The Japanese wife of a western man developed stomach cancer and was treated in a University hospital in Tokyo.  Her stomach was removed and for some months she was reasonably well.  Then her condition worsened.  She lost weight, could hardly eat, and her abdomen (tummy) swelled up from spread of the cancer.  A local hospital looked after her at home, with a doctor visiting once a week.  This treatment was not of the highest level, with the prescribing of multiple drugs some of which were inappropriate and caused side-effects, and drugs which were needed for effective relief of pain and discomfort not being used.  The poor lady’s condition progressed to the point where re-admission was unavoidable.

But what happened then?  Her care (if you can call it that) was shared between a team of doctors none of whom appeared to be in overall charge, and it seemed no one was prepared  to explain to the patient and her husband what the situation was and what they were trying to do about it.

But the worst failing was reluctance to use a proper pain-relieving drug, that is, morphine.  Was this difficult?  Did it require specialised knowledge?  No.  It required basic knowledge of terminal care, easily accessible to any doctor.  The husband in this case had to make a thorough nuisance of himself before the staff would bestir themselves to give her morphine.  Fearful of what might happen if he wasn’t there, he would not leave her side.  Although she was in a single room, would they provide a bed or futon for him?  No.  He had to make do with two chairs.  Were the staff concerned enough to ensure he could leave to obtain some food for himself and then return to the hospital?  No.  The place was locked up at night.

The principles of pain relief in this situation are that morphine must be given in an adequate dose to relieve the pain and it must be given regularly in order to prevent return of pain.  It can be given by mouth or injection.  The common practice in Japanese hospitals of using a morphine-like drug by a skin patch is a waste of time. It is impossible to get an adequate and easily adjustable dose into the blood-stream using a skin patch.

The patient, or her husband, should not have had to beg for morphine.  Were the hospital doctors afraid that a terminally ill patient may become addicted?  Were they afraid that such a patient’s life may be shortened?  Are there rules that limit the dose and frequency of the administration of this merciful drug?  Were the doctors incapable of understanding that when someone is dying, treatment aimed at cure or prolonging life is futile, and the focus of treatment must change to assist the patient to achieve a good – that is – pain-free death?  This is nothing whatever to do with euthanasia.  In practice, with skilled administration of morphine, when a patient’s pain and distress are relieved, they may well live longer and die peacefully, no more wracked by pain.

Where is the decency and humanity of those who have, or should have, the ability and the means to relieve another human being’s suffering, but fail to act effectively?

How long will it take in Japan before high quality palliative and terminal care are routinely available to all who need it?

Note: This problem was highlighted by a Japanese doctor, Fumio Yamazaki, in a book, the English edition of which came out in 1996, called “Dying in a Japanese Hospital”, published by The Japan Times.

© Gabriel Symonds, December 2013

He helpfully explains his latest wheeze in a YouTube video[1].  This really must be seen.  Is he the world’s worst actor?  He appears to be reading from a teleprompter with the camera angled from slightly below.  He’s not actually looking at the camera, which is slightly disconcerting especially in conjunction with his orthodontically challenged teeth and Essex accent.  How does he manage to wrinkle his forehead and frown at the same time?  Maybe he practised in front of a mirror.  But what is he actually saying?  Here are some snippets:

The Government’s bin weighing the risks and benefits of how electronic cigarettes and other nicotine containing products are regulated…advertising can be controlled…long-term safety can be monitored…the quality of the products will be [inaudible]…the Government want quality products to be available to help smokers to quit, to cut down, or just to cut out particular cigarettes…

Now, which particular cigarettes does he think the Government wants smokers to cut out?  May I make a suggestion?  There is only one cigarette which smokers need to cut out: the first one of the day.

It is depressing how the Government and those in the ‘tobacco control community’ are still playing the same old tune.  Well, I suppose it keeps Meany in a job and taxes on nicotine products flowing into the Government’s coffers.

The confusion around e-cigs is further illustrated by Dr Michael Siegel of the Boston University School of Public Health, who thinks people use e-cigs to “develop a new identity” and that “there are elements of kind of a hobby”.[2]

This reminds me of the scene in Oscar Wilde’s famous play, The Importance of Being Earnest, (1895), where Jack Worthing (Earnest) is being interviewed by his formidable future mother-in-law, Lady Bracknell.

Lady Bracknell: …Do you smoke?

Jack Worthing:  Well, yes, I must admit I smoke.

Lady Bracknell:  I’m glad to hear it.  A man should always have an occupation of some kind…

One should not get too carried away by the alleged benefits of switching from cigarettes to ‘vaping’, as inhaling vapourised nicotine from an e-cigarette delivery device is called.  A man by the name of Shawn in a promotional video[3] for Zee Cigs® has uploaded his chest X-rays from 2006 and 2011.  He switched to e-cigs in 2009, he says, and claims his lungs look cleaner in the latter.  This is nonsense.  The difference in the appearances is because the later X-ray is slightly more penetrated (a higher dose of X-rays was used) so the lungs appear darker.  Both films are normal.  One cannot tell from a chest X-ray whether anyone is a smoker.

