JRSM Readers Research Articles

Being open to basics

A cardiothoracic surgeon called me recently to discuss publishing a series of articles in JRSM. He wanted short pieces with clear messages. He wanted to take over a whole issue of the journal. I resisted. It isn't in the best interests of readers, I argued. JRSM has a multispecialty readership and it would be unfair to burden these Bohemian souls with a full edition on the performance of cardiothoracic surgeons. His retort, a reasonable one, was that cardiothoracic surgeons have been at the forefront of public engagement with performance data, and that other specialists would be interested. I still resisted, judging that a whole issue devoted to one theme was still too indulgent for a monthly journal. Perhaps I'm wrong? Perhaps readers would prefer themed issues, like those more often seen in weekly journals, although even weekly journals tend to shy away from full themed issues for the reason I've mentioned. Nonetheless, it might be something to experiment with? A successful themed issue in any journal requires a good idea and a dedicated guest editor. Any readers who fulfil both of those criteria are invited to write in. This issue, though, is something of a departure, and I'd welcome your feedback. Our clinical review on advances in motor neurone disease explains that the last decade has been one of major improvements in patient care and rapid scientific advances.1 So much so that new therapies now seem possible. Much of this advance is based on genetic discoveries, making genetic as well as risk stratification more feasible. The clinical possibilities of these genetic advances are easily understood, but the departure for JRSM is this month's research paper on the detection of a human endogenous retrovirus protein in human tissues.2 Chen Fei et al. explain that these retroviruses are believed to contribute to human evolution but scientists have struggled to detect them in specific human cells and tissues, a challenge that forms the basis of their JRSM paper. There are no immediate clinical implications of this research. Is it too far removed from the interests of JRSM readers or does opening your mind to a little science nourish and stimulate? I'd welcome your views. Indeed, science is opening up with the rise of open access journals. Authors and readers need to instantly identify the type of journal that they are either submitting their article to or reading. Is it an open access journal or is it one that retains a traditional publishing model? JRSM has an open access companion publication that caters for articles that JRSM cannot accommodate but are of interest to clinicians. From 2014, the name of this companion journal will change from JRSM Short Reports to JRSM Open to better reflect the opportunities it offers authors for open access publishing. The nature and variety of articles published by JRSM Open will remain unchanged.3

A call for inspiration

What inspires you? What was the moment that turned your mind to medicine? Whose influence cast a spell that set your future course? Perhaps it's hard to pinpoint an event or an experience that galvanized you? Medicine is a career of variety and unexpected paths, and this month I'll be speaking to sixth form and GCSE students in the hope of offering some inspiration as they consider a life of doctoring. JRSM readers with children of that age will know that preparations begin early in these competitive times. Gone are the days of a last minute impulse on a university application form. Today's students mount a four-year campaign to gain a place at medical school, armed with entry criteria, exam preparation, interview training, and work experience. When sixth form principals advise sagely on the difficulties of students winning an Oxbridge place, their one consolation is: “It could be worse, you could be applying for medical school.” What most medical students don't realise is that they are entering a career of infinity possibilities. Medicine's multi-specialty nature means that there is a medical career to suit all personalities. Your degree is merely the key to an Aladdin's cave of opportunity, a blessing that is hard to appreciate on a thankless night on call or in the middle of a disastrous ward round. Many doctors are fortunate to experience a variety of specialities as they find the one that they were destined for. Nor is variety confined to medicine. The broad experiences of a doctor's life help many people turn to second careers as managers, business people, writers, performers, politicians, and revolutionaries. Add in foreign travel and the international nature of many specialties, and medical school becomes more than a passport to a career. But how can you know that when you fill in your university application? How do you know what it takes to be a cardiologist, an orthopaedic surgeon, a microbiologist, a clinical director, or even a journal editor? How do you know that medicine, a career that might seem glamorous from the way the media portrays doctors, is the right career for you? For amid the myriad of exciting opportunities lie as many avenues of misery, hurt, and disillusionment. Imagine you are sitting in front of a hall full of sixth form students or young doctors on graduation day. What would you say to them about what inspires you? What was the moment that transformed your career? Share that inspiration and that moment with JRSM readers by sending in a submission for our Podium section. In these days of demoralization, a little inspiration is a welcome pleasure.

