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The Curious Incident of the Dog in the Night-


Article in BMJ Clinical Research October 2003

DOI: 10.1136/bmj.327.7418.815-a Source: PubMed Central


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Jill Elizabeth Thistlethwaite

University of Technology Sydney


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The Doctors Tale: cine at Durham, qualifying in 1958. After restore public trustwell aware that there
house jobs and vocational training, he were other high profile cases in the offing
Professionalism and Public joined his father in general practice before (those of the serial killer Harold Shipman,
Trust teaming up with colleagues in two other and the disgraced gynaecologists Rodney
Donald Irvine practices to form the Lintonville Medical Ledward and Richard Neale). He concluded
Groupa multidisciplinary teaching prac- that there was a need for doctors to demon-
Radcliffe Medical Press,
tice. Later he became regional adviser in strate that they were keeping their knowl-
21.95, pp 247
ISBN 1 85775 977 X
general practice, was a member of the edge and skills up to date if they wished their
Merrison Committee of Inquiry into the names to remain on the register. He
Rating: Regulation of the Medical Profession in the envisaged that this would require a new
1970s, and in 1982 became chairman of process, for which he coined the term
council of the Royal College of General revalidation.
Practitioners. This concept was put to the GMC for the
Before his election to the presidency of first time in November 1998, by which time
the GMC, he chaired its committee on the governments new proposals for clinical
professional standards and ethics. In my governanceincluding audit, continuing
view he was an outstanding chairman of that professional development, and annual
committee, which produced seminal publi- appraisalhad already been launched.

ir Donald Irvine was president of the cations, the most important of which were Despite unanimity that specialists and
General Medical Council between Good Medical Practice and Duties of a Doctor. general practitioners must be able to
1995 and 2002. The Doctors Tale has Three themes emerge from his account. demonstrateon a regular basisthat they
been written for anyone . . . who is The first is the importance of role models in are keeping themselves up to date and
interested in what may be seen as an impor- his professional development. The second is remain fit to practise in their chosen field,
tant moment in the history of medicine in a concern for the (undue) influence of the principle of linking revalidation with
the UK. Sir Donald aims to give the reader hospital consultantsespecially those work- registration was deferred to a subsequent
an insight into the medical profession, its ing in teaching hospitals. The third is his meeting. Although this was a major
culture, and what makes it tick. Conse- belief that the BMA was a reactionary body. disappointment for Sir Donald (and drew
quently, he devotes the first few chapters to These factors were to colour his period as adverse comment from some commenta-
the origins of the medical tribes, the devel- president of the GMC. tors), the outcome was unsurprising
opment of professional self regulation, and Donald Irvine inherited from his pre- because the proposals lacked detail.
the introduction of the NHS. decessor the implementation of the per- Nevertheless, the time for reflection and
Born the son of a progressive, single- formance procedures, a task in which he was further discussion was well spent and led to
handed general practitioner in Ashington, ably assisted by the new chief executive, Fin- acceptance of the link at the next meeting of
Northumberland, Sir Donald studied medi- lay Scott, who had already set about council. These events were followed by a
modernising the workings of the GMC and challenge to Sir Donalds presidency in
its divisions. Both of them recognised 1999 (the year in which I completed my
deficiencies in the GMCs disciplinary term as an appointed member).
procedures, including the fact that a doctor For me, the most interesting section of
who had been found guilty of serious Sir Donalds book relates to the year 2000,
professional misconduct could apply for which he describes as the GMCs annus hor-
restoration to the register after only 10 ribilis with its high profile conduct proceed-
months. ings, tensions within and between the
It was, therefore, natural that, when medical tribes, and significant pressures
concerns surfaced about the record of from the government. Despite this, much
paediatric cardiac surgery at Bristol Royal was achieved including the launch of
Infirmary, Sir Donald should choose to consultation relating to the revalidation pro-
chair the GMC inquiry himself. (This cedures and the early stages of reform of the
hearing investigated the conduct of two sur- GMCs constitution. I enjoyed this section
geons, James Wisheart and Janardan Dhas- and Sir Donalds mature reflections on
mana, and the infirmarys chief executive, Bristol. The overall result has been a
John Roylance. Wisheart and Roylance slimmed down GMC with much greater lay
were struck off the register; Dhasmana was representation and strengthened conduct
banned from performing cardiac surgery procedures.
for three years, a ban that was later By contrast, I found the chapter covering
extended.) Sir Donald describes the events the years 1980-90 disjointed and the section
succinctly in a 15 page chapter but, given titled The doctors tale: the next chapter
the centrality of this episode, it is strange self indulgent. They detract from what is

that the determination is consigned to an otherwise a well written account.

