37
13. Ramsay DM, MacLeod DAD, Buist TAS, Heading RC. Persistent
gastrointestinal bleeding due to angiodysplasia of the gut in von Willebrand’s disease. Lancet 1976; ii: 275-78. 14. Boley SJ, Sammartano RJ, Adams A, et al. On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging. Gastroenterology 1977; 72: 650-60. 15. Weiss HJ, Hawiger J, Ruggeri ZM, et al. Fibrinogen-independent platelet adhesion and thrombus formation on subendothelium mediated by glycoprotein IIb/IIIa complex as high shear rate. J Clin Invest 1989; 83: 288-97. 16. O’Brien JR. Shear-induced platelet aggregation. Lancet 1990; 335: 711-13. 17. Moake JL, Turner NA,
Stathopoulos NA,
Nolasco LH, Hellums
JD.
Involvement of large plasma von Willebrand factor (vWF) multimers and unusually large vWF forms derived from endothelial cells in shear stress-induced platelet aggregation. J Clin Invest 1986; 78: 1456-61. 18. Goldsmith HL, Turitto VT. Rheological aspects of thrombosis and haemostasis. Thromb Haemost 1986; 55: 415-35. 19. Alam M, Lewis JW Jr. Cessation of gastrointestinal bleeding from angiodysplasia after surgery for idiopathic hypertrophic subaortic stenosis. Am Heart J 1991; 121: 608-10. 20. Banerjee AK. Angiodysplasia associated with hypertrophic obstructive cardiomyopathy (HOCM). Br J Clin Pract 1990; 44: 326-27. 21. Mathus-Vliegen EMH. Laser treatment of intestinal vascular abnormalities. Int J Colorect Dis 1989; 4: 20-25.
VIEWPOINT Exitus auditus—no fun
A nice friend has kindly shown me his paper on audit and education. It is a splendid account of how PME (postgraduate medical education) and CME (continuing medical education) should go, with boundaries and areas for integration. These are important matters for doctors in training and for those who care about them-me, all of us of course. Why then does the heading "Audit as an educational tool" make me reach for Ogden Nash’s Kind of an Ode to Duty ? That begins:
"0 Duty, Why hast thou not the visage of a sweetie or a cutie? Why displayest thou the countenance of the kind of conscientious organizing spinster That the minute you see her you are aginster?" And ends: "But as it is thou art so much forbiddinger than a Wodehouse hero’s
forbiddingest aunt That in the words of the poet, When Duty whispers low, Thou must, this erstwhile youth replies, I just can’t."
Well all right, escapist, and you’re not a serious person. I writing this just in case there is quite a lot more wrong with the current fixation on audit than that. It is of the essence that a learned profession looks at what it does. Doctors have been at it since Hippocrates, but Francis Bacon put it best: "For the unlearned man knows not what it is to descend into himself, or to call himself to account... like an ill mower, that mows on still, and never whets his scythe" (The Advancement of Learning, 1605). Medical research is the best expression of this pursuit. It sets itself high standards. Operational research (better: tactical research) is a very proper branch, using the same high standards. There is a pressing challenge to make medicine care and cost effective, not to be shirked as something beneath academic dignity. The aim is good diagnostic and therapeutic tactics as part of good medicine: research to find out how to do things simply, elegantly, and well. So of course our trainees, consultants, and principals, whether in teaching or general district hospitals, or in general practice, should do research on what looks interesting, important, and soluble. And they have done so for a long time. Yet suddenly there is audit. Since the UK Government’s white paper on National Health Service reforms, we are all into it, led by the great and the good, notably the Royal Colleges. The Government said there was plenty wrong with us, and so we have discovered it too. Postgraduate medical education is a mess-look, the Minister spoke, York am
