Editor's choice

The subtleties of medicine

Medicine is a subtle and complicated business, and the subtleties and complications probably come though more strongly in interactions with patients than in medical journals. After all, fact is stranger than fiction. But the subtleties of medicine are there in journals for those (perhaps not many) with time to reflect on scientific papers.

Consider, first, the study from England that looks at what happens to patients with low back pain (p 1356). Journals and textbooks say that "80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment." How can this be compatible, wondered the researchers, with population surveys showing that almost 40% of the adult population has back pain in a year and that a third of those experience pain for longer than four weeks. The simple answer is that most patients give up going to see the doctor even though their pain persists. So the well known fact that only a small minority of symptoms are presented to doctors can now be combined with the observation that many patients may learn to live with symptoms rather than continue to bother doctors

Consider, second, what causes pre-eclampsia? It affects about a third of pregnancies, but we are hazy on its causes. Great wisdom suggests that it's something to do with mothers or fetuses and probably both. Norwegian researchers have been looking at the role of fathers and discovered that if a woman has a baby by a man who has already fathered a pre-eclamptic pregnancy in another woman then she has an increased chance of developing pre-eclampsia (p 1343). And if a woman has a half sister who had pre-eclampsia, then the risk of her developing pre-eclampsia is higher if they share fathers than if they share mothers. A safe conclusion from this and other work is that mothers, fathers, and fetuses are all important. A more tentative conclusion is that the results are compatible with studies in mice showing that renin genes from the father and angiotensin II genes from the mother contribute to the risk of hypertension in pregnancy.

Consider, third, what you might do if you met an acquaintance with a new baby and wondered if the baby might be hypothyroid. Would you say something? Gordon Barclay experienced this dilemma (p 1368). He was not the acquaintance's doctor. He might be wrong in his diagnosis. He did what I suspect most doctors would have done and said nothing. A few days later the acquaintance rang: "I noticed you looking strangely at my baby and I took her to my doctor. He thinks she is hypothyroid. Thank you very much for noticing."

These are just some of the subtleties and complexities in this issue of the journal. Luckily they go on and on, meaning we can publish weekly for 158 years and yet rarely repeat ourselves.