Do e-cigs help smokers to quit, to cut down, or just to cut out particular cigarettes?

It is common sense that if you are going to inhale nicotine repeatedly every day for years or even for the rest of your life, it should be safer to do this using the relatively pure form of nicotine in e-cigs compared with ordinary cigarettes whereby you unavoidably inhale thousands of other chemicals in addition.   So, I suppose that if e-cigs are found, after appropriate scientific studies and clinical trials, to be safe or to impose very low health risks, then there shouldn’t be any objection to allowing them to be on open sale.

Whether they should be allowed to be used openly in public is another matter.  Will it become acceptable for them to be used in places where smoking cigarettes is currently forbidden?  Will it be okay to use them in restaurants, theatres, concert halls, churches, and on planes?  Will it be okay to use them in front of children?  They emit no fumes hateful to other people’s noses and are, apparently, not harmful to the user, so what’s the problem?

The objections to the use of e-cigarettes are: 1) They perpetuate the widely held but mistaken idea that ceasing to be addicted to nicotine (in whatever form) is terribly, terribly difficult unless you have an external agent to take over the task for you.  2) Using these products provides a ready excuse to relapse back to smoking cigarettes.  The user can claim that e-cigs, as a smoking cessation aid, didn’t work!  3) They buy into the mind-set which nearly all smokers have, that they don’t really want to stop using nicotine, so e-cigs provide superficially credible justification to carry on doing it because it is apparently less harmful than ordinary cigarettes.

There is a further potential problem, that ever-inventive Big Tobacco, fearing progressively decreasing cigarette sales, is positioning itself to jump on the bandwagon and be in the forefront of production, promotion and selling of e-cigs.  After all, it has the most experience in peddling nicotine to the public.  This may well result in many people using both e-cigs and conventional cigarettes while labouring under the illusion that reduced cigarette smoking results in health benefits.

Even so, it seems likely that e-cigs will be promoted as a safer alternative to tobacco.  This is curious.  Why does anyone need an alternative to tobacco?  Do you need an alternative to the flu when you have recovered?  It remains to be seen whether smokers will abandon cigarettes en masse and migrate to being e-cigarette users, and whether young people who haven’t yet started smoking will not take up e-cigs or tobacco or both so that the cigarette market will die an unlamented natural death.

Well, I wouldn’t hold your breath waiting for the results of this experiment.  Nobody yet knows the long term effects of using e-cigs.  My guess it that it won’t do you any good.  The glaring inconsistency in the debate over whether to regulate e-cigs (the UK Government has already decided to do this) is, of course, that dangerous conventional cigarettes are largely unregulated – they are on open sale to all of legal age who wish to buy them – but the apparently much safer e-cigs are now to be regulated in the same way as medicines and medical devices.  It is intended that e-cigs will “meet the new quality and safety standards.”  So, the Government is going to have a finger in the pie: if you want to poison yourself you will have to use a good quality, Government approved, poison.

Here is a golden opportunity.  E-cigs are to be regulated but ordinary cigarettes are to continue to be allowed to be sold.  By all means let e-cigs be regulated, but ordinary cigarettes should be banned (or a ban gradually phased in) at the same time.  If e-cigs are really a safe, or safer, satisfactory alternative to cigarettes, no smoker will be able to complain he or she is left high and dry to suffer intolerable cravings and withdrawal effects.  E-cigs – much healthier and cheaper – are at hand!  Give up smoking and take up vaping!

But why would anyone in their right mind want to inhale nicotine in any form, at all, ever?  Is it because they need a new identity or a hobby?  Does it provide an occupation of some kind?  Do those who inhale nicotine see visions of heaven?  Do they experience a wonderful pleasurable sensation?

One promotional video for e-cigs which I saw shows a happy crowd in a bar, chatting with their friends while imbibing alcohol and extolling the virtues of this new nicotine delivery device.  They can have doses of nicotine without annoying other people and, apparently, without damaging their health.  So there they are, all doing it together and having such a lot of fun.

Alas and alack.  Why, Oh why can’t these good people enjoy a drink in a bar with their friends without inhaling a poison at the same time?  Some try to make a virtue out of an apparent necessity and wear a badge proclaiming: I’M NOT SMOKING, I’M VAPING.  The etymology gives a clue:  it is derived from Latin vapidus, meaning insipid, disagreeably bland.  In the archaic medical sense it meant exhalations arising in the stomach affecting the health, and vapour (US vapor) as a verb means to emit vapour, or to brag, make empty boasts, show off.

The only thing vaping shows is that the user is a nicotine addict getting his next fix.