1990. The stampede to breast beating had not been regarded European speciality until a few years ago, but now we rival the best in such religious fervour. Everybody can and must do it, we are all sinners Lord. And the beauty is, it is education. Get on with it, you laggards. Have you completed your loop in the cycle of audit? There are two important distinctions that mark out research. It is non-conformist, meaning free, and it is exciting, meaning fun. Research, however humble, is free-wheeling, and no respecter of hierarchies. There is a structure to good research, but not too many super-nannies are required. What counts is whether you achieve something; holding yourself to account (or audit) is inbuilt. It costs some money of course. The good teacher must excite, stimulate, and amuse, and a touch of histrionics is not out of place (attributed to Sir Derrick Dunlop). Education, a natural duty, only works for adults who want to learn. The dead, dull hand of "Thou must" is for the church-pounding the pulpit is not enlightening. Perhaps audit need not be like that, need not be boring. I suspect, however, that something set in rigid, ubiquitous hoops is by nature religious rather than fun. The clerics are certainly there. We are putting up a complex superstructure of monitoring ourselves in tiers, which is very attractive to the many masters of ceremony required. The cycle of audit is not for free thinkers. Under the title "Audit, peer review, and intellectual conformity" Carlen,l writing in The Lancet last year, pointed out that the ties of authority and dogma come to bind professional attitudes with ease. Yellow fever and mosquitoes or childbed fever are well known examples, their pioneers vilified. More recently, the surgeon George Crile Jr, departing from traditional mastectomy, was reprimanded by the Cleveland Academy of Medicine. A chest surgeon who urged 300 colleagues to support measures to curb smoking was laughed off the floor. The value of the annual medical check-up is showing signs of cracking. Yet hopping outside the audit loop is deviation, and thus an offence. How to keep inside the cycle is education. Opportunist that I am, of course I shall join in. We are organising the audit attachment for our registrars, and we devote an academic meeting each term to the subject. as a
ADDRESS. Department of Radiology, University of Cambridge, Cambridge CB2 2QQ, UK (Prof Thomas Sherwood, FRCP)
38
Medicine is more important than the prevailing weather, and for the best reasons we sail with it. We shall survive. But I am not kidding myself that audit rather than research has much to offer the proper aspirations of a teaching hospital or its medical school. Or to doctors and their patients, in the long run. Is it conceivable that the audit rage will one day
look like mass mini chest minded, and useless?
radiography-worthy, high-
I am not quite sure. I think I know that the shackles of intellectual coercion plus dullness are medieval, and not education.
REFERENCES 1. Carlen R. Audit, peer 338: 822-23.
review, and intellectual conformity. Lancet 1991;
BOOKSHELF The
Fragile Species
Lewis Thomas. New York: Scribner’s. 1992. ISBN 0-684194201.
Pp 193.$20.
In an age of inundating detail and techno-speak it helps to hear from a man with the simple belief that medical science brings hope. Thomas offers us 14 heartfelt essays about medicine and biology, at least seven of which are adapted from lectures. He likes big subjects such as Ageing and AIDS, and big themes, such as Communication and Obligations. A fine stylist with a wide range of scientific interest, he handles a broad brush with skill and ease. Close to his heart is the theme of cooperation. He begins the essay of that title with a cheerful disclaimer that he will adopt biased selection of supporting evidence, some of it either "anecdotal" or "trivial", and most of which involves "technical matters beyond ... my own professional competence". His conclusion? That the driving force in nature is cooperation. Some of the essays in this book need tightening up. Whilst lectures pass from voice to ear, essays read from page to eye, and need more detail and less rhetoric. Thomas’s main difficulty is repetition, and this was avoidable. Distinguished speakers on the scientific lecture circuit are entitled to re-use good material, but his sermon on nuclear war is spoilt by a preliminary sketch in the preceding chapter. Bats and moths, children and language, the biospheric self-regulation of the Earth’s atmosphere, and Fibonacci numbers make several appearances. The date and details of the first life on Earth (archaebacteria 37 billion years ago) grace no fewer than seven of the fourteen essays. For the reader rather than the listener, that’s six times too many. Middleton Lodge, New Ollerton, Nottingham NG22 9SZ, UK
MICHAEL LOUDON
International Textbook of Diabetes Mellitus Edited by K. G. M. M. Alberti, R. A. Defronzo, H. Keen, P. Zimmett. Chichester: John Wiley. 1992. Pp 1021 and 1729 (volume 1 and 2). ,(;99.95. ISBN 0-471914975.