In praise of a paper journal

A JRSM reader recently told me that she was switching back to the print publication because visiting the website (jrsm.rsmjournals.com) to read JRSM wasn't part of her routine and was never likely to be. The only way to read JRSM, then, was to pick up the print edition. We know visitors to journal websites are usually seeking specific information, a particular article that they have discovered via a web search. They may not necessarily be regular readers of your journal, and have no particular loyalty to it. Reading one article is unlikely to convert them into regular readers. The first challenge for journals, therefore, is to develop online services that will be valuable to readers and are not possible in print. Despite radio, television, the Internet, and now Kindle, people still enjoy reading a book or a journal in print. Will print journals ever disappear entirely? Many will die – eventually – but plenty will survive to satisfy our desire for touching words on a page. The journals that endure will publish much else besides research. They will major on editorials, essays and reviews. They will synthesize knowledge for a community instead of publishing random bites of information. They will also need to entertain. The second challenge for journals, therefore, is to develop a print version that will be valuable to readers without publishing research. None of this is new, these prophecies have been written for more than a decade, but the challenge is more immediate. Online-only journals, many with an author-pays model like JRSM Short Reports (shortreports.rsmjournals.com), are attracting a larger number of submissions. Their value is in publishing research quickly and being less selective about their publication policies. JRSM Short Reports is now on PubMed Central and we have applied for full indexing. The online world is moving rapidly in terms of publication of research. Meanwhile, the print world is more sedate but it needs to quicken its speed of change. Bigger, richer, weekly journals have sufficient resources to adapt and have an in built inertia that can weather the winds of change. The predicament is more acute for smaller journals, and their battle for survival, because of the laws of economics, will become more acute. These are dangerous times. JRSM floats somewhere between the big beasts of the publishing ocean and the minnows battling for survival, although our aspiration is to swim with big beasts rather than be consumed like minnows. As such, we are considering the next stage in the evolution of both print and online versions of JRSM. We have many ideas for development but we welcome suggestions from JRSM readers about how the journal might better serve their needs in print and online while positioning itself cleverly for the future of medical journals.

How do we bring doctors and managers closer together?

How do we bring doctors and managers closer together?

First descriptions: Back to the future

Every journal has its own publication policy, and there are many tens of thousands of medical journals. When an irate author accosts me about a landmark paper, whose importance I must have missed, standard JRSM practice is to review the original decision but only a small proportion of such appeals are successful. Decisions at medical journals are made for many reasons and the most frequent one should be a judgement by the journal editors about the interest of the paper to readers. Assuming, though, that a research paper is methodologically sound or a case report is plausible how do you decide what to publish? For case reports, this question is particularly troublesome, simply because there are so many submitted for publication and generally so little to choose between them. The JRSM's current strategy is to publish two categories of case reports. A case report that is a useful reminder, or clinical lesson, for a broad range of JRSM readers is likely to attract the interest of JRSM editors. Nothing too rare and nothing too common, lessons should be helpful to clinicians in an author's specialty but also to clinicians in other specialties. Again, this is a difficult decision which is based on the information provided by the authors, the opinion of the peer reviewer, and the judgment of the editor. The same triangulation decides on the second category of case reports that are published, which are first reports of adverse drug reactions. These are easier to determine as we use reviewers who are experts in drug safety, and establishing whether or not a case report is the first report of an adverse event is easier than judging the usefulness of a clinical lesson. In addition, authors are required to inform their national drug regulatory authority and the drug manufacturer, if they have not already done so. Written consent to publication from the patient, or the next of kin in the event of death, is required for all case reports published in JRSM. You can download a consent form from the journal's website. We now introduce a third category of case report inspired by a new book that delves into the JRSM archive, Doctoring Medicine, from which we will serialise a selection of chapters over the coming months. The Royal Society of Medicine has a grand tradition of reporting first clinical descriptions. The great names of medicine, including Edward Jenner and James Parkinson, have published first descriptions in previous incarnations of the JRSM. The new category of case report, also to be published in the Grand Round section of JRSM, will feature first clinical descriptions. We will make mistakes. Some first descriptions that we publish may transpire not to be first descriptions at all. We know journal peer review is fallible. Some readers will debate the usefulness of some first descriptions. We know journal decision-making is fallible. But we will attempt to reconnect with the essence of the Society in the hope that we might publish reports from the future great names in medicine. At the very least, we hope to fascinate readers.