A commendable aim, but I don’t see how it’s going to be helped by the mixed metaphor.  One could launch a ship, or assemble a toolkit, but launching a toolkit?   Also, grammar is evidently not the writer’s strong point: there is a singular subject (antibiotic prescribing) with a plural verb (they are).

These points aside, how do they describe this activity?

We are told that:

“Each year the RCGP chooses three clinical areas and supports efforts to raise the profile and awareness of these areas both within general practice and across primary care.  Each priority programme runs for three years and is led by a clinical champion. The role of the clinical champion is to work in partnership with key decision-makers and opinion-formers in each clinical area on projects that seek to improve the care provided and patient outcomes.”

By the way, what’s the difference between within general practice and across primary care?

The doctor at the centre of the push to reduce inappropriate antibiotic prescribing has the familiar sounding name of Michael Moore.  He is the “RCGP Clinical Champion for Antimicrobial Stewardship”, no less.

What a wonderful collection of clichés and buzz-words!  Raise the profile, priority programme, partnership, key decision-makers, opinion-formers, champion, stewardship.  At least they left out the stakeholders.

But aren’t we getting a bit carried away here?  Chambers Dictionary defines champion as one who fights in single combat for himself or for another; one who defends a cause; a successful combatant; in sports, one who has excelled all others; a hero.

It reminds of me of The Champion, a boys’ weekly story paper which was published between 1929 and 1955, with characters with stirring names such as Rockfist Rogan and Jet Jackson.

The doctor’s namesake, Michael Moore of the paunch and base-ball cap, it seems to me, is a real champion in his efforts to right the wrongs visited upon the downtrodden, the victimised, those lacking health insurance, etc.  See his films The Awful Truth, Sicko, etc.

In contrast, this Michael Moore works in partnership with key decision makers.

©Gabriel Symonds, March 2013

The so called favorite mistake, we learn, was made by an actor by the name of Jeremy Irons, who lit a cigarette while seated at a lunch next to the late Princess Diana.  Favorite mistake, eh?  Let’s make a joke of it!  It’s no joke.  It’s the most embarrassing and humiliating thing one could possibly do to oneself – a toe curling, wish-the-ground-would-open-up-and-swallow-me mother of all social gaffs.

Most of the page is taken up with a photograph of said actor.  If one were to look no lower than his neck, it is obvious to anyone with a passing knowledge of physiognomy that this man is a heavy smoker: the lines, the bags, the prematurely aged skin á la W H Auden.   Lower down one sees a small cigar in his right hand, with billowing smoke.

The whole thing is a wonderful example of how smokers are deluded about why they smoke, what they think they get out of it, and why they can’t stop.  Mr Irons confesses: ‘For most of my life, apart from a few lengthy periods when I have stopped, just to prove I can, I have enjoyed smoking…’  Okay, hold it right there.  Here we have the paradoxes, the contradictions, the self-justifications.  If he so much enjoys smoking, why does he want to stop?  And why does he need to ‘prove’ to himself that he can stop if he wants to.  Does a non-smoker need to prove to himself that he is a non-smoker by lighting up?  In Mr Irons’s case, all he is proving is that he cannot stop permanently.  He stops for a while, apparently feels confident he can quit for whatever stretch of time he deems appropriate, and then he starts smoking again.  In other words, he’s merely using this exercise in self discipline as an excuse to resume smoking.

Towards the end of the meal he enquired of Her Royal Highness: ‘May I smoke, ma’am, or would it disturb you?’  Now, what did he think she would say to this impertinent question?  ‘Well, actually, it would disturb me.’  What would he do then?  Hang his head in shame and grit his teeth till the end of the event when he could pollute his own air without upsetting HRH?  No, of course she would never have given a direct prohibition under these circumstances, but it is abundantly clear from her tactful hint of the danger to Mr Irons’s health if he insisted on smoking that she didn’t like it and would much have preferred it if he hadn’t.  A gentleman, or even someone who isn’t a gentleman but who has an ounce of common sense, would not ask such a question.  What Mr Irons is really saying, it seems to me, is this:  ‘I’m frightfully sorry, ma’am, but although I know you hate smoking I’m so selfish that I couldn’t give a tinker’s cuss about your likes and dislikes, and since I want to smoke I’m jolly well going to, and if you don’t like it – too bad!’

Now, I’m not suggesting for a moment that Mr Irons is so crass that he would actually say such a thing, or even think it, but this is what it amounts to.  This little dialogue illustrates the state smokers are in: they feel a compulsion to smoke, and if there is the slightest chance they can get away with it, that is what they do, even if it means upsetting other people.

He then gets into his self-justifying stride, unhindered by any sense of absurdity:  ‘Agreeing with her in outline I explained that my profession put many strains on my health, some of which were alleviated by my habit.’  Oh really?  What particular strains does acting put on one’s health, apart from that of passive smoking from the need to associate with smokers, of which there are apparently rather a lot among actors?  And how does smoking alleviate these strains?

