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BMJ 2002;325 ( 6 July )

Editor's choice

Medical journals and the "real world"

Medical journals are often accused of being remote from the real world. They present the results of trials conducted on highly selected patients in ideal circumstances. They view the world from London, Boston, or Chicago unaware that in Peioria or Harrogate patients don't turn up, won't comply with treatments, and scoff at "patient centredness" and that the local hospitals are falling down and run by people who until yesterday were running sewage plants. Well, this issue has a whiffeven a stinkfrom the real world.

The BMJ has published many studies suggesting that serum screening for Down's syndrome in pregnant women is more effective than screening based on age, but an audit of over 150 000 deliveries suggests that may not be true (p 15). The models in support of serum screening assumed that 5% of mothers were over 35. In fact, 15% are. An editorial considers why eradication of Helicobacter pylori often fails in ordinary practice (p 3). The answer seems to be growing antibiotic resistance. Antibiotics have traditionally been prescribed for children with acute otitis media, but systematic reviews suggest that there is little benefit (p 22). But it's hard in the real world to suggest to parents that antibiotics are not indicated. Now a further review suggests that it may be worth giving them to children who have high temperatures or who are vomitingalthough even then it may be worth waiting for 24 to 48 hours.

Selected patients with stroke can probably be helped with thrombolytic drugs if seen quickly and if they undergo computed tomography. A multicentre study from Britain shows how hard this is to achieve in the real world. Only 37% of patients arrive at hospital within three hours of their stroke. Computed tomography was requested within three hours of arrival in hospital in 22% of patients but undertaken in only 8%. Ideally, all patients with serious illness would be admitted quickly to hospitals with the full range of services. But many people live a long way from such hospitals, and, says a report from the Royal College of Physicians, patients in at least 30 "isolated" hospitals are at increased risk because of the lack of intensive care (p 8). The realpolitik of reconfiguring such hospitals is terrifyingat least to politicians.

Any notion of the real world is philosophically questionable (why, for example, are my dreams less real than what I do during the day?) and certainly relative. In the United Statesunlike in the vast majority of countriesthey have thought it acceptable to execute mentally retarded prisoners. Now the Supreme Court has ruled it unacceptable (p 9). But consider the real world of Sierra Leone described in the obituary of Arthur Osman Farquar Stuart (p 47), the "people's doctor" of Sierra Leone. "What a relief," he wrote, "to be free of the soldiers who would cut a pregnant woman's belly open to settle a bet whether she was carrying a baby boy or baby girl."

Footnotes

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© BMJ 2002
 

PDF of this article Email this article to a friend Respond to this article Related editorials in BMJ Other related articles in BMJ Download to Citation Manager Alert me when: New articles cite this article

Related editorials in BMJ:

Causes of failure of eradication of Helicobacter pylori .

Peter J Jenks
BMJ 2002 325: 3-4. [Full text]  

 

Other related articles in BMJ:

PAPERS
Retrospective audit of different antenatal screening policies for Down's syndrome in eight district general hospitals in one health region.

Diana Wellesley, Tracy Boyle, John Barber, and David T Howe
BMJ 2002 325: 15. [Abstract] [Abridged text] [Full text]  

 

PRIMARY CARE
Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial • Commentary: research directions for treatment for acute otitis media.

Paul Little, Clare Gould, Michael Moore, Greg Warner, Joan Dunleavey, Ian Williamson, Chris Del Mar, and Jenny Doust
BMJ 2002 325: 22. [Abstract] [Abridged text] [Full text]  

 

OBITUARIES
Arthur Osman Farquhar Stuart.

Hugh T Fay and E Luke I B Amara
BMJ 2002 325: 47. [Full text]  

 

NEWS ROUNDUP
Acutely ill patients at risk in 30 "isolated" hospitals.

Ann McGauran
BMJ 2002 325: 8. [Abridged text] [Full text]  

 

NEWS ROUNDUP
United States bans the execution of "mentally retarded" prisoners.

Deborah Josefson
BMJ 2002 325: 9. [Abridged text] [Full text]  

 

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