The rhythm method

doi:10.1136/bmj.b2668

Published 2 July 2009, doi:10.1136/bmj.b2668
Cite this as: BMJ 2009;339:b2668

Editor's Choice

The rhythm method

Jane Smith, deputy editor, BMJ

jsmith{at}bmj.com

The weekly print BMJ has a familiar rhythm, which those of youwho start at the front and work steadily to the back may recognise.

At the front—indeed, most of the way through—wehave lots of serious stuff. This week, for example, severalarticles consider the complexities of diagnosis. Wytze Lamérisand colleagues studied 11 diagnostic imaging strategies foracute abdominal pain (doi:10.1136/bmj.b2431). Although computedtomography after radiography was the most sensitive investigation,they conclude that radiography followed by ultrasound, withcomputed tomography reserved for people with negative or inconclusiveultrasound results, is the best strategy, with good sensitivityand less exposure to radiation. In their accompanying editorialAdrian Dixon and Christopher Watson set these findings in thecontext of advances in imaging, increasing surgical specialisation,and pressure on beds (doi:10.1136/bmj.b1678). "It will becomeuntenable for a patient to stay in hospital with an undiagnosedabdominal problem because of a lack of access to modern imaging,"they say. Imaging will direct patients to the right surgicalspecialty, and it will save time by preventing patients fromlanguishing in beds while being observed.

Yet time is still available in primary care, and is a powerfuldiagnostic tool, suggest Susanna Almond and Nick Summerton intheir discussion of the "test of time" (doi:10.1136/bmj.b1878)Used wisely, it helps "protect the patient from the harm ofunnecessary investigations and the ‘cascade’ effectof unexpected abnormal results generating further tests." Intheir companion article on acute diarrhoea in adults Roger Jonesand Greg Rubin show how (doi:10.1136/bmj.b1877).

But despite the carefulness of these strategies, cliniciansoften stay wedded to a wrong diagnosis, in the face of counterevidence,and in his Analysis article Ian Scott aims to explain why (doi:10.1136/bmj.b1860,p 22). It’s our cognitive psychology. The same mentalprocesses that allow us to think very efficiently can let usdown in over 40 different ways.

Political and organisational thinking often seems less precisethan clinical reasoning, and no less problematical. Nigel Hawkes,for example, muses on how stubborn Britain’s inequalitiesremain—and how little health care can do about it (doi:10.1136/bmj.b2604).And Jeanne Lenzer reveals how lax regulation of medical devicesis (doi:10.1136/bmj.b2321).

But then you reach the back of the BMJ—and some iconoclastundermines it all. This week there are several candidates: LiamFarrell invents Dante’s 10th circle of hell (for patientswith certain expectations) (doi:10.1136/bmj.b2644) and TheodoreDalrymple suggests merit in an 18th century debate on whetherthe ancients or the moderns were best (doi:10.1136/bmj.b2410).He thinks Hippocrates might have the edge. But my prize goesto Tom Jefferson for his review of the book Dread: How Fearand Fantasy have fuelled epidemics from the Black Death to theAvian Flu (doi:10.1136/bmj.b2610). This is a tale of fear—andthe people who profit from it; and for Jefferson it explainshis puzzlement at "why and how a relatively benign disease suchas flu [has] been turned into a fund raising, raging monster..."

For readers who start at the back of the BMJ the whole experienceis, of course, the other way round.

Cite this as: BMJ 2009;339:b2668

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