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Oxford Handbook of General Practice

Article in The BMJ · January 2003

DOI: 10.1136/bmj.326.7379.56/a · Source: PubMed Central

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Narrative-based Primary patient. Launer advises the clinician also to medically unexplained somatic complaints.
construct a new story jointly with the However, GPs also deal with many people
Care: A Practical Guide patient—a story that works for both of them. with chronic conditions. The process of
John Launer A good story is one that is coherent, aestheti- co-construction of a new story is likely to be
Radcliffe Medical Press, cally appealing, and useful for the patient. different when the practitioner believes that
£21.95, pp 272 Launer contends that this work can lead his own story is particularly “good” (that is,
ISBN 1 85775 539 1 to the resolution of the patient’s problem. The supported by extensive scientific data). The
www.radcliffe-oxford.com theoretical section of the book does not pro- doctor talking to a patient who has had a
vide data to support this contention. How- myocardial infarction presents advice that is
Rating: ★★
ever, the techniques are drawn from family based on strong evidence, while the doctor
therapy, and intended for use over the whole bases his advice to the patient with fibro-
range of problems patients bring to the GP. myalgia on much weaker data. There is much
Taking examples from actual primary more room for movement by both parties in
care practice, Launer presents the tech- the latter situation than in the former.
niques in a clear, explicit fashion. He gives Launer recognises the tension between
examples of questions that lead patients to patients’ stories and those doctors’ stories
think of their problem in new ways. These that are based on professional knowledge.
questions invite the patient to consider spe- However, discussion of this tension appears

A
s a general practitioner, I find the mostly near the end of the book. “How far
interviewing techniques presented cific possibilities in one of several domains.
Questions can relate to the family context— should one go in pushing . . . versions of nar-
in this book interesting. They look rative thinking . . . that suggest that phenom-
as if they might be useful to my patients and “What effect would it have on your wife if
ena like strokes and death should be
to me. Launer invites readers to structure your back pain went away?”—or the geo-
considered as mere consensual stories? How
their clinical conversations making use of graphical context—“How would things be
might one integrate a view of the world as
the idea that knowledge occurs through the different if you were still living in India?”
composed from stories, with a scientific
stories—the narratives—that we tell others Practitioners can invite patients to consider
approach to knowledge and expertise”
and ourselves about our experiences. the effects of possible courses of action—
(p 198). The book provides us with almost
In a usual clinical encounter the patient “What would happen if you exercised every
no examples in which clinicians and patients
brings his story about his condition (which he day?”—and the prerequisites and barriers to
negotiate these issues.
may get a chance to tell to the doctor). The cli- change—“What would need to happen in
nician develops her story on the basis of what order for you to stop smoking?” Ellen Rosenberg associate professor of family
the patient says and her professional knowl- Most of the clinical examples concern medicine, Montreal, Canada
edge. The clinician then tells her story to the people with psychological distress and/or [email protected]

Oxford Handbook of suddenly started looking serious. When reminded myself about investigation of
teaching us, instead of regaling us with tales secondary amenorrhoea, the incubation
General Practice of drunken stupor from their past, they period of campylobacter, which thyroid carci-
Chantal Simon, Hazel Everitt, started murmuring about Bulstrode’s triad, noma is the bad one, and details of the Men-
Jon Birtwistle, Brian Stevenson “of course,” or Webber’s test, “of course.” It was tal Health Act 1983.
Oxford University Press, the “of course” in particular that used to I really like the book’s heavy clinical
£22.95, pp 1060 unsettle me. emphasis. GP registrars are usually shocked
ISBN 0 19 263270 1 I came to the conclusion that there must by the volume of varied clinical conditions
be some arcane text that I had somehow that they meet in their training year. They
Rating: ★★★
missed in my studies in which lay all those moan that they get almost no formal
esoteric bits of information necessary for the training in the essential process of rapid and
initiate into medicine. There was no such accurate assessment of presenting symp-
text, of course. I was merely experiencing the toms. They are urged to look for hidden
embarrassing recognition that medicine is agendas. But it is pointless looking for
difficult. hidden agendas if you don’t know how to
But now there is such a text—in fact, manage the explicitly manifest ones. This
several. The Oxford Handbook series will not book redresses the balance.
tell you what Bulstrode’s triad is, but the I would recommend it to every GP regis-
books do give an astonishing amount of