Doctors and managers: radical thinking required

Amid the slashing sound of treasury cuts, Her Majesty's Government has raised the whisper of clinician leadership. Pragmatic medics may view this as a cynical attempt to subdue the profession in troubled times for the health service. Others will view it as an opportunity to restore rightful leadership to the NHS and banish the 20-year plague of managers. A middle road that marries the most clinically savvy managers with the most managerially skilled clinicians is probably the wisest. Invariably, the future reality of the NHS is tricky to decipher from present government rhetoric but the preparations for clinician leadership are gathering pace. Aidan Halligan believes that the financial crisis will impact on the duty of care to patients although instead of being a disaster for patient care, the emergence of a new cadre of clinical leaders could result in the NHS’ finest hour. To that end, Halligan and colleagues at University College London Hospitals have set up an NHS staff college to establish a new global standard in the development of healthcare leaders (JRSM 2010;103:387–91). Four themes of leadership will be at the heart of the NHS staff college curriculum: self-awareness, self-management, leading the team, and big leadership. But most leaders could devise their own themes within moments. The success of the NHS staff college, and other leadership initiatives, will not be in the use of terminology. It will be dependent on bridging the distance between doctors and managers, restoring a sense of vocation for healthcare professionals, and removing a culture of fear and slavish compliance. ‘If we always do what we always did,’ writes Halligan, ‘we will always get what we always got.’ And it is this challenge I wish to throw open to JRSM readers. If we accept the survey results of the Institute for Health Improvement, the American Joint Commission and the Rand Corporation that point to a rift between doctors and managers, how do we bring these protagonists closer together? What do we need to do now to improve the relationship between doctors and managers? We might need radical thinking, and I invite JRSM readers to submit their 50–100 word contributions by the end of October, the best of which will be published in the December issue of the journal. ‘Only one man in a thousand is a leader of men,’ said the management guru Groucho Marx, ‘the other nine hundred and ninety-nine follow women.’ He might have solved the crisis of the NHS with such original thinking. Now it's your turn.

JRSM and society meetings

Medical journals have interesting relationships with their owners. The Lancet is owned by Elsevier, the BMJ by the British Medical Association, and the JRSM, of course, belongs to the Royal Society of Medicine. Ownership by such powerful organizations has its benefits. These journals have security in our financially troubled times. They have access to sales and marketing support to help promote and grow their readerships. They can even venture into international markets. Benevolent ownership that allows the journal editorial freedom is every editor's dream. Unfortunately, the reality is never so idyllic. Powerful commercial organizations such as Elsevier have stringent business targets, which include objectives for the journal. It is hard for even the most independent editor not to be mindful of a journal's commercial performance. Powerful medical associations, like the BMA, have large memberships to placate. They will be conscious of the political ramifications of what is published in their house journal. The editor will be mindful of sensibilities within the organization. In addition, commercial pressures are increasingly influencing the strategies and the objectives of medical associations. Is it possible for an editor to be truly independent when dealing with the real politik of any organization? Probably not, but any decent editor will fight for the independence of their journal. A scientific society, like the RSM, is much different to a commercial organization or a political medical association. The principles of scientific freedom are easily extended to the journal, allowing it to operate autonomously. This is certainly the case with the JRSM, where I have never experienced any attempt to interfere with the editorial decision-making of the journal. RSM members can be proud that the society's officers are upholding the highest principles of governance in relation to the JRSM. Of course, authors and readers might not always agree with the decisions of the journal but that is the way with any publication. Journals are about debate and debating the decisions of the editorial team are a legitimate exercise. Ownership by societies, however, comes with an added complication, as the letter by Geoffrey Walker highlights (JRSM 2010;103:346). Should society journals publish the proceedings of society meetings? I welcome your views. JRSM did once publish proceedings but no longer does as a routine. A simple fact is that there are too many meetings at the society and not sufficient pages in the journal to cover them. In addition, all authors should have an equal chance of publishing in the JRSM, provided that their articles are of relevance to JRSM readers. JRSM already receives far more articles than it can publish, which is why the new sister journal, JRSM Short Reports, has been launched. Many meetings are wonderful to attend but difficult to recount in the form of a journal article. Indeed, a direct report of a meeting makes for dull reading and is unlikely to be published. It is another form of vanity publishing. The RSM's new video lectures service on the RSM website now broadcasts the best of the lectures delivered at the RSM. We would broadcast and publish every lecture or meeting held at the RSM if both the demand and the resources existed. There isn't the demand and there aren't the resources. The JRSM's objective is to become the leading clinical journal on UK medicine and healthcare. To that end, the journal has to reach out to RSM members but also reach beyond them. The RSM is a society that engages in the wider debate on medicine and healthcare outside the walls of 1 Wimpole Street. JRSM's editorial policy reflects that positioning. If JRSM is to grow and flourish, provide a valuable service for members, as well as attract new ones, then it must continue with its current approach. But that doesn't mean that members enthusiastic to write up a meeting should not consider the JRSM. There are two ways to be published. First, you consider writing a clinical review, essay or editorial based on the most interesting theme of the meeting. You will need to submit via the online submission system and your paper will be considered equally with other submissions if it is judged to be appropriate for the JRSM's readership it will be published. Second, if you have several potential articles you might want to offer the journal a series or – if the theme of the meeting was too narrow for general readers – you could consider a supplement to JRSM, although supplements will require additional funding. At the very least, I am happy to discuss potential articles. The route to JRSM is not closed for meeting organizers and speakers but there is certainly no automatic entry.

