennis Potter seemed to find a morphine-assisted tranquillity in his final interview. Although it is an absolute certainty, most of us have no wish to dwell on the prospect of dying. Death is taboo in many cultures, and coming out with a potentially terminal illness is a powerful tool for any writer. But is it possible that by moving dying and death into the public domain articles like these have produced a framework by which the rest of us can be judged? Because of this unwillingness to be open about our own certain deaths, few people are prepared for it. Clare Vaughan described it as “the biggest adventure of all.” She said that her openness about the illness allowed relationships to blossom. “My friends and colleagues have told me that dying isn’t usually like that,” she wrote, “more a sad and slow withdrawal from life.” Pieces like these often provoke a huge public response, mostly from what Oscar Moore described as “compassionate onlookers.” As readers, we believe that we are sharing intimate moments with complete stran-
gers. We want to experience this threat to our health vicariously, safe in the knowledge that it has not happened to us yet, but that perhaps we will be better prepared for it when it comes by reading about it happening to someone else first. But it may be a false reassurance. Referring to his lymphoma, Martyn Harris wrote that “I want to try to write about it as it happens, to make myself feel better, perhaps some others, too;
RICHARD OLIVER
A very public death
Oscar Moore looks AIDS in the face
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Views & reviews our emotional balance and digestion; three million Jews killed in Poland cause us moderate uneasiness. Statistics don’t bleed; it is the detail which counts.” Oscar Moore knew what it was like to be an individual and a statistic. He wrote that at a recent seminar on new treatments, one speaker blithely noted that everything he said applied only to people with a CD4 count of more than 50, because people with cell counts lower than 50 had a life expectancy of only five to seven months. Moore described how “Fatigue, shock and an uncertainty that if I stood up I wouldn’t fall over prevented me from pointing out that, by his logic I had been technically dead for eighteen months having had a cell count of zero for the past two years.”
Genetic Choices? Science Museum, London
a recessive gene for cystic fibrosis while the white ones were “normal.” The idea was to rotate the wheel to make the discs collide with the purposely placed obstacles and ricochet their way to the bottom. The two discs that arrive at the bottom first give you the genetic make up of the child— mimicking the random nature of inheritance from two carrier parents. Unfortunately, I got two oranges. Still, so far so good. But at this point I had a real yearning for ethics—unusual for a medical student. Most people have an insight into genetics through the media. The most obvious, though dramatically exaggerated, example of this is Jurassic Park, Steven Spielberg’s film written by (Dr) Michael Crichton. Although most will say “it’s only a film,” what it did do, albeit rather briefly, was raise the all important question that went something like: “Your scientists were so busy wondering whether they
Ethical issues in genetics ignored Educating the public about current thinking in science is important. If it wasn’t done it would further fuel the paranoia that “the powers that be know something that we don’t.” No doubt that was the Science Museum’s aim when it unveiled its new exhibition, Genetic Choices? The exhibition consists of posters, interactive displays, a short video, and a specially commissioned sculpture. The posters are both informative and eye catching, with their strong pink backgrounds and multicoloured chromosomes. Each begins with a question, followed by a short blurb about the subject, and ends with either another question or a statement designed to make you think. And, indeed, they do make you think. As one of the (many) hosts told me, the challenge was to take a vast amount of information and present it in a concise, accessible, and easy to understand format. They have done this well. I found myself wondering whether I would want to know if I had a genetic disease that would start in middle age (such as Huntingdon’s chorea) or if I was passing a genetic condition on to my unborn child. And, being of an ethnic group myself, I was impressed to see information on genetic diseases in ethnic groups, like the Jewish population and Tay-Sachs disease and sickle cell anaemia in Afro-Caribbeans. So far so good. The interactive displays were interesting, if only because they presented information in a different format, perhaps designed to stop visitors getting bored. There were two touch screen displays that together covered the essential questions on cystic fibrosis, Duchenne’s muscular dystrophy, Huntington’s chorea, heart disease, and sickle cell anaemia. There was also a curious vertical wheel that had four discs inside—two orange and two white. The orange discs represented 384
Despite this century’s extraordinary scientific achievements, we know that we cannot indefinitely postpone the inevitable. People who write about dying in the prime of their life can at least offer us some insight into the ultimate challenge for all of us. They remind us that our obsession with quality of life and lifestyle should be accompanied by an understanding of the quality of death and a realisation that it is a unique journey for each of us. Naomi Craft, medical journalist and general practitioner, London
PWA Looking AIDS in the Face by Oscar Moore is published by Picador, price £6.99. Odd Man Out by Martyn Harris is published by the Daily Telegraph, price £12.99.
could, they didn’t stop to think whether they should.” It’s this question that is inadequately answered in the exhibit. The closest we get is a poster that says, “The future of genetic testing depends on how tests are legislated and controlled as well as on the progress made in the science of testing.” By far the most interesting part of the exhibit was a sculpture of a fetus in a womblike case fed through a wire rather than an umbilical cord. It sat, symbolically, on what appeared to be a mountain top, giving the impression of the creation of a “superchild.” Was genetics taking us in the direction of designer babies? Are we talking about perfecting the human race? Are advances in genetics an unfair tampering with the “survival of the fittest” rules in the game of life? It was a shame that these questions that were tentatively raised by the exhibit were never really explored. Pritpal S Tamber, student editor, BMJ
SCIENCE MUSEUM
but if you are ill or frightened of illness, do not believe in ‘me’ too much.” Oscar Moore described his column as a one sided but none the less profoundly satisfying correspondence with absent friends. But he was aware that his audience extended beyond his social circle. It included not just fellow sufferers but also well people with no immediate threat to their wellbeing, who nevertheless liked having their curiosity about life on the other side of the “sick/well looking glass” satisfied. For some, reading something emotional provides an excuse to unload other unrelated stresses. The more we can identify with the subject, the more involved we get and the greater its impact. In 1945, Arthur Koestler wrote, “A dog run over by a car upsets
Genetic Choices? Eye catching but not soul searching
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