I
remember getting a bit of a shock before trar together with Clinical Evidence (published
my medical finals. Jovial consultants who highly compressed information. The Oxford by BMJ Books). The downside is that the print
had spent two and a half years telling us Handbook of General Practice is of the same is small, which forces me to put on my
how the only thing that they had learnt at extremely high standard as the others. It is reading glasses, which makes me look like my
medical school was not to mix wine and beer packed with all those bits of information you father, which makes me think about my age
need twice a year and can’t recall from last and mortality.
Items reviewed are rated on a 4 star scale time—prescribing oxygen cylinders, causes of
(4=excellent) mononeuropathies, hyponatraemia, algo- Kevin Barraclough general practitioner,
rithms for warfarin, and so on. I have Painswick, Gloucestershire

56 BMJ VOLUME 326 4 JANUARY 2003 bmj.com

 reviews

Medicine and Art medical systems are praised for being holis-
tic, whereas patients in the West are
Alan E H Emery, Marcia L H Emery
“disappointed by modern scientifically-
Royal Society of Medicine based medicine.”
Press in association with the I learnt that Goya’s acute neurological
Royal College of Physicians,
illness in 1792 was probably Vogt-Koyanagi-
£40, pp 112
ISBN 1 85315 501 2 Harada syndrome; that the process of
metastasis was first recognised by Joseph
Rating: ★★ Récamier; that in Science and Charity, painted
in 1897, the 16 year old Picasso used his
painter-father as the model for the doctor;
and that Elizabeth Blackwell funded the
completion of the Johns Hopkins Hospital
and School of Medicine only on condition
that it admitted women medical students. At

A
lan Emery is a distinguished British

MUSEÉ DE L’ASSISTANCE PUBLIQUE, PARIS/BAL

neurologist and an amateur painter; the end of book is a list of medical
his wife, Marcia, is a librarian and conditions depicted in paintings.
trained psychologist. This book reflects their The one black and white illustration is
shared love of art and history, and contains excellent. As with all but the most expensive
more than 50 colour illustrations of works books on art, there is the notorious problem
that portray the changing role of medicine that the colour reproductions are not of
in society. Each illustration is accompanied, high quality. This might be because the pub-
on the opposite page, by a short article giv- lishers were given inadequate colour trans-
ing a succinct summary both of the career of parencies, or it might be down to poor
the artist and the medical event illustrated. printing or a failure to show the authors the Detail from Le Tubage by Georges Chicotot
Fifteen of these articles have previously final colour proofs. The last three art books (1904)
appeared in Clinical Medicine, the journal of that I read that had satisfactory colour
the Royal College of Physicians. pictures were printed abroad—two in Italy medium and the measurements in the
The historical range is from a statue of and one in China—and one of those books legends, and to place the names of copyright
Imhotep (physician to Pharaoh Djoser) from had to be withdrawn after publication and holders in an appendix.
2600 BCE to a Lancet cover from 2001 of reprinted to a satisfactory quality.
Louise Riley’s tapestry The Patient and I hope that the plates in the next edition Jeremy Hugh Baron honorary professorial
Researcher. The book includes both well of Medicine and Art will fill the whole or lecturer, Mount Sinai School of Medicine, New York
known and obscure artists and a wide variety almost the whole of the pages rather than Competing interest: JHB is a fellow, and has been
of clinical activities. Traditional Indian leave large white margins. It would be help- a member of council, of both the Royal College
Ayuverdic, Chinese, and Tibetan Buddhist ful to have an index of artists, to put the of Physicians and the Royal Society of Medicine.

Cold Wars: The Fight Despite all the immediate difficulties of The work at the Common Cold
postwar Britain, the Medical Research Research Unit, as described in this volume, is
against the Common Cold Council established the Common Cold fascinating from many aspects. The virolo-
David Tyrrell, Michael Fielder Research Unit in Salisbury in 1946 in a dis- gists there successively identified the cold
Oxford University Press, used American hutted hospital. Until the viruses, grew them in culture, and character-
£19.99, pp 253 unit closed in 1990, its research team ised their structure. Work on the human vol-
ISBN 0 19 263285 X produced a fascinating and steady stream of unteers detailed the exact mode of spread—
basic and clinical research into the common droplets from the nose rather than the
Rating: ★★★
cold and related viral infections. Much of patient’s fingers or fomites—and established
this work was carried out on thousands of that an extraordinary variety of claimed
human volunteers, many of whom returned “preventions” and “cures,” including inter-
year after year to be inoculated with a dose feron, were ineffective.
of cold virus (or dummy control), and to live The studies spread far and wide from
for a week in comfortable, well fed isolation. Salisbury. Interesting investigations were
In this nicely written and illustrated carried out at the British Antarctic Survey
book, Dr Tyrrell, who ran the research Station, on the islanders of Tristan da
programme at the unit from 1957 until its Cunha, and on volunteers on the isolated
closure, together with the writer Michael Seal Island, off the west coast of Scotland.
Fielder, trace the history of the common Outbreaks of colds occur as soon as these