What single change to your working life will restore your faith in medicine as a profession – and why?

What single change to your working life will restore your faith in medicine as a profession – and why?

The distinction between gross negligence and recklessness in English criminal law

Merry states that ‘in practice the distinction between gross negligence and recklessness may be very subtle’.1 I wonder if his discussion of both the law and the relevant medical errors is outdated. Recklessness in English criminal law is advertent, and as Merry states, requires the conscious choice to take an unjustified risk. Criminal negligence is variously defined, but is usually regarded as not requiring advertence. One textbook definition is ‘… the inadvertent taking of an unjustifiable risk’.2 Historically, confusion has arisen from gross negligence manslaughter being sometimes known as reckless manslaughter. This should no longer be the case. The current leading cases, which Merry does not cite, are Adomako3 and Misra.4 Following these cases, a conviction for gross negligence manslaughter requires the existence of a duty of care, breach of that duty resulting in death and a risk of death which would be obvious to a reasonable prudent person. Additionally, the defendant's conduct must have fallen so far below the standard of a reasonable practitioner as to be grossly negligent in the view of the jury, and thereby warranting a criminal conviction for manslaughter. Although there is overlap, reckless manslaughter has a distinctly different meaning. Similarly, Merry's discussion of intrathecal vincristine administration would be enhanced by discussion of the incident at Nottingham in 2001. A junior doctor was prosecuted for gross negligence manslaughter, and pleaded guilty. However, an external inquiry identified over 50 other contributory factors to the fatal event.5 I hope this additional material may prove interesting and informative to JRSM readers.