I was recently referred a diabetic man with a horribly infected neuropathic foot, heavy proteinuria, and visual deterioration. Twenty years ago he had seen a physician who "... saw me in his rooms and, over a cigar and brandy, told me I had a touch of diabetes. I went away considerably relieved and forgot about the problem". Diabetes is, of course, a common worldwide disease with a substantial mortality and morbidity. For such a serious condition there have been few standard textbooks on the subject. This might be a good thing given that many books become out of date
before they appear on library shelves! However, health-care workers and scientists do need an easily accessible source of references to obviate the need for a literature search each time they require information. This large text comes in two volumes and presents the reader with all that he or she ever wanted to know about diabetes, as well as much that he or she did not need to know. Although there is inevitably some overlap between chapters, the text is well presented and informative. It is vital that books such as these cite references accurately; in this case, there are occasional errors. For instance, the reference to the recent linkage study of adenosine deaminase in type 2 diabetes misprints the chromosomal localisation as 209, not 20q. Unfortunately, this error also occurs in the text, which might confuse those of us who thought that there were only 46 chromosomes. Every important area of diabetes is covered, with the final chapter on primary disease prevention ending on a sombre note. Seventy years ago, E. P. Joslin wrote "... it is proper at the present time to devote time not alone to treatment, but still more, as in the campaign against typhoid fever, to prevention. The results may not be quite so striking or as immediate, but they are sure to come and to be important". The authors of the final chapter look back over 70 years with "... no cause to be proud about the achievements [in prevention] ...". Despite 1700 pages of information, there is still much that we do not know about pathogenesis, prediction, prevention, and treatment. In the meantime, even people with "a touch" of diabetes need careful appraisal and follow-up. To read this book is like reading a series of monographs by selected experts. The great benefit comes from having all the work in one place on the bookshelf rather than scattered throughout reprints and journals. By today’s standards the book is reasonably priced and is value for money, if only because of the time saved from looking up separate reviews and photocopying them in a library. University of Birmingham and East Birmingham Hospital, Birmingham B9 5ST, UK
A. H. BARNETT
Clinical and Experimental Toxicology of Organophosphates and Carbamates
Ballantyne, T. C. Marrs. Oxford: Heinemann. 1992. Pp 641. ,C170. ISBN 0-750602716. B.
The potential toxicity of pesticides, which are biologically active molecules and widely distributed in the environment, is a matter of considerable public concern. Ballantyne and Marrs have invited contributions from over 80 authors, many of them world experts in their field. Most chapters are
13. Ramsay DM, MacLeod DAD, Buist TAS, Heading RC. Persistent
gastrointestinal bleeding due to angiodysplasia of the gut in von Willebrand’s disease. Lancet 1976; ii: 275-78. 14. Boley SJ, Sammartano RJ, Adams A, et al. On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging. Gastroenterology 1977; 72: 650-60. 15. Weiss HJ, Hawiger J, Ruggeri ZM, et al. Fibrinogen-independent platelet adhesion and thrombus formation on subendothelium mediated by glycoprotein IIb/IIIa complex as high shear rate. J Clin Invest 1989; 83: 288-97. 16. O’Brien JR. Shear-induced platelet aggregation. Lancet 1990; 335: 711-13. 17. Moake JL, Turner NA,
Stathopoulos NA,
Nolasco LH, Hellums
JD.
Involvement of large plasma von Willebrand factor (vWF) multimers and unusually large vWF forms derived from endothelial cells in shear stress-induced platelet aggregation. J Clin Invest 1986; 78: 1456-61. 18. Goldsmith HL, Turitto VT. Rheological aspects of thrombosis and haemostasis. Thromb Haemost 1986; 55: 415-35. 19. Alam M, Lewis JW Jr. Cessation of gastrointestinal bleeding from angiodysplasia after surgery for idiopathic hypertrophic subaortic stenosis. Am Heart J 1991; 121: 608-10. 20. Banerjee AK. Angiodysplasia associated with hypertrophic obstructive cardiomyopathy (HOCM). Br J Clin Pract 1990; 44: 326-27. 21. Mathus-Vliegen EMH. Laser treatment of intestinal vascular abnormalities. Int J Colorect Dis 1989; 4: 20-25.
VIEWPOINT Exitus auditus—no fun
A nice friend has kindly shown me his paper on audit and education. It is a splendid account of how PME (postgraduate medical education) and CME (continuing medical education) should go, with boundaries and areas for integration. These are important matters for doctors in training and for those who care about them-me, all of us of course. Why then does the heading "Audit as an educational tool" make me reach for Ogden Nash’s Kind of an Ode to Duty ? That begins:
"0 Duty, Why hast thou not the visage of a sweetie or a cutie? Why displayest thou the countenance of the kind of conscientious organizing spinster That the minute you see her you are aginster?" And ends: "But as it is thou art so much forbiddinger than a Wodehouse hero’s
forbiddingest aunt That in the words of the poet, When Duty whispers low, Thou must, this erstwhile youth replies, I just can’t."