W
ho hasn’t had a cold, or indeed
cold from the early Egyptians—there are communities are in contact with the outside
colds, in the past 12 months?
hieroglyphics for the nose and for coryza world. Even the psychological aspects of
Probably no one reading this
(catarrh) next to each other—to the present. colds were studied. Indeed, there was an
review, unless you spent the time completely
Professor Walter Kruse, of Leipzig, a apparent association between stress and
isolated—for example, on an Antarctic
distinguished bateriologist, who shared with increased susceptibility to infection.
weather station or on Tristan da Cunha. Yet
Doctors, related professionals, and inter-
the cold, the commonest of all illnesses, has Shiga the identification of the dysentery
ested lay readers will find much to fascinate
no prophylaxis and no effective cure. This in bacillus, first showed that a filterable agent
them in this book. It illustrates beautifully
spite of the longest list of suggested could transmit the common cold from the
the vagaries, difficulties, false pathways,
therapies for any disease, ranging from John nasal secretions of a patient to volunteers.
raised hopes, crashing disappointments,
Wesley’s advice in 1747 to “pare very thin This was published in 1914 and the first
tedium, and all too rare but wonderful
the yellow rind of an orange, roll it up inside world war put paid to further studies in
moments of medical research.
and thrust a roll into each nostril” to Nobel Kruse’s laboratory. It was not until the 1930s
laureate Linus Pauling’s prescription of a that the viral nature of the disease was firmly Harold Ellis emeritus professor of surgery,
daily dose of 12 g of vitamin C. established. University of London

BMJ VOLUME 326 4 JANUARY 2003 bmj.com 57

reviews

bined HRT is not recommended for long

NETLINES term use except in limited circumstances, that
even short term use is associated with risk,
d Many medical libraries have been quick and that HRT should be used only where
off the mark in establishing an online menopausal symptoms are troublesome and
presence. Medlib (www.medlib.netfirms. women are fully informed of the risks.
com), which describes itself as the medical
The Australasian Menopause Society
library gateway, claims to be the largest
directory of medical library websites. Lessons from the argues, however, that sections of the
guidelines are “alarmist,” “overly proscrip-
MedLib has links to more than 750
medical library websites, which are HRT story tive,” and likely to “become a useful tool for
lawyers looking to cause trouble.”
catalogued by continent. There is the
facility for visitors to feed back The Royal Australian and New Zealand
information about any library website that The media must become more College of Obstetricians and Gynaecologists
is not yet included. This is a good database critical of unproven interventions says that it is still reviewing the guidelines.
with plenty of practical value to a global The varying reactions to the women’s
audience. health initiative findings can be viewed in