In the aftermath of the Bristol hearing, Charles George medical director, British Heart
Donald Irvine: mature reflections on Bristol Sir Donald moved rapidly in an effort to Foundation

814 BMJ VOLUME 327 4 OCTOBER 2003


Reducing the Burden of to personal weakness when they realise how

many other people are afflicted and the tre-
Headache mendous costs of not managing the
Eds J Olesen, T J Steiner, R B Lipton problem appropriately. Primary care doc-


Oxford University Press, 85, tors can see that they can reduce the huge
pp 425 burden of headache by treating one patient
ISBN 0 19 851589 8 at a time.
An authoritative text articulating the
burden of headache and exploring
strategies to reduce it is, therefore, eagerly
awaited. Unfortunately, this bookwhich is
volume 11 in the Frontiers in Headache
Research seriesis unlikely to inspire greater
action or enhance the scientific reputation
of the headache community.
Despite, or perhaps because of, an
impressive list of 140 expert contributors
from 13 countries, the book is a frustrating
Migraine: underdiagnosed and undertreated?

eople who study, treat, or suffer from jumble of short essays and studies. An
headache know that it dont get no unfortunate consequence is that the few
respect. Nevertheless, great progress gemssuch as Dahlofs thoughtful essay on
is being made. Advances in basic science are understanding the complete experience of relatively few studies can be applied to the
raising appreciation of its complex patho- living with migraine, Smith and Hasses primary care patient, who often has multiple
physiology. New drugs (and greater applica- study of the impact of migraine on family comorbidity. Nevertheless, readers can take
tion of evidence based recommendations) life, and Halperns candid analysis of the comfort in the fine chapter by Maziels that
allow more effective management of several many unknowns in pharmacoeconomic explores strategies to better serve patients
types of headache. It is time to add progress studies of migraineget lost in the disorgan- with migraine in the United States. (It is also
in measuring and articulating the societal or ised text. In fact the book illustrates the most one of the few chapters to question the
public health aspects of headache to the common problems in the world of head- over-reliance on treatment with triptans for
momentum towards legitimacy. ache: the predominance of migraine, the all aspects of migraine.)
The importance of making the burden excessive influence of drug companies, and The book leaves one longing for a few
of headache more widely known goes the difficulty of conducting good clinical good evidence based review articles or
beyond trying to get more attention for a studies on the topic. meta-analyses to evaluate and synthesise all
favourite cause or even (dare one hope) The intended audience is not described this diffuse information. A shorter, more
stimulating funding for studies and treat- in the preface and is certainly not clear from focused, and authoritative book is sorely
ment. When patients and health profession- the text. Primary care doctors from all coun- needed on this important topic.
als appreciate the wider dimensions of a tries will grow weary of the repetition that
condition, they often approach diagnosis migraine (sometimes all headaches) is Anne Walling professor of family and community
and management in a more constructive underdiagnosed and undertreated, and they medicine , University of Kansas School of Medicine,
manner. Patients are less likely to attribute may want to argue that consultation rates for Wichita, USA
not being able to deal with just a headache headache are rapidly increasing and that

The Curious Incident Whereas you and I might notice some close contact, even with his family, that he
cows in a field, some flowers in the grass, needs a routine and a pattern, and that he is
of the Dog in the and a village in the distance, he would see very good at numbers and memorising
Night-time 19 cows with different markings, a village things.
Mark Haddon with 31 visible houses and a church with a Not your ordinary 15 year old then. He
square tower, and three different types of doesnt drink or smoke or get fixated with
Jonathan Cape, 10.99,
grass and two colours of flowers. Such the female form. Following the example of
pp 224
ISBN 0 224 06378 2 attention to detail means that Christopher Sherlock Holmes he decides to do some
is anxious in new places, because he has to detecting to solve the mystery of who killed
Rating: catalogue everythingresulting in a situa- his neighbours dog with a garden fork. A
tion like a computer overload, with a crash- teacher suggests that he writes down what
ing of functions. New places can make him he has foundand this is his narrative, inter-
groan. spersed with drawings and puzzles. On the
The author, Mark Haddon, suggested in way to unmasking the culprit he discovers a
an interview that the word autism should be lot about his dysfunctional family and how
removed from the books cover. He believes to catch a train.
that Christopher relates everything we need I would never have imagined what it is
to know without resort to labelling. Christo- like to be autistic or the hard work involved