I suspect Mr Irons finds there are stresses inherent in the acting profession, such as the unsocial hours, worry about forgetting one’s lines, and the risk of unemployment – though fortunately for him he seems to have been fairly successful so this particular worry probably hasn’t been relevant in his case.  So, whatever difficulties he’s had to cope with, smoking has helped, he claims.  The widespread illusion: smoking relieves stress.  But what is so stressful about sitting at lunch next to one of the world’s most beautiful women?

I have never met Mr Irons, but I did once have the honour of meeting Princess Diana.  She was a most charming and gracious lady, and as with many royalty, had a natural way of putting you at your ease.  So why was Mr Irons so stressed that he made a complete ass of himself?  He seems to have partially understood the reason:  ‘Maybe the lesson was that I should value sitting next to a beautiful woman more than I value a cigarette.’

Mr Irons may be a good actor – he may even be a great actor for all I know – but rather than being remembered, say, for his fine characterisation of the king in Richard II, it is likely it will be for his notoriety as the man who, in the style of an H M Bateman cartoon, lit up next to Princess Diana.  I do not say this to criticise Mr Irons, much less to condemn him, but to point out how this behaviour so clearly shows the tragedy of smoking:  smokers, unless they can for a short time with another cigarette fill that terrible void that cigarettes cause, can’t really enjoy anything in their lives.

© Gabriel Symonds, November 2011

For a start, there are too many words here.  Why not just say ‘Management of generalised anxiety in adults’?  Everyone has anxiety from time to time, so at what point does generalised anxiety, or even plain old fashioned anxiety, become a ‘disorder’?

Well, the first sentence of this piece tells us that ‘Generalised anxiety disorder affects about 4.4% of the adult population in England.’  This is according to the results of a household survey in 2007.  The sort of questions that were asked, presumably of randomly selected unsuspecting householders, were these:

Have you felt generally anxious/nervous/tense on four or more of the past seven days?
Has the anxiety/nervousness/tension been very unpleasant in the past week?
When anxious/nervous/tense, have you had one or more of following symptoms:

• heart racing or pounding?
• hands sweating or shaking?
• feeling dizzy?
• butterflies in your stomach?

and so on.

Someone has decided that if you achieve a certain score you are deemed, not just to be suffering from anxiety, but to have a mental illness called ‘Generalised anxiety disorder’.

What to do about it?

To start with, doctors are advised to ‘Consider a diagnosis of generalised anxiety disorder in people presenting with anxiety or substantial worry…’

Wow, rocket science!

Then, we are told to ‘Conduct a comprehensive assessment that considers the degree of distress and functional impairment…’

Gee, thanks.  Isn’t this what any doctor worthy of the name would normally do for any patient in distress?

Let’s get down to the nitty-gritty.  ‘For all known and suspected presentations of this disorder, provide education about it and the treatment options.’

Provide education about it!  Now we’re getting somewhere!  Or is it the blind leading the blind?  How about the doctor first educating himself or herself about the circumstances, background, and history of the patient’s problems?

However, ‘If symptoms have not improved after education and active monitoring’ (what is passive monitoring, then?) offer one or more of the following first line, low intensity interventions, guided by the person’s preference’:

• Individual non-facilitated self-help (usually involving minimal contact with a healthcare professional)…
• Individual guided self-help (supported by a trained practitioner…)
• Participation in psychoeducational groups (conducted by trained practitioners…)
• Individual non-facilitated and guided self-help should include printed or electronic materials of a readability level suitable for the individual…

And so on, and on…

Suppose none of these ‘interventions’ works?  What then?  Well, the next step is a choice of:

• An individual, high intensity psychological intervention…
• Drug treatment

And after that:

• If the condition has not responded to a full course of high intensity psychological treatment, offer a drug treatment
• If the condition has not responded to a drug treatment, offer either a high intensity psychological intervention or an alternative drug treatment
• If the condition has partially responded to a drug treatment, consider offering a psychological intervention in addition to drug treatment

That should have all bases covered!

What about this ‘drug treatment’ business?  According to this guideline, a drug called sertraline, which is supposed to increase the level of serotonin in the brain, and which was originally used for depression ‘emerged as clearly the most cost effective drug for generalised anxiety disorder…but patients should be…warned that no marketing authorisation (licence) has been issued for the drug’s use in generalised anxiety disorder.’  Oh dear.

