Editor's choice

A doctor ponders, a journalist reveals

BMJ editors are part doctors part journalists. The doctor in me reads this week's journal and reflects on how hard medicine is becoming and how increasingly it is about unglamorous treatment of elderly patients with chronic disease. The journalist in me wonders about the implications of the revelation that medical students are performing intimate examinations on anaesthetised patients without consent (p 97).

Medicine comes first. A group from Newcastle have been trying to stop elderly patients with dementia who have fallen from falling again (p 73). The 274 patients were assessed by doctors, physiotherapists, and occupational therapists, and then one group was randomised to receive intervention on every possible risk factorincluding balance, drugs, environmental hazards, feet and footwear, and vision. The result was no improvement compared with conventional care: three quarters of patients in both groups fell again, and a fifth died.

Hip protectors can halve the rate of hip fractures among elderly patients in nursing homes, but people often don't wear them. A German group has tried increasing the number of patients who wear them by offering free equipment together with education to staff and residents (p 76). Twenty five nursing homes were randomised to receive the intervention, and, compared with 24 control nursing homes, four times as many residents wore hip protectors and the rate of hip fractures was nearly halved.

A study from Aberdeen examined the four year results of a trial of secondary prevention in over 1300 patients who had a working diagnosis of coronary heart disease (p 84). Patients in the intervention group received multiple tests, treatments, and advice. The result after four years was 128 deaths and 125 coronary events in the control group and 100 deaths and 100 events in the intervention group.

Medicine is increasingly about complex and multiple interventions in chronically sick and often elderly patients with marginal improvements.

I predict that none of these important studies will make it into the mass media. In contrast, the journalists are likely to cover the study that shows that medical students are still performing intimate examinations on anaesthetised patients without consent (p 97). And they are right to do so. Medicine will once again be shamed, but the response most likely to improve care for patients will not be to blame the medical school but rather to encourage improvementas Peter Singer argues in his editorial (p 62).

Many medical schools have produced guidelines on good practice and the difficult issues that arise in medical education. But the challenge is to walk the talk. "You couldn't refuse comfortably [to examine an anaesthetised patient who hadn't given consent]," said one student. "It would be very awkward, and you'd be made to feel inadequate and stupid." Students should never be put into such a position, but if they are they must be brave and refuse. Should we select medical students for bravery?

Footnotes

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