re you lazy? Do you never look at pher is a wonderful storyteller, in the literary in bringing up a child who has autism. Mark
anything properly but rather just tradition of showing rather than telling. I Haddon has to be congratulated for a book
glance at things? This novels wonder what diagnosis I would have made that is educational and entertaining, happy
narrator, Christopher Boone, who has and sad, and a page turner all in one.
without the benefit of inside information.
autism, reckons that most people are lazy.
The narrator does not mention that he has
Aspergers syndrome, the neurological dis-
Jill Thistlethwaite senior lecturer in community
Items reviewed are rated on a 4 star scale order characterised by poor social skills and based education, Academic Unit of Primary Care,
(4=excellent) behavioural disturbances. He shows us that University of Leeds
he goes to a special school, that he dislikes

BMJ VOLUME 327 4 OCTOBER 2003 815


announced, Frank Bruno is neither mad,

bad or even sadlike many thousands of
other Britons recovering in psychiatric units,
These articles scored the most hits on the BMJ s
Frank is simply ill. By Thursday, Sun readers website in the week of publication
were being told, Boxers children praise our
fund for mentally ill. Heres how you can AUGUST
support the Suns campaign to help people
Knocking Bruno suffering mental health problems . . .
1 Editorial: Paying for
BMJ 2003;327:241-2 5925 hits
Because SANEwhich stands for
when he is down Schizophrenia a National Emergencyhad
2 Editors choice: Learning from indigenous
How the media still stigmatises changed the Suns reporting style, and had BMJ 2003;327 (23 August) 3872 hits
people with mental illness even got the paper to help raise funds for 3 Clinical review: Implantable devices for
mental health, it might seem that there are treating tachyarrhythmias
signs of progress in the battle against the BMJ 2003;327:333-6 3665 hits

he term stigma derives from the
ancient Greeks, who used it to refer stigma surrounding mental illness. However, 4 Editors choice: Whats your price?
to bodily signs designed to expose the Suns initial readiness to express deeply BMJ 2003;327 (9 August) 3095 hits