O
ne of the more fascinating medical
d Anyone looking for information on stories of recent times was that sur- many lights. They reflect the scientific
essential drugs and medicines—“those that rounding the findings of the wom- process of critical assessment of new
satisfy the priority healthcare needs of the en’s health initiative trial of hormone findings; that interpretation of evidence
population”—should check out the World replacement therapy. inevitably involves subjective judgment; the
Health Organization’s offering This was not simply because the findings difficulty of coming to terms with unex-
(www.who.int/medicines/). There is an were so significant, in challenging long held pected new evidence and of relinquishing
explanation and brief overview of the assumptions about the merits of hormone entrenched beliefs and practices; the varying
subject with listings containing links to a replacement therapy (HRT) in disease perspectives of clinicians versus those with a
large number of relevant documents and prevention. Of equal interest has been the broader, population based focus; and battles
resources, such as a model formulary. diversity of the medical profession’s over professional turf.
d For data about all things to do with response to the findings. They may also reflect damage control.
chlamydia, visit www.chlamydiae.com, The trial, part of which was published For industries confronted with negative
which has a section for the general public last year (JAMA 2002;288:321-33), showed research, a major aim of crisis
and another for health professionals. The increased risk of cardiovascular events management—as the tobacco industry has so
site is text heavy and contains several from continuous combined oestrogen- ably shown—is to create confusion and argu-
excellent documents; navigation is progestogen hormone replacement, ment about the significance of the findings.
straightforward and there is a superb links although it showed benefits for hip fractures Many have criticised the media’s cover-
section. Part of the site is password and bowel cancer. The relative risks for age of the study for provoking unnecessary
protected, but to register you just have to invasive breast cancer, coronary heart
complete a simple online form. alarm by reporting the increase in relative
disease, and stroke were increased, although
risk of harms, rather than the absolute risk.
d The next time that you are asked an the absolute risks were small.
The irony, of course, is that the presumed
awkward science based question (perhaps Soon after the study’s publication, Cana-
benefits of HRT in preventing heart disease
by a child!) you might find it helpful to dian epidemiologist Professor David Sackett
were widely promoted, through the media
visit ScienceNet (www.sciencenet.org.uk). wrote of the “arrogance” of preventive
and elsewhere, in terms of relative risk
This is a free service that even has a medicine in promoting unproven interven-
reduction, as are many other medical
telephone helpline for UK users. The site tions and estimated that hundreds of
has a large archive of questions and thousands of healthy women had been interventions.
answers in the popular science field, and harmed as a result of HRT’s widespread use. Another criticism of the media might be
these can easily be accessed by a search But others questioned or sought to that for many years we were too ready to pro-
engine or via the quick links drop-down downplay the significance of the findings. In mote enthusiasts’ beliefs about the benefits of
box, both of which are available from the Australia, eminent specialists were quoted in HRT—whose very name, some argue, is a
home page. Medical science is well the media saying that the fallout from the marketing rather than a scientific term.
represented. study was a “beat up” and that women should We often failed to ask the experts that we
d Isabel (www.isabel.org.uk) is a continue to take HRT, and that it would be a quoted enough tough questions about what
sophisticated site dedicated to helping “knee jerk reaction” to stop doing so. evidence was available to support their
doctors dealing with paediatric cases. Others said it could not be assumed that claims, or about their conflicts of interest.
Named after a girl who fell seriously ill the findings would apply to other HRT We also often failed to appreciate that
with complications resulting from products, and compared the increased studies providing evidence suggestive of
chickenpox, this is a cutting edge website breast cancer risk with that of having a few benefit—laboratory research, studies looking
built from a solid database of paediatric drinks a day. Another wrote: “No women on at surrogate measures in humans (such as
information. One of the star features is a HRT should stop therapy simply because of effect on cholesterol), and observational
tool that offers a list of potential poorly handled publicity which made mild studies examining the differences between
differential diagnoses according to the risks seem like major ones.” women who elected to take HRT and those
information entered. Other features Many specialists were critical of the who didn’t—provided less reliable evidence
include clinical algorithms and an image media coverage and of the New South Wales than randomised trials such as that of the
library. There is a registration process, but
Cancer Council, which issued a release women’s health initiative.
it is well worth the effort.
highlighting the increased relative risk for It’s not only the medical profession and
Harry Brown general practitioner, Leeds breast cancer, for provoking public alarm. drug regulators who have had a painful
[email protected] Several months later, the dust is yet to lesson from this study. The media also have a
settle. The Australasian Menopause Society lesson to learn about the pitfalls of premature
(AMS) recently refused to endorse New Zea- enthusiasm for unproven interventions and
We welcome suggestions for websites to land guidelines on HRT, which had been uncritical amplification of experts’ claims.
be included in future Netlines. Readers updated to take account of the women’s
should contact Harry Brown at the health initiative findings. Melissa Sweet freelance journalist specialising in
above email address. The guidelines, produced by the New health and medicine in Australia
Zealand Guidelines Group, say that com- [email protected]

58 BMJ VOLUME 326 4 JANUARY 2003 bmj.com

 reviews

PERSONAL VIEW SOUNDINGS

The inside story on prison health care Count your blessings

I
can speak from first hand experience “Ah, the children of the night . . .”
about the lack of health care within the “Yeah yeah, what beautiful music
prison service, albeit from the perspec- they make yaddyaddyadda,” I said, sitting
tive of the much over populated female well away, not from concern for my
estate. personal safety (a general practitioner
The job of being a prison doctor is hard. should never show fear), but when your
Many inmates are drug users or self diet is fresh blood your breath stinks.
harmers. They pull fast ones to get legal pre- “I’m a busy man, Count, skip the
scriptions to alleviate the gnawing need for theatrics.”
heroin or crack cocaine. They try to get sick “I am in a most grave predicament,”
notes so they do not have to work. However, he said, in a rich deep voice, which would
not all prisoners are addicts or skivers, yet we be ideal for flogging complementary
are treated as if we are. On the “out,” as it is medicines. “This warfarin—so many of
colloquially known in prison, a general prac- my clients are taking it now that it is
titioner doesn’t have to ascertain physically causing me considerable distress.”
that someone has been up all night “There, there,” I said, for even
vomiting—his or her word is accepted as the vampires deserve counselling, “tell me
truth. Unfortunately, someone residing at about it.”
Her Majesty’s pleasure is and always will be “I bite the neck, the blood flows, I lap
an inmate first and foremost. it up with eager tongue, the blood clots, I