Anxiety is a very common normal reaction to adverse life circumstances; it doesn’t usually arise in a vacuum.  The first step for a ‘healthcare professional’ (as doctors used to be known) is to take a history.  A sympathetic ear and genuine concern for the patient’s distress is often of itself of considerable benefit.  Maybe some exploration of underlying problems and conflicts can help patients find a way through their unhappiness.  There may be associated aggravating circumstances, such as excessive alcohol consumption, which need specific help and advice.  It is this approach which I find the most valuable in patients suffering from anxiety.  Drugs should be used sparingly, if at all, and with the aim of tiding the patient over a bad patch; they are not a cure.

Is it helpful to categorise a normal human reaction as a ‘disorder’, or is it merely a way of hiding our ignorance and allowing us to present a façade of understanding where little exists?

©Gabriel Symonds, April 2011

Sitting on the shelf behind me in my office, among many other books, is the venerable Oxford Textbook of Medicine, IV^th Edition. I often refer to this authoritative text in the course of my work. It was published in 2003, and a new edition came out in 2010.  Well, I do my best to keep up to date, so I thought I would buy the new edition.  It is a massive production of over 3000 pages, in three volumes weighing in total about 12Kg, and naturally is quite expensive.  So I looked for the cheapest price I could find, which was – you guessed it – from amazon.co.uk, and ordered it from them.  Good idea, right?  Wrong.

The books were delivered in a cardboard box which I opened in eager anticipation to browse through the new edition.  What a disappointment!  The books were damaged!  How could this be?  Surely, the highly esteemed amazon.co.uk has the wit and experience, commonsense and care, to pack them properly.  But no!  The books were in the original publisher’s cardboard box – fine if you were just carrying them home from the shop – and this had been placed in a slightly larger but rather flimsy outer cardboard box, with some packing material on three sides only of the smaller box.  Because of this, unsurprisingly, the books arrived with their corners ‘bumped’ and the spines torn.

Well, amazon.co.uk has a system for dealing with this.  They even helpfully provide a printable label and a website page to ease the return of damaged books.  I informed them by e-mail that the books were damaged due to inadequate packing.  You are asked to return goods by courier, but this would cost almost as much as I paid originally, and I wanted assurance that they would refund this relatively large amount.  The trouble is that there is no simple way of communicating with them.  An e-mail message produces an anonymous automated response.  As a last resort I tried telephoning them – a thankless task.  My call was held in a queue for quite a long time, eventually to be answered by a woman who could barely speak English and who identified herself only by her first name.  Would she tell me her surname?

‘No.’

‘Why not?’

‘It’s against company policy.’

‘What do you mean?’

‘Security reasons.’

Well, fancy that!  She has my full name but refuses to tell me hers, for ‘security reasons’.  This is not satisfactory.  I might need to refer to our telephone conversation in case of difficulty.  Does amazon.co.uk imagine enraged customers, if they know the full name of the staff member on the telephone, will be tempted to go round to their offices and heave a brick with his or her full name on it through the window?  I asked to speak the supervisor.  Same rigmarole again, except that the supervisor’s English was slightly easier to understand.  I had to swallow my pride and tell them the reason for my call: please ensure to refund in full my carriage charges and make sure the replacement is properly packed! They agree.  So all will be well, right?  Wrong.

In due course the replacement arrives.  With bated breath I open the parcel.  You can guess.  Same thing, except the damage was slightly less than the first time.

I was an expert at the game by then and used their website to request a call from a senior manager at the firm.  A call comes:

‘Hello, my name’s Michael, how may I help you?’

‘Will you please tell my your full name?’

‘I’m afraid for security reasons I’m not allowed to.’

The voice had a charming Irish lilt to it and as he was even called Michael, my annoyance didn’t last long.  Swallow my pride again and get on with the business.  He’s very sorry, they will replace the books a second time.  No, thank you, I can’t stand this any more!  I’ll accept the damage – not too noticeable ­– but what about some compensation?  Of course – how about 15% of the purchase price?  All right.  And my return carriage costs will be repaid in full.

All this trouble and waste of time could have been avoided by ordering the Textbook from the publisher’s Japanese subsidiary.  True, the cost would have been considerably more, but it almost inconceivable that a book sent by a Japanese supplier would arrive in anything other than perfect condition.

Funny, isn’t it, how one has to learn the same lesson over and over:  you get what you pay for!

©Gabriel Symonds, March 2011

It is perhaps no coincidence that these are connected.

Occasionally I buy books from Amazon UK.  The service is reasonably efficient – the books I order are delivered when they say they will be and the carriage charge is no more than one would expect.  So far so good.

However, there is one matter, one word, or rather the lack of one word, which rankles.

When a book is about to be sent out you get an e-mail informing you of this fact, but what does the subject line say?  This is what it says: “Your Amazon.co.uk order has dispatched…” (sic)

Now wait a minute.  My Amazon.co.uk order has dispatched?  Dispatched what?  Oh, I see, they mean my Amazon.co.uk order has been dispatched.  Then why don’t they say so?  Obviously, they don’t realise they are making a grammatical error.