something unusually bad about the moral hurtful attitudes about mental illness sug- 5 Editorial: Treatment of postmenopausal
status of the possessor. The signs were cut or gest that the coals of stigma are still glowing, osteoporosis
ready to be fanned into flame by a media BMJ 2003;327:355-6 2973 hits
burnt into the body, advertising that the
bearer was a blemished person, to be eager to pander to the prejudices and fears 6 Editors choice: Showing discrimination
of their audience. BMJ 2003;327 (16 August) 2728 hits
avoided, especially in public places.
Last week the UK tabloid newspapers Jo Phelan, of the Columbia University 7 Editorial: Treatment of anal fissure
School of Public Health, New York City, has BMJ 2003;327:354-5 2625 hits
went out of their way to ensure that the
ancient Greeks would have felt right at presented data to the Annual Meeting of the 8 Letter: No more free lunches: It is time we
American Sociological Association, which, all grew up
home in 21st century Britain. In their
along with other research, suggests that nega- BMJ 2003;327:241 2498 hits
23 September editions, they raced to cover
tive public attitudes to people with mental ill- 9 Editorial: What do symptoms mean?
the sensational story that national hero
ness are worse today than they were in the BMJ 2003;327:409-10 2409 hits
and boxer Frank Bruno had been admitted,
1950s. One theory is that this is partly 10 Editorial: Anti-inflammatory drugs and
under a section of the Mental Health Act, to
Alzheimers disease
a psychiatric hospital. because the modern medias representation
BMJ 2003;327:353-4 2359 hits
The Sun led the way with the front page of mental illness remains, at best, medieval.
lead headline Bonkers Bruno locked up, While the ire of the charities might have
while the Daily Star opted for Sick Bruno in focused on the tabloids, the UK broadsheets
siege drama. Following a storm of protest were actually adding their own more sedate Sunday Times, headlined The big fight: a
from many mental health charities, the Sun but substantial contribution to stigma. They troubled man against himself. None of the
toned down its headline in later editions the presented an endless parade of evidence for hundreds of column inches suggesting that
same day to Sad Bruno in mental home. Brunos recent instability, little of which Brunos illness was linked to marital prob-
But it was still sobering to mental health amounted to symptoms of mental illness. lems, retirement, or the loss of the media
professionals that Goodmayes Psychiatric There was also an intimate raking over of limelight seemed to show any awareness of
Hospital, the institution to which Bruno was Brunos personal life in order to assemble a recent medical research evidence that
admitted, should be referred to as a mental cascade of causes and diagnoses. Twenty- repeated blows to the head in numerous
home after the Sun had thought long and eight days are allowed under the Mental sports are associated with depression.
hard about trying not to offend. Health Act to form an assessment, but most Dr Stephen Pereira, consultant psychia-
The next day, back-pedalling furiously, journalists can complete one by the editors trist in charge of the intensive care unit at
the Sun had joined forces with the mental afternoon deadline. Goodmayes Hospital, told me that central to
health charity SANE to launch a campaign Particularly troubling was the implicit the media response seemed to be the idea
to raise money for people with mental notion that people with mental illness have that being sectioned was something awful.
health problems. Now a model of political some deep character flaw, which is the true For him, this illustrated the widest chasm
correctness, on 24 September the Sun cause. An example of this was an article in the between mental health professionals and
the public. He argued that there was a sense
in which it could be construed that being
sectioned was a benefit: it meant that some-
one was finally going to get help. Much
worse was the prospect for those whose psy-
chiatric problems remained undiagnosed or
Arguable though that may be, no one
can dispute that having a television crew
waiting outside Frank Brunos home as the
police escorted him away to hospital must
have been horrific for him and his family.
Someone must have tipped the media off
for cameras to be there before he got to hos-
pital. Doctors and psychiatrists, as advocates
for their patients, should campaign against
this aspect of media intrusion. However, it
remains charities such as SANE that are at
the vanguard of this kind of fight, with doc-
tors usually nowhere to be seen.
Raj Persaud consultant psychiatrist and senior
lecturer, the Maudsley Hospital and Institute of
Psychiatry, London