REBECCA NADEN/PA PHOTOS

From my experience there is a complete stop. So it has always been. Now the
lack of health care for everyone. At HMP bleeding does not stop, the blood is
Drake Hall there is no night cover, and only everywhere, up my nose, on my dress
three officers on for a population of 315 shirt—do you know how expensive these
women, which is shocking. This led to one things are nowadays?—and I am a
pregnant inmate being taken down to the vampire, if I see blood I must drink of it.
segregation unit to miscarry—the segrega- Other inmates are the main carers I even bring along a first aid kit, stick on
tion unit is the only place where there are a little bandage to stop the bleeding.” He
officers constantly in attendance. We had no keep their lives intact for them.) Women gave an embarrassed, mournful shrug.
panic buttons in our cells to call for help in have often left their children behind and are “Yet still I am putting on a little weight.”
an emergency. Losing a baby is bad enough typically the sole or primary carers. Not “You aren’t comfortable with your
without being subjected to this type of dehu- knowing where the children are and not body,” I observed, comprehending,
manising treatment. seeing them on a regular basis, if at all given “hence the big castles.”
Other inmates are the main carers for the distances some mothers are placed away “I don’t feel good about myself,
those who are sick and mentally ill. I person- from their families, only makes matters doctor. The ladies, they used to love me,
ally telephoned Stafford Hospital’s worse. There are only 13 women’s prisons in they would lie there in those
maternity unit, using my own valuable England and none in Wales. come-to-bed nightdresses, the
telephone units, in an attempt to get some Without doubt the most horrific thing intoxicating scent of garlic filling the air. I
help for the woman, only to be told that that I have come across while in prison is love garlic, you know, it’s a little joke of
unless a directive came from the prison itself “decrutching.” This is the term used when a mine.” A wintry smile broke through,
the hospital could do nothing. This inmate prisoner comes in with drugs secreted in her then his tone briefly became sharper:
was finally transferred to HMP Foston Hall, vagina and other inmates pin her down and “This is confidential—right?”
which has a hospital wing. It was some days remove those drugs with any available tool. “Of course,” I said.
before the medical staff arranged a scan, This has led to serious injuries, which are all “Ah,” he whispered, sad again, “how
only to discover that the inmate had been kept quiet because if the victim reports they would scream, how they would moan
carrying twins and had lost only one. It is them, she will be charged with supplying. with rapture, and next morning pretend
inconceivable that this could happen any- Female rape with implements—does it get they remembered but a nightmare. Now
where other than in prison. any worse than this? they scream only because I am become so
So vast is the scale of mental health Finally a warning—hepatitis and HIV fat I am squashing them. ‘Get off me,
problems that accompany the physical are rife in the female estate and most Porky,’ said one.
needs of women in prison that it would take women conduct sexual relationships with “And it gets worse: when I transform
a team of highly trained and dedicated pro- other prisoners for all sorts of reasons. into a bat, I am too heavy to take off, I
fessionals to begin to come to grips with Many are also prostitutes when not in flap and I flap and I flap but I remain
them. Most women in prison have been prison. These relationships go on without squat on the ground; the children of the
sexually abused either during childhood or any protection or education at all. How long night, how they snigger and smirk at me.
in adolescence. These problems are greatly before the ticking bomb explodes into the I now must climb the drainpipe, so
magnified simply because women come into wider population and everyone pays the undignified, what with the extra weight
prison with all their emotional baggage price? and all. Last night, the drainpipe came
(unlike men, who “get their heads down and down; I got a pain in my chest, I’m
do their time” while their wives or girlfriends Penny A Mellor advocate, Coven, Staffordshire breathless, and I’m having palpitations.”
[email protected] I examined him; the irony was thick.
“Your pulse,” I said, “is irregularly
If you would like to submit a personal view please Competing interests: PM is a former inmate of irregular . . .”
send no more than 850 words to the Editor, BMJ, three prisons and is currently involved in an
investigation into the health care for pregnant Liam Farrell general practitioner, Crossmaglen,
BMA House, Tavistock Square, London WC1H
prisoners that is being conducted by HMP County Armagh
9JR or email [email protected]
Women’s Estate.

BMJ VOLUME 326 4 JANUARY 2003 bmj.com 59

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