BMJ  2003;327 (22 November), doi:10.1136/bmj.327.7425.0-h

Editor's choice

Beyond doing

We all love action. We want to do. Thinking, in contrast, can be so irritating—going round in circles, confusing each other, and wasting time in mental cul de sacs. "We're too busy around here to think" may be said with more pride than shame, but thinking hard is fundamental to medicine.

It must be hard to think in the middle of a battle, and the pressure to help those who are severely injured is extreme. Deaths in war occur in three phases, write Jon Clasper and David Rew, who served in the 2003 Gulf war (p 1178). About half of those who are going to die do so within minutes from non-survivable injuries. Medicine has nothing to offer. About a third die within hours, mostly from hypoxia and hypovolaemic shock, and a fifth die days later from sepsis, multiorgan failure, and other complications. Those who die within hours might well be saved if given everything that modern medicine can offer, which has led to the dispersion of surgical teams around war zones.

Unfortunately most of these "second phase patients" managed by the dispersed teams die—because it takes too long for them subsequently to reach a fully equipped hospital. Clasper and Frew think their way to the unpalatable conclusion that it's best to concentrate surgical teams in well equipped hospitals. We need "realism about what is achievable."

Monitoring drug treatment seems like a good idea in order to make sure that the drug is at a concentration where it will be effective but adverse effects are common. About half of the entries in the electronic Medicines Compendium suggest monitoring, write Munir Pirmohamed and Robin Ferner (p 1179). Yet—and have you thought of this before?—drug monitoring is rather like screening: it must meet various criteria in order to be useful and not another triumph of action over thought. Pirmohamed and Ferner have adapted criteria for monitoring from the classical criteria for screening.

The adverse effect must be potentially serious, and the test simple, safe, precise, and validated. There must be an effective, evidence based intervention, and the monitoring strategy should reduce morbidity or mortality from the adverse effect. The benefits should outweigh the physical and psychological harm, and the cost should be proportionate. Just as many screening tests advocated by zealots fail the classic criteria so may many monitoring tests.

In these two cases thought should lead to less action, but sometimes it may lead to more. Hamish Cole, a retired radiotherapist, describes a chance meeting in his village with a man undergoing radiotherapy (p 1203). One of the man's biggest problems was erratic transport. Cole thought of organising a driver volunteer each day. An unexpected bonus was that the man and his wife felt supported by the whole community. But why, Cole wonders, hadn't such a simple idea occurred to him in 30 years of working in radiotherapy departments?

(rsmith{at}bmj.com)

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Relevant Articles

Trauma life support in conflict

Jon Clasper and David Rew
BMJ 2003 327: 1178-1179. [Extract] [Full Text] [PDF]

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BMJ 2003 327: 1179-1181. [Extract] [Full Text] [PDF]

Driven to distraction

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BMJ 2003 327: 1203. [Extract] [Full Text] [PDF]

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