Declare all or be damned

All the evidence on general and multispecialty medical journals points to the rather unsurprising finding that most readers only read one or two articles of interest to them – providing that the journal is having a good week or month. Like most editors I probably delude myself that JRSM readers read much more of the journal than that. But if you were to only read two articles in this month's issue, I have my recommendations ready for you. A scandal in the House of Lords about peers accepting payment to influence legislation has exposed the fallacy of impartiality that is often associated with government and politicians. A few weeks before that scandal broke, I agreed to publish an editorial by Richard Smith and colleagues about the fallacy of impartiality in academic publications (JRSM 2009;102:44–45 ). The authors argue that competing interests in academic publications have become focused on the view that authors linked to for‐profit companies are heavily conflicted whereas those associated with the public sector and academic institutions are not. Indeed, why are representatives of government, royal colleges, medical societies and trade unions any less motivated by personal success or the success of their organizations than employees of companies and businesses? Moreover, the lack of transparency about the competing interests of public sector and academic institutions leaves them hostage to the hidden influences of powerful lobbying groups and organizations, as well as individual whims and fancies. ‘Our message is simple,’ say Smith and colleagues. ‘A view of the world that sees employees of private for‐profit companies as conflicted and doctors, or employees of public or academic bodies as not, is naive, potentially deceptive, and likely to distort reader response to new information.’ New information in surgery is sometimes revolutionary but often hard to substantiate with a robust study that would satisfy epidemiologists and methodologists. Peter McCulloch readily recognizes the difficulty of moving from proof of concept to trial development in surgery (JRSM 2009;102:51–55 ). Yet he argues that the real‐life development of surgical techniques shows a clear series of phases, which differ importantly from those in classical drug development. McCulloch goes further by proposing new reporting guidelines, modifications to randomized controlled trials, and novel study designs to address current difficulties in allowing evaluation to reach the stage of a randomized controlled trial. Finally – and yes I know this is a third article – if you would rather listen rather than read, you might consider the review on general medical podcasts (JRSM 2009;102:69–74 ). Many readers will be blissfully unaware of the upsurge in podcasts, an online audio recording, from medical publications. Will podcasts revolutionize medical communication? My own view is that the quality of medical journal podcasts has been amateurish and they have failed to add sufficient value. Is this a failure of the promise of the Internet? Possibly. But the Internet has been successful in exposing hidden competing interests, whether associated with private for‐profit, public sector, or academic organizations. The challenge is for journals to respond appropriately, and the JRSM requires authors to declare all competing interests, be they financial, political, religious or even related to being a public servant or academic.

An eclectic but combustible mix of shareholders, sex, societies, and spinal manipulation

JRSM readers often tell me that they find the journal to be an eclectic mix, leaving me unsure whether I have just received a compliment or a complaint. But if ‘eclectic mix’ means ‘something for everybody’, I'm all for it. On that basis, this issue of the JRSM will not disappoint. Journals struggle to convince their readers to change behaviour. Many journals are written in an inscrutable scientific script that defies understanding. Those that are readable—something the JRSM aspires to be, but which you may believe we fail to achieve—struggle to publish enough of direct relevance to clinical practice. Even when they do, there may be powerful external forces, such as companies and governments, unwilling to allow them to change behaviour based on the evidence. Increasingly, journals try to modify the practices of companies and governments. While changes in clinical practice can be difficult to measure, a drop in share price or a U-turn in government policy are rare but highly visible events. When the JRSM and others began a campaign against Reed Elsevier's support of arms exhibitions—were they about saving lives or ending them?—there seemed little hope of immediate relief for the unhappiness of the editorial team and readers of the Lancet, Reed Elsevier's premier healthcare journal. Richard Smith took the campaign to Reed Elsevier's annual shareholders' meeting, where he and his fellow minority-shareholders-in-arms bombarded the Board with questions (JRSM 2007;100:350). A thin crowd, writes Smith, didn't care much for him and his fellow lobbyists, although he believes they made an impact with the Board. This was one example of the visible campaign against Reed Elsevier. Meanwhile, a less publicised campaign by the Lancet's editorial team exerted internal pressure upon senior management. Hence, last month's decision by Reed Elsevier to exit the arms exhibition business was a triumph for the Lancet's editorial team, a smaller but significant triumph for the journals and scientists who campaigned on behalf of the Lancet, and a victory for minority shareholders. As Smith and his dissidents showed, it doesn't pay to hold your tongue. I once made that mistake in my brief stint in psychiatry, when I failed to ask a patient her sexual history. As a very junior doctor, I felt embarrassed at probing a depressed woman's intimate details—but my consultant damned me for being ‘mealy mouthed’. After that I made it a habit to ask tricky questions, even when there was probably no need to—a good training for journalism. With Kevan Wylie's editorial kicking off a series of articles on sexual health (JRSM 2007;100:300-301), I now realise that being mealy mouthed is a problem for many doctors. Qualitative research has shown that doctors fear opening up ‘a can of worms’ or sexualizing the consultation, for example. Wylie, a free-talking consultant in sexual medicine, has no truck with such inhibitions, stating that ‘Knowledge is necessary to secure the confidence of the physician to broach and manage the topics within the specialty.’ This new series is an attempt to bridge this knowledge and confidence gap, and begins with an article on sexual assault (JRSM 2007;100:321-324). The JRSM's eclectic mix becomes combustible else-where, as Alan Maynard launches a few grenades at the Royal Colleges (JRSM 2007;100:306-308). Are they fit for purpose? They need to be, he argues, ‘but they have grown without regard to purpose and value for money.’ Another well known agitator, Edzard Ernst, revisits the safety of spinal manipulation with a further systematic review which concludes that, because of the uncertain incidence of adverse events, ‘In the interests of patient safety we should reconsider our policy towards the routine use of spinal manipulation’ (JRSM 2007;100:330-338) I can hear the complaints whizzing into my email inbox already—an adverse effect of the eclectic mix.

