Editor's choice

Challenges to orthodoxy?

It is foolish to be too certain of the natural order of things. Once the "Book of Life" is finally completed, we are expected to end up with between 30 000 and 40 000 genesbarely double that of the nematode worm, which has 18 000 (p 381). Only 0.2% of those genes are responsible for individual variation. We are not as well endowed with genes as we thought, or had hoped. In its own way, this week's issue challenges convention, in print and on the web.

Faced by a patient with recurrent low back pain, 80% of doctors would reach for an x ray form and put in a referral for lumbar radiography. Most doctors (88%) do this to reassure patients; nearly as many (78%) do it to reassure themselves. But radiography of the spine, as Kendrick and colleagues point out (p 400), is not associated with improved functioning, severity of pain, or overall health status of the patient. Radiography does have two effects, however: it increases patients' satisfaction and increases doctors' workload. The challenge for doctors is to reassure patients without recourse to radiography.

Psychiatric questionnaires that assess anxiety and depression are another frequently used investigation. In theory, they are a simple and inexpensive method of improving recognition, management, and outcome of psychiatric disorders in non-psychiatric settings. But Gilbody and colleagues (p 406) find that the reality is different. Clinicians are often reluctant to act on a positive finding, and if they have not been trained in psychiatry they lack confidence in dealing with what they find, resulting in no effect on patient outcome. Depression would be altogether better treated, argues Andrews (p 419), if clinicians managed it as a chronic disease rather than a succession of acute episodes.

A concept that might also be fresh to readers is put forward by Fagot-Campagna and Venkat Narayan (p 377). "Type 2 diabetes mellitus in children," they tell us, "is an emotionally charged issue and an emerging public health problem." It is a childhood chronic disease that primary care workers should watch out for. The prevalence is rising in North America, and data from Japan suggest that its incidence in schoolchildren has almost doubled in two decades.

If you visit our website this week you will find a paper that presents evidence against the link between the MMR vaccine and autismyou will not find it in this week's print version of the BMJ, but you will next week. The internet offers rapid publication, free of those time constraints in the paper world that frustrate both authors and readers. We consider articles for fast track review and publication, and posting the most important or timely ones on our website, ahead of print publication, means the process can be even quicker.

Footnotes

To receive Editor's choice by email each week subscribe via our website: www.bmj.com/cgi/customalert