After searching around on their website I tracked down someone not in Customer Relations, but in Executive Customer Relations, no less, and politely pointed out the incorrect wording and suggested they change it.

What do they do?  Thank me for drawing attention to their embarrassing error and hang their heads in shame as they scuttle away to their computer to add the missing word?  No, they do not.  This is the reply I received:

Dear Mr. Symonds

Thank you for taking the time to contact Amazon.co.uk with your comments on our dispatch email.

We value this kind of customer feedback, as it helps further our efforts to provide the best possible service.

However we do not have any future plans to change our email heading and I hope that this does not discourage you from placing orders with us in the future.

Thank you for your interest.

Best Regards

(Name)

Executive Customer Relations

So I wrote again:

Thank you for your message, which I find most surprising.

You say you value this kind of customer feedback, yet when I point out a simple but glaring grammatical error the correction of which requires merely the insertion of one word, you say “we do not have any future plans to change our email heading”.

Will you please tell me why this is.

Frankly, your current illiterate e-mail heading does discourage me from placing future orders with you.

Perhaps you would reconsider the matter.

Etc.

To this, I received the following reply:

I am sorry to hear that our dispatch email may discourage you from placing future orders with us however as I previously mentioned we do not have any plans to change this. I have passed your suggestion to the relevant department for consideration.

I apologise if this decision causes you any disappointment however I am unable to enter into any further discussion in relation to this.

Regards

(Name)

Executive Customer Relations

It could be considered an impertinence to refuse to discuss this matter further with a customer, should he wish to do so.

Note how the writer does not apologise for allowing an illiterate e-mail to be sent to the buying public, which is what she (for it is a woman) should to do if she had any sense or decency, but instead says that she “apologises” if this decision causes me any “disappointment”.  How kind of her to offer her sympathy with this meaningless statement.

It is said that the attitude of shopkeepers to customers in three countries differs thus:

In America the customer is always right.  In Japan the customer is God.  And in Britain the customer is a damn nuisance.

Yes, we know that, but what has it got to do with medicine?

Patience, please.  All will be revealed in next month’s exciting installment!

©Gabriel Symonds, February 2011

Browsing through the electronic Telegraph (Telegraph.co.uk) 22 April 2010 in an idle moment, I came across this intriguing, if slightly puzzling, alliterative headline: ‘Red Wine Bolsters Brain Against Strokes’.  Sounds like good news!  Not quite sure about the ‘Bolsters’ but maybe drinking red wine helps to prevent one getting a stroke.

But wait a minute – the sub-heading is a bit of a come down: ‘Red wine protects the brain from damage after a stroke, new research suggests.’  Oh dear, the main headline is misleading, then.  It seems red wine can protect the brain from damage only after you’ve already had a stoke, and this is not proven: the ‘new research’ only suggests this happens.  Better than nothing, I suppose.

Let’s read on:

‘Researchers discovered that a compound found in red grape skins and seeds lessens the effect of a blood clot on the brain and aids recovery.  It could be so effective that the substance, known as resveratrol, reduces the long-term brain damage by as much as 40 per cent.’

My hopes rise again.  But what does it mean ‘[R]educes the long-term brain damage by as much as 40 per cent.’?  Without knowing what is being compared with what, and whether this refers to relative or absolute damage reduction, such a statement is meaningless.

Never mind.  Drinkers of red wine, it seems, will or may suffer less brain damage if they are  unfortunate enough to have a stroke, compared with teetotallers.  Better than nothing.

Hopes slightly buoyed up.   Lets plough on.

Oh, oh, I knew it.  Here we go again:

‘Two hours after feeding mice a single modest dose of resveratrol the scientists induced a blood clot or ischemic stroke by essentially cutting off blood supply to the animals’ brains.’

My eyes glaze over.  Mice.

Can someone – anyone – please enlighten me about what inducing a stroke artificially in mice has got to do with naturally occurring strokes in humans.

There are enormous and obvious anatomical, physiological, and behavioural differences between mice and men (or women) so that such experiments – if the object is to discover something useful to the human race – are pointless and a waste of time.

To put it another way, I challenge – not for the first time – anyone who does these sorts of experiments to answer this simple question: what is the scientific basis for believing that the results of experiments on animals can be extrapolated to humans?  There is none.

It has been estimated that in no more that 50% of animals experiments are the results useful in predicting what will happen in humans.  In other words, you may just as well toss a coin.  Apparently, pre-feeding resveratrol results in less brain damage in induced strokes in mice.  Does this mean it will apply to strokes occurring in humans?  We don’t know.  Suppose pre-feeding resveratrol to mice resulted in the same amount or more brain damage in induced strokes in mice.  Would this mean the same would apply in humans?  We don’t know.