816 BMJ VOLUME 327 4 OCTOBER 2003



A tight squeeze Bioterrorism

When discussing bioterrorism it is

lthough most pathology in paediat- Is your cuff on its last legs, Doc? the
rics is psychosocial, once in a while a father asked, with a concerned smile. usually assumed that terrorists pursue
constellation of clinical signs trig- Maybe, I smiled back. Lets check the ideologies and that bioterrorism always
gers a dim recollection of something other arm. avails itself of micro-organisms or toxins.
learned long ago. Staring through the glass This time I had to listen intently to pick Terrorism can be coercive,
darkly, you suddenly see the light. up the first distant sounds at 100. I pumped extortionist, or retaliative, and it can be
It was a slow afternoon on a brilliant up the cuff again, just to make sure. pursued solely for the sake of self
summer day. A father walked in with his four Something stirred in the back of my brain. gratification.
year old son for an appointment. The only Lets have you lie down on the table. The poisoning in the Tokyo
problem was that he had come to the wrong My fingers fumbled at the waistband of underground may have had ideological
place. Although the boy was our patient, his Rickys underwear then rolled over the motivation. The bombing of German
mother had made an appointment for his femoral canals. Two times, three times I cities and the dropping of atomic bombs
physical examination elsewhere, as he moved my fingers. I could barely detect the on Japan were acts of terrorism of the
needed a physical before starting kindergar- femoral pulses. I checked the radial pulses. coercive kind. The anthrax letters in the
ten and we couldnt fit him in before then. Sure enough, there was a marked difference: United States seem to have been sent to
The office manager said we could squeeze the left was diminished. please a bent mind.
the boy in, and so it was that I saw him after I straightened up and pulled the stetho- Metazoans have long been used to
all. scope from my neck. Theres a definite dif- intimidate. The historian Livy writes of
Our newest and young- ference between the arms, the fear that Hannibals elephants caused
est medical assistant took Is your cuff on its and I can barely feel the among the Romans. The Emperor Nero
his vital signs and escorted pulses in his groin. threw Christians to carnivores in the
him and his father to an last legs, Doc? the The father quietly circus to subdue the new religion and to
examination room. I recog- father asked, with searched my eyes. I noted entertain. The horses of the
nised the name when I saw the slight shoulder shrug. conquistadors vanquished the Incas and
the chart. A bit of a tragic a concerned smile So, whats up? Could it be the Aztecs by intimidation.
situation: the boy and his something to do with his Yet the best example of terrorism in
elder brother had both shown severe behav- growth? Hes grown a lot this past year. the service of a non-ideological cause
ioural problems at young ages. Autism had I think Ricky needs to see a heart can be found in the Bible, in Exodus 8
been diagnosed in the elder boy, and I doctor. He may have a narrowed segment in and 9. Yahwe, in order to coerce the
suspected that his brother fell somewhere his aorta. Pharaoh into releasing the Hebrews
along the autistic spectrum as well. Is his heart OK? from forced labour and allowing them
How have you been? I greeted the Near as I can tell. But we really need to to decamp, terrorised the Egyptians by
father. Havent seen you in a while. have a better look at his aorta. The heart visiting pestilence upon them. He
Thats a good thing, he smiled. The doctor can do that with ultrasound. appears to have deployed
boys have had a stretch of good health these How do they fix something like that? micro-organismsthe murrain killing
past few months. I cleared my throat. Surgery, usually. horse, ass, camel, ox, and sheep, and the
I glanced at the chart. Rickys here for a They have to take out the defective section, boil breaking forth with blains upon
physical today. Looks like hell be starting then sew the ends back together. man and beastand he certainly used
kindergarten this year. So were talking open heart? metazoans for the purpose: frogs, lice,
Yeah, finally. Hard to believe, with all Not exactly. But they would have to flies, and finally locusts.
weve been through. open the chest, yes. Apart from the fact that Yahwe
I thought of the extensive developmen- A stillness descended on the room. Nei- deployed metazoans as well as
tal evaluations, the trials of drugs to control ther of us spoke. I knew the father was micro-organisms and that he did not do
Rickys violent behaviour (which sometimes beginning to fall apart inside. Ten minutes so for the sake of ideology, there are
ago Ricky was a healthy child who hadnt further lessons in the report in
resulted in self mutilation), the heartbreak of
been ill for months. Now he had a Exodus, which was recorded at the
knowing something was very wrong, yet not
coarctation of the aorta and would probably beginning of the Judaeo-Christian
knowing why, and then the heartbreak of
need major surgery. and subsequently Western cultural
finally knowing why.
Once I would have been ecstatic in diag- tradition. Clearly the series of
I looked quickly over the data on the
nosing such a condition. My colleagues pestilences that were visited upon the
examination form but stopped short when I
would have clapped me on the shoulder. Egyptians were acts of bioterrorism;
saw the blood pressure: 140/90 mm Hg,
Nice pick up! they wouldve said. Some the motivation was far from ideological;
borderline hypertension for an adult, let
might have turned away, jealous at not and the intent to intimidate (terrorise)
alone a four year old child. Perhaps the
having had the chance to step briefly into and the reasons were overt
assistant got it wrong, I thought. She was just
the limelight. (announced).
starting out after completing her internship.
But now, after 24 years of practice, There is another matter to consider:
I decided to check Rickys blood pressure. I in the Judaeo-Christian tradition Yahwe
having raised four children of my own, I
wrapped the paediatric cuff around his right is not perceived to have been a terrorist,
know that in paediatrics every diagnostic
arm. There we go, I said, a little bit of a and Moses and Aaron are not looked
coup translates into a potential tragedy
tight squeeze, then well let it go again. upon as accomplices. The reason for this
for a parent. Instead of that surge of pride
I popped the stethoscope into my ears, is that in that tradition they were
I feel something I cant quite put my
inflated the cuff past 160, opened the valve, believed to have acted in a just cause.
finger oncall it humility perhaps. Or call it
and watched the needle sweep back across
the face of the dial. At 136 the first Korotkoff
sounds surged in my ears, then muffled at 84. Imre Loefler editor, Nairobi Hospital
Brian T Maurer paediatric physician assistant,
Lets try that again, I said. I repeated Proceedings, Kenya
Tariffville, Connecticut, USA
the process, but the result was the same.

BMJ VOLUME 327 4 OCTOBER 2003 817

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