Too Little Quality; Too Many Doctors

What does it take for the Archbishop of Canterbury to pontificate on the nation's health? JRSM readers with an interest in medical history—and I know there are many—could probably catalogue centuries of religious interference in matters of public health. The Archbishop of Canterbury is now only a commentator on health unlike the Pope who is a policymaker instructing us on the benefits of chastity or the evil of condoms. But you suspect that when England's Primate offers an observation on the health service something must be bothering him. In early May, Dr Rowan Williams articulated concerns for the quality of patient care and wondered aloud about the wisdom of economic expediency, number crunching, and target setting. What about quality, dignity, and equity, was his message at the annual Florence Nightingale commemoration? Dr Williams touched on a debate that is being rehearsed daily in the UK's hospitals and general practices. Where does efficiency end and quality begin? Can we devise a system that delivers the efficiencies demanded by managers and politicians but also offers the quality of care that clinicians cherish? Is the marriage of efficiency and quality a flimsy romance worthy of Barbara Cartland? It did not require divine intervention for Dr Williams to identify a problem with the National Health Service. The media and the annual nurses' conference have seen to that. The government wants us to believe that the current financial cuts, organisational changes, and service reforms have generated a creative tension—a kind of big bang—that will catalyse the creation of a shining new health service. When the dust settles we will be shiny healthy people at no extra cost to the taxpayer. Sceptics, and there are many, believe that the only meltdown nearly as alarming as the polar ice caps is that of our beloved NHS. Others, who have never loved a tax-based system, are smiling I told-you-so smiles at the prospect of the private market that might be about to erupt. John Wright and colleagues invoke Florence Nightingale to begin their description of a series of hospital quality improvement interventions that reduced mortality at Bradford Royal Infirmary (p. 303). Their study is a quality improvement report, otherwise known as a `closed loop' audit or a `before and after' study. These studies account for much of the research output in today's NHS. Purists shun quality improvement reports but it is a type of study that the JRSM will publish. Quality matters. The key to a good quality improvement report is a valuable narrative account of the strategies for change. These strategies should be supported by research evidence. The learning point in a quality improvement report is about the implementation rather than its statistical sophistication or the magnitude of the effect. One measure of the quality of a health service might be the number of doctors and nurses per head of population. But where do you stop? Does the United Kingdom need 100 000 doctors or 1 million? Karen Bloor and her fellow health economists argue that we might have reached the point where the number of doctors is sufficient to meet the demands of our population (p. 281). Indeed, we might be in a state of overprovision, which would help to explain the government's and the GMC's sudden demand for overseas graduates to have a work permit. Arun Natarajan and Balasubramanian Ravikumar compose a requiem for international medical graduates. `Lives and livelihoods will be ruined,' they predict (p. 272). Another method of reducing the number of doctors would be to have them struck off. Robin Ferner and Sarah McDowell highlight an alarming rise in the number of doctors charged with manslaughter since 1990, a rise that cannot be explained by the recent increase in the number of doctors (p. 309). This fashion for retribution, they conclude, is not the way to foster an open culture that is required to deliver the quality of care that the Archbishop of Canterbury is demanding.