Significantly, Professor Sylvain Doré at the Johns Hopkins University School of Medicine in Baltimore who conducted these stupid experiments, has not tested resveratrol in clinical trials.  Clinical trials are the only way one can find out whether resveratrol is useful or not in limiting brain damage following strokes in humans.

Furthermore,  it should be noted that: ‘The scientists induced a…stroke by…cutting off [the] blood supply to the animals’ brains.’

Charming.  Mice are sentient beings.  What right does Professor Doré, or anyone else, have to cause pain and suffering in these creatures?

It is no wonder that such experiments have been called crude, cruel, and useless.

©Gabriel Symonds 2010

The former is not, as you might think, a chocolate bar.  As for the latter, I cannot help being reminded by the quirky spelling of the running ‘guru’ James Fixx, who unfortunately dropped dead at the age of 52 from a heart attack while running,  in 1984.

They are both prescription medicine trade names: an oral contraceptive and an anti-arthritis drug, respectively.

The disease that killed James Fixx has also been claimed to have caused the deaths of 40,000 to 60,000 Americans who died of heart attacks while taking Vioxx®.

Yasmin® was promoted to doctors in 2002 as an oral contraceptive which was “truly different”, with a claimed favourable effect on pre-menstrual tension, skin condition, and weight gain.  However, a year later an independent review found that Yasmin® had no advantages over existing, much cheaper, oral contraceptives. The Scottish Medicines Consortium advised in 2003 that Yasmin® is not recommended.  In spite of this it was, and still is, extensively prescribed.

In the case of Vioxx®, when the drug was withdrawn, the manufacturer, Merck, was hit with a deluge of lawsuits from patients and their survivors on the charge that they withheld information about adverse effects on the heart in order to get the drug quickly approved and on the market.  Quite right they should be sued, you might say.

But just a minute.  It is the manufacturer who is being sued?  What about the prescribing doctors?  Why aren’t they being sued as well, or instead?

When a new drug comes out it is often heavily promoted, and the drug company representatives (‘reps’, salesmen, detail men) visit doctors with information about their new drug.  And what do the doctors do?  They immediately prescribe it.  Like there is no tomorrow.  It is reported that nearly 107 million prescriptions for Vioxx® were dispensed in the US between 1999 and September 2004.

Why, Oh why, do the doctors do it?  Do they assume, because a drug has been approved for marketing and is available for prescription, it is safe?  Apparently, yes.  Are doctors so influenced by the blandishments of Big Pharma that their critical faculties fly out of the window?  Are they bereft of judgment, of caution?  Apparently, yes.  Are they over-awed by a free ball-pen, or even a free dinner, so that they go right ahead and widely prescribe the new drug?  Apparently, they do.

It has been demonstrated time and again that new drugs, approved after necessarily limited trials, are thought to be safe but later turn out not to be.

For me, the fact that a drug is new, is a reason not to prescribe it immediately, but to await independent confirmation of its possible benefits and freedom from harmful effects.  Of course, if someone came up with an effective and safe cure for cancer, I would use it straight away, but many new drugs are ‘me too-ers’ which are  similar to existing drugs; their claimed benefits or improvements are often questionable, or marginal.

How are new drugs to be tested, then?  There is no simple answer, but I intend to discuss this matter in a future article.

In the meantime, just as there are so-called NIMBY people (‘Not in My Back Yard’ – nuclear power stations and waste disposal plants, for example, are necessary but I don’t want them near where I live), I would not mind, in relation to using new drugs, being known as a NOMP doctor: ‘Not On My Patients’.

One of its functions is to ‘provide recommendations for the treatment and care of people by health professionals’.

So far so good.  But what does NICE have to say about a disorder that causes widespread suffering and a huge economic burden – low back pain?

They published a ‘guideline’ on this matter in May 2009 running to 240 pages, with the repetitious title: Low back pain: early management of persistent non-specific low back pain.

A summary of the guideline was published in the British Medical Journal (13 June 2009, p1441) which left me feeling rather bemused as to why they had bothered.

The very title contains a contradiction: ‘early’ management (i.e., treatment) of ‘persistent’ …pain.

If the pain is persistent, how can treatment for it be described as early?  Persistent pain is defined in the guideline as that which has lasted from between 6 weeks to 1 year.  So, if a patient has had pain for, say, five weeks, what then?  This doesn’t count as persistent?  Is the patient told to wait till the six weeks have elapsed and then one can apply the guideline?  And if the pain has lasted for, say, 11 months, one can still regard this stretch of time as sufficiently short so that if treatment is started at this point it is still considered early?

Let us stick just with the title of the paper a little longer.  What is ‘non-specific low back pain’ anyway?  Apart from the relatively rare serious disorders which can affect the lower back, such as cancer or tuberculosis, it seems to mean undiagnosed back pain.  Then it should be so called, and doctors’ ignorance should not be covered up this sort of pseudo-diagnosis.  Then at least our minds might be focussed on the need to try and make some sense of these ubiquitous disorders.