Well all right, escapist, and you’re not a serious person. I writing this just in case there is quite a lot more wrong with the current fixation on audit than that. It is of the essence that a learned profession looks at what it does. Doctors have been at it since Hippocrates, but Francis Bacon put it best: "For the unlearned man knows not what it is to descend into himself, or to call himself to account... like an ill mower, that mows on still, and never whets his scythe" (The Advancement of Learning, 1605). Medical research is the best expression of this pursuit. It sets itself high standards. Operational research (better: tactical research) is a very proper branch, using the same high standards. There is a pressing challenge to make medicine care and cost effective, not to be shirked as something beneath academic dignity. The aim is good diagnostic and therapeutic tactics as part of good medicine: research to find out how to do things simply, elegantly, and well. So of course our trainees, consultants, and principals, whether in teaching or general district hospitals, or in general practice, should do research on what looks interesting, important, and soluble. And they have done so for a long time. Yet suddenly there is audit. Since the UK Government’s white paper on National Health Service reforms, we are all into it, led by the great and the good, notably the Royal Colleges. The Government said there was plenty wrong with us, and so we have discovered it too. Postgraduate medical education is a mess-look, the Minister spoke, York am
1990. The stampede to breast beating had not been regarded European speciality until a few years ago, but now we rival the best in such religious fervour. Everybody can and must do it, we are all sinners Lord. And the beauty is, it is education. Get on with it, you laggards. Have you completed your loop in the cycle of audit? There are two important distinctions that mark out research. It is non-conformist, meaning free, and it is exciting, meaning fun. Research, however humble, is free-wheeling, and no respecter of hierarchies. There is a structure to good research, but not too many super-nannies are required. What counts is whether you achieve something; holding yourself to account (or audit) is inbuilt. It costs some money of course. The good teacher must excite, stimulate, and amuse, and a touch of histrionics is not out of place (attributed to Sir Derrick Dunlop). Education, a natural duty, only works for adults who want to learn. The dead, dull hand of "Thou must" is for the church-pounding the pulpit is not enlightening. Perhaps audit need not be like that, need not be boring. I suspect, however, that something set in rigid, ubiquitous hoops is by nature religious rather than fun. The clerics are certainly there. We are putting up a complex superstructure of monitoring ourselves in tiers, which is very attractive to the many masters of ceremony required. The cycle of audit is not for free thinkers. Under the title "Audit, peer review, and intellectual conformity" Carlen,l writing in The Lancet last year, pointed out that the ties of authority and dogma come to bind professional attitudes with ease. Yellow fever and mosquitoes or childbed fever are well known examples, their pioneers vilified. More recently, the surgeon George Crile Jr, departing from traditional mastectomy, was reprimanded by the Cleveland Academy of Medicine. A chest surgeon who urged 300 colleagues to support measures to curb smoking was laughed off the floor. The value of the annual medical check-up is showing signs of cracking. Yet hopping outside the audit loop is deviation, and thus an offence. How to keep inside the cycle is education. Opportunist that I am, of course I shall join in. We are organising the audit attachment for our registrars, and we devote an academic meeting each term to the subject. as a
ADDRESS. Department of Radiology, University of Cambridge, Cambridge CB2 2QQ, UK (Prof Thomas Sherwood, FRCP)
38
Medicine is more important than the prevailing weather, and for the best reasons we sail with it. We shall survive. But I am not kidding myself that audit rather than research has much to offer the proper aspirations of a teaching hospital or its medical school. Or to doctors and their patients, in the long run. Is it conceivable that the audit rage will one day
look like mass mini chest minded, and useless?
radiography-worthy, high-
I am not quite sure. I think I know that the shackles of intellectual coercion plus dullness are medieval, and not education.
REFERENCES 1. Carlen R. Audit, peer 338: 822-23.
review, and intellectual conformity. Lancet 1991;
BOOKSHELF The
Fragile Species
Lewis Thomas. New York: Scribner’s. 1992. ISBN 0-684194201.