Curb Your Enthusiasm

This issue of the JRSM has a festive flavour. We offer three challenges to JRSM readers. Michael O'Brien's grand round will test the innermost ganglion of your brain (p 569), Anjan Panja has created a medical version of Su Doku (p 576), and our picture quiz will examine the depths of your knowledge of medical art (p 575). A special section for this issue explores medical classics, but with a twist. The enlightening power of hindsight allows several contributors to debunk ideas, theories, treatments and people that at one time or another were thought to be sacred in the world of medicine. Curb your enthusiasm is the message. ‘It is not entirely a male thing’, says Trisha Greenghalgh (p 545), ‘but the Human Genome Project has always struck me as an extension of the fantasies my three bothers used to have over their Meccano sets’. Nick Freemantle questions the contribution of the Reverend Bayes, father of Bayesian statistics (p 546), while Irvine Loudon shatters the legend of Ignaz Phillip Semmelweis, held by some to be the most famous name in the history of obstetrics (p 555). Ian Forgacs and Christopher Martyn, both editors, remind us of the worthlessness of cliches and impact factors (p 554, p 556). A straw poll of this section, however, would reveal the world of neurology as the most overhyped. Elliot Slater's description of the diagnosis of hysteria as ‘not only a delusion but a snare’ is roundly criticized by Jon Stone and fellow neurologists from Edinburgh (p 547). Saad Shafqat bemoans Jean-Martin Charcot's passion for cerebral localization and the 3-day neurological examination (p 549). And Ben Harper wonders whether Huntington Disease would have been more deservedly named Lund Disease (p 550). If this series of contributions inspires you to write then do not think that you have missed out. We look forward to publishing more revisionist contributions as an occasional series. Submissions to journals are a good indication of what is bothering people and the incessant reorganization of health services in the UK and elsewhere is subjected to some insightful analysis by the high-priests of evidence based medicine. Andy Oxman and colleagues create a new word, redisorganization, which probably rings true with many of you (p 563). They discover that the literature is almost impenetrable due to creative jargon and meaningless terminology, there are over 2500 organizational theories, and an ethics committee is urgently required to prevent ‘uncontrolled, unplanned experimentation inflicted on providers and users of health services’. Thanks to the organization of journals, Jeffrey Braithewaite and colleagues also echo these sentiments but prefer to call it restructuring, and conclude that ‘unlike sex, restructuring is not essential for the propagation of humankind’ (p 542). Finally, a scoop for the JRSM. In this month's piece from the James Lind Library, Iain Donaldson unearths Franz Anton Mesmer's attempt to organize a controlled trial of his ‘animal magnetism’ treatment, the second earliest instance of random allocation being proposed for a clinical trial (p 571). Mesmer's study never took place because of a disagreement between Mesmer and the Royal Commissioners appointed to investigate his work. One of the commissioners who chose to discredit Mesmerism was Benjamin Franklin, whose own life and work in medicine is celebrated with uncurbed enthusiasm by Lisa Gensel (p 534).

Clinical trials and tribulations

Clinical trials and tribulations

MONICA: Monograph and Multimedia Sourcebook

MONICA: Monograph and Multimedia Sourcebook

Book of the Month: In the Wake of Terror

Book of the Month: In the Wake of Terror

Health improvement and the RSM. Interview by Robin Fox.

Dame Deidre Hine, who takes office as President of the Royal Society of Medicine this autumn, qualified at the Welsh National School of Medicine in 1961. After junior hospital posts and a period in general practice she obtained the dph and was appointed to a combined clinical and administrative post in community child health with the Glamorgan County Council. In 1974 she became a specialist in community medicine (child health) to the South Glamorgan Health Authority. In 1980 she took up the post of senior lecturer in the Department of Geriatric Medicine in her former medical school (now the University of Wales College of Medicine), combining this with continued work as a specialist in community medicine. In 1993 she was appointed to the post of Deputy Chief Medical Officer in the Welsh Office. Five years later she left the Civil Service to become director of the Welsh Breast Cancer Screening Service. In 1990 she returned to the Welsh Office as Chief Medical Officer, a post from which she retired in 1997. Some of her thoughts on the National Health Service will be known to JRSM readers from her Jephcott Lecture last year (July 1999 JRSM, pp. 332-338). In August last year she was appointed to chair the Commission for Health Improvement (CHI). She is interviewed here by Robin Fox.