The title could more honestly, and concisely, be written: Treatment of persistent undiagnosed low back pain.

But this won’t do.  It violates the first rule of therapeutics: no treatment without diagnosis.

Now, let us get to the meat of the recommendations.  We should ‘Offer educational advice that includes information on the benign nature of non-specific low back pain…’

It includes such information?  So, what information besides should be offered?  Considering that the doctor (I’m sorry, I mean the health professional) – apart from realising (or hoping) that the patient’s ‘non-specific’ pain is not life-threatening – is abysmally ignorant of the cause and treatment of the patient’s condition, how can he or she presume to offer ‘educational advice’?  It is the blind leading the blind.

Then, we are supposed to ‘Encourage the person to be physically active and continue with normal activities (what’s the difference?) as far as possible’.  Oh, great.  Isn’t this what the patient is struggling to do anyway?

Now we get down to the nitty gritty:  ‘Take into account the person’s expectation and preferences…’  Don’t we do this as a matter of course?  Isn’t this passing the buck?  Let the patient (I’m sorry, the person) decide!   Suppose the person responds:  ‘I don’t know, doctor, what would you recommend?’  Or, ‘I leave it up to you, doctor.’  Or – no passing the buck here – ‘If you had my back pain, what would you do, doctor?’

The next paragraph is titled: ‘Therapies for low back pain’.  This looks more hopeful!

‘Offer one of the following treatment options, taking into account the patient’s preference (they’ve said that already): an exercise programme, a course of manual therapy, or a course of acupuncture.’

What a let down.  Here is the patient, suffering from low back pain for at least the last six weeks, coming to a ‘health professional’ for help, and all that should be done, according to this guideline, is to offer – not forgetting the person’s preference of course – one of these non-specific ways of passing the time.  Why should the patient bother at all?  What is the reasoning behind any of these treatments having any effect whatsoever on the back pain?  Will somebody please enlighten me.

Not to worry, there’s more:  ‘Combined physical and psychological treatment programme’.

Now we’re getting somewhere!  ‘[F]or people who have received at least one less intensive treatment and who also have high disability and/or substantial psychological distress’, a mere ‘100 hours over a maximum of eight weeks’ should sort it out.  I kid you not – this is actually what it says.

What about drug treatments?  Surely, here must be some nuggetts of wisdom.  Let’s see:  ‘Advise regular paracetamol (acetoaminophen, Tyelenol®, Panadol®) as the first medication option.’  Well, I could have thought of that.  However, ‘When paracetamol alone provides insufficient pain relief, offer non-steroidal anti-inflammatory drugs (commonly used for painful conditions of the moving parts of the body, referred to as NSAIDs for short) or weak opioids (related to morphine), or both.’  Wow, real rocket science!  And, for those with poor memories, don’t forget to ‘Take into account…the patient’s preference’!

All right, let’s not be cynical.  After all, these are experts who are offering guidance to us lesser forms of medical life, so they presumably know what they are talking about.  Don’t they?

After exhorting us to ‘Give due consideration to the risk of side-effects from NSAIDs’, (thank you, that would never have occurred to me) next on the list is the advice that ‘Either an oral NSAID…or a cyclo-oxygenase-2 (COX2) inhibitor (such as celecoxib) may be offered when an anti-inflammatory painkiller is recommended.’

Now hang on a minute.  Isn’t there something about cyclo-oxygenase-2 inhibitors of which one should be careful?  Oh yes, it’s in my September 2009 edition of the British National Formulary, page 561, in the box:

Cyclo-oxygenase-2 inhibitors are associated with an increased risk of thrombotic events (e.g. myocardial infarction and stroke) and should not be used in preference to non-selective NSAIDs except when specifically indicated…

The anti-arthritis drug celecoxib belongs to the same chemical group as rofecoxib, one trade name of which is Vioxx®, which was withdrawn in 2004 because it was suspected of causing heart attacks in thousands of users.

If all this hasn’t cured you, and if you haven’t had a heart attack or a stroke from the COX-2 drug, there is still hope:  spinal fusion (an operation using bone grafts or metal rods and screws to fix together two or more vertebrae).  Now, I ask you.  In patients with undiagnosed back pain what is the logic of recommending spinal fusion?  It is most curious, because in the list of ‘Treatments not recommended’ is the item ‘Lumbar supports (devices to reduce spinal movement) such as corsets.’  It would be hard to think of a more effective way of reducing spinal movement than an operation for spinal fusion.

Another treatment helpfully listed among the not-recommended sort, is ‘Injection of therapeutic substances into the back’.  Should one inject them into the front, then, or perhaps the side?  This patronising prohibition appears to have been thought up by people who have had no experience in actually treating patients with back pain.

It seems to me the writers of this guideline should go back to the drawing board.