Pp 193.$20.
In an age of inundating detail and techno-speak it helps to hear from a man with the simple belief that medical science brings hope. Thomas offers us 14 heartfelt essays about medicine and biology, at least seven of which are adapted from lectures. He likes big subjects such as Ageing and AIDS, and big themes, such as Communication and Obligations. A fine stylist with a wide range of scientific interest, he handles a broad brush with skill and ease. Close to his heart is the theme of cooperation. He begins the essay of that title with a cheerful disclaimer that he will adopt biased selection of supporting evidence, some of it either "anecdotal" or "trivial", and most of which involves "technical matters beyond ... my own professional competence". His conclusion? That the driving force in nature is cooperation. Some of the essays in this book need tightening up. Whilst lectures pass from voice to ear, essays read from page to eye, and need more detail and less rhetoric. Thomas’s main difficulty is repetition, and this was avoidable. Distinguished speakers on the scientific lecture circuit are entitled to re-use good material, but his sermon on nuclear war is spoilt by a preliminary sketch in the preceding chapter. Bats and moths, children and language, the biospheric self-regulation of the Earth’s atmosphere, and Fibonacci numbers make several appearances. The date and details of the first life on Earth (archaebacteria 37 billion years ago) grace no fewer than seven of the fourteen essays. For the reader rather than the listener, that’s six times too many. Middleton Lodge, New Ollerton, Nottingham NG22 9SZ, UK
MICHAEL LOUDON
International Textbook of Diabetes Mellitus Edited by K. G. M. M. Alberti, R. A. Defronzo, H. Keen, P. Zimmett. Chichester: John Wiley. 1992. Pp 1021 and 1729 (volume 1 and 2). ,(;99.95. ISBN 0-471914975.
I was recently referred a diabetic man with a horribly infected neuropathic foot, heavy proteinuria, and visual deterioration. Twenty years ago he had seen a physician who "... saw me in his rooms and, over a cigar and brandy, told me I had a touch of diabetes. I went away considerably relieved and forgot about the problem". Diabetes is, of course, a common worldwide disease with a substantial mortality and morbidity. For such a serious condition there have been few standard textbooks on the subject. This might be a good thing given that many books become out of date
before they appear on library shelves! However, health-care workers and scientists do need an easily accessible source of references to obviate the need for a literature search each time they require information. This large text comes in two volumes and presents the reader with all that he or she ever wanted to know about diabetes, as well as much that he or she did not need to know. Although there is inevitably some overlap between chapters, the text is well presented and informative. It is vital that books such as these cite references accurately; in this case, there are occasional errors. For instance, the reference to the recent linkage study of adenosine deaminase in type 2 diabetes misprints the chromosomal localisation as 209, not 20q. Unfortunately, this error also occurs in the text, which might confuse those of us who thought that there were only 46 chromosomes. Every important area of diabetes is covered, with the final chapter on primary disease prevention ending on a sombre note. Seventy years ago, E. P. Joslin wrote "... it is proper at the present time to devote time not alone to treatment, but still more, as in the campaign against typhoid fever, to prevention. The results may not be quite so striking or as immediate, but they are sure to come and to be important". The authors of the final chapter look back over 70 years with "... no cause to be proud about the achievements [in prevention] ...". Despite 1700 pages of information, there is still much that we do not know about pathogenesis, prediction, prevention, and treatment. In the meantime, even people with "a touch" of diabetes need careful appraisal and follow-up. To read this book is like reading a series of monographs by selected experts. The great benefit comes from having all the work in one place on the bookshelf rather than scattered throughout reprints and journals. By today’s standards the book is reasonably priced and is value for money, if only because of the time saved from looking up separate reviews and photocopying them in a library. University of Birmingham and East Birmingham Hospital, Birmingham B9 5ST, UK
A. H. BARNETT
Clinical and Experimental Toxicology of Organophosphates and Carbamates
Ballantyne, T. C. Marrs. Oxford: Heinemann. 1992. Pp 641. ,C170. ISBN 0-750602716. B.
The potential toxicity of pesticides, which are biologically active molecules and widely distributed in the environment, is a matter of considerable public concern. Ballantyne and Marrs have invited contributions from over 80 authors, many of them world experts in their field. Most chapters are
