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A British general practitioner, much loved by his patients, murdered at least
215 of them and probably killed another 45 (p
181). It took him more than 20 years. The important questions
seem to be why; why wasn't he detected sooner; and could it happen
again? Nobody knows why Harold Shipman killed, but a High Court judge
has speculated that he was "addicted to killing." Once he'd started
he seemed unable to stop
and
needed "larger doses." He got away with it for so long because he was
trusted, the practice of singlehanded general practitioners was
largely unmonitored, and the authorities took a long time to accept
what seemed unbelievable. We all want to think that it couldn't
happen again, but it is hard to build systems that will deal with
extreme events without having adverse effects on the
everyday.
Interestinglybut not
perhaps unbelievablyShipman
has reported the forensic psychiatrist who examined him to the General
Medical Council for breach of confidentiality (p
181). The GMC official who opened the letter of complaint must
have been astonished, but Shipman still has rightsand
a society is to be judged on how it deals with the rights of those at
the very edge of society. Nobody is closer to the edge of British
society than Shipman.
In Kerala a doctor has got himself into trouble for giving sildenafil (Viagra) to three babies who were extremely ill with pulmonary hypertension (p 181). All three survived. "There were children dying in my presence, and I was expected as a responsible physician to use all available methods to save my patients," says the accused doctor. The BMJ often finds itself struggling with the question of where clinical innovation ends and experiment begins. This smells like an experiment.
Something strange has also emerged in Scotland. A group has examined all patients with endometrial cancer and found that those who wait longer for treatment survive longer (p 196). The authors don't know why, but it seems unlikely that any government will demand longer waiting times in order to reduce cancer deaths.
But governments may be asking their advisers to look at indications for arthroscopic lavage or debridement for osteoarthritis of the knees (p 182). The New England Journal of Medicine has reported a trial in which patients were randomised to debridement, lavage, or placebo surgery, in which a small incision was made but no instruments inserted. During two years' follow up there was no difference in the three groups, potentially pulling the plug on a billion dollar industry in the United States. The trial raises the question of whether all surgical procedures should be tested against placebo. Virtually none have been, removing perhaps any evidence base from surgery.
Lastly, the BMJ is proud to report a true "breakthrough." For years we
have reported on overcrowding in emergency departments. Now an
Argentinian intervention has not just reduced attendance at an
emergency room but abolished it altogether (p
228).
Footnotes
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