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Rapid Responses: Rapid Responses published:
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Benificence vs self interest
- Mark Worsley (8 January 2007)
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What a Review!
- Jay Ilangaratne (10 January 2007)
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BMJ wastes opportunity to raise serious issues
- Pritpal S Tamber (10 January 2007)
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Patients and journals
- Liz Wager (11 January 2007)
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Complacency in the School of Psychology in Birmingham
- Iain Chalmers (12 January 2007)
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Knocking Clinical Science
- Raymond Courteney Tallis (12 January 2007)
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Using the public
- David M Perks (14 January 2007)
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Richard Smith's book
- Alex Paton (16 January 2007)
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The author responds
- Stuart WG Derbyshire (20 January 2007)
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Re: The author responds
- Jay Ilangaratne (27 January 2007)
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When "Peer Review" Means "Not Peer Reviewed"
- Clifford G. Miller (16 February 2007)
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Why did I write a book that was so critical of medical journals? A gallimaufry of theories
- Richard Smith (14 March 2007)
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Mark Worsley, Anaesthetist & Intensivist Stirling Royal Infirmary FK8 2ND
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Derbyshire, in his review (1) of Richard Smith's 'The Trouble with Medical Journals' acknowledges the author's position that doctors as human beings are subject to human faults, but takes the author to task for pointing this out, preferring to hope that their moral character will prevail: 'Medics deliver more because they are compelled by professional concern to act against their self interest..'. In his Personal View (2) on the facing page, however, Justin Zaman wonders whether we need 400 plastic surgical trainees when there only seem to be 20 training programmes. 'Is there really all that burns and reconstructive work?' Perhaps the apparent popularity of plastic surgery reflects self interest rather than benificence? Doctors strive to do their best for their patients, but are subject to the same human temptations and failings as anyone else. It would be better to acknowledge these difficulties, discuss them openly and provide guidance, rather than dismiss them as they are somehow embarrassing to the profession. In the context of medical journals, Smith's book offers such discussion and guidance and contrary to the reviewer's conclusion, should be considered useful. Mark Worsley, Stirling 1. Derbyshire SWG.Medical Journals:past their sell by date? BMJ 2007; 334:45. (6 January) 2. Zaman MJ. We don't need another 400 plastic surgeons. BMJ 2007; 334:44. (6 January) Competing interests: None declared |
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Jay Ilangaratne, Founder www.medical-journals.com
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It is rather surprising that the reviewer feels[1], there would be "serious problems" if patients are put into editorial boards as suggested by Dr Smith. Looking into the reasoning of the reviewer's supposition, it is clear that he firstly attempts to generalise that all patients would be too ill to undertake such tasks,and it would be overly burdonsome on them to do so. It is unlikely that Dr Smith was referring to patients in such extreme states of illness or anyone who thought such role would have a negative impact on the illness. Surely, there are enough people(patients) out there, who would be more than fit and willing to undertake such role. Perhaps, the reviewer is unaware of the extremely useful roles played by patients in both governmental and private sectors in various capacities including positions akin to membership of an editorial board. The point about "unlikely to be representative" is hardly a major issue in the context of the suggested role. The reviewer says the "most serious problem" is that "patients are not medical professionals".With respect, this indicates the reviewer's lack of knowledge of the real composition of editorial boards of medical journals, and his misinformed belief that a medical qualification/experience is a prerequiste to be a part of an editorial team. Perhaps, the reviewer has also failed to appreciate the in-depth personal experience and first-hand knowledge that a well informed patient could bring to a journal's editorial success. Further, at a time when doctor-patient partnerships in decision-making,Patient-Choice, and greater transparency are promoted at an unprecedented level, it is suprising indeed, that the reviewer thinks the introduction of patients "can only enhance antiprofessional and consumerists views and....erode professional concerns as doctors lose control of their own discipline"; at best, I find that a very extreme guess, and at worst, it could amount to scaremongering.Though the truth might hurt some, it is entirely unjust to suggest that this book contributes to "erosion of professionalism". However, irrespective of the quality of this reveiw, perhaps Dr Smith might be pleased that his former journal has given some publicity to his post-BMJ writings. References [1]Stuart W G Derbyshire. Medical journals: past their sell by date? BMJ 2007; 334: 45 09.1.07(08.1.07) Competing interests: I've had many dealing with Dr Smith when he was the editor of BMJ. I'm a patient. |
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Pritpal S Tamber, Managing Director Medicine Reports Ltd
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I am amazed that the BMJ has published such a negative review of a book that should be shaking medicine's foundations. Medical publishing has many failings; the fact that this book is not compulsory reading for all may well be yet another. Although starting positively, Derbyshire describes Smith's concerns as not "obviously supportable". Smith, together with colleagues at JAMA, has probably done more than anyone to search for 'evidence' for the true value in the cornerstone of medical publishing: peer review. Much of the research conducted at the BMJ during his tenure showed that there is little to no objective value to the process [1], and yet journals and their editors persist with - and advocate - it; their only defense being 'there's nothing better', even though few have tried to find an alternative (to my mind there is only one notable exception [2]). Derbyshire also talks of the "essentially positive fundamentals of the profession". While this may be true, one has to remember that so much can rest on a publication - a job, a promotion, a grant approval, the licensing or the withdrawal of an intervention. It would be naive to believe that all medical publishing is informed by these "positive fundamentals". Indeed, there are more and more articles describing how unscrupulous authors have 'played the system' and corrupted the scientific record bringing potential harm to patients worldwide [3]. Indeed, many editors can tell unlimited anecdotes about the behaviour of (admittedly) some authors, reviewers and readers that have hardly had their "moral character" enhanced by their chosen profession. To my mind, the book is brimming with important ideas but Derbyshire describes them as "neither necessary nor helpful". The one that he dismisses in detail is putting patients onto editorial boards, his rationale being that it would put "the journal into the hands of novices who have no stake in the intellectual integrity of the journal". He implies that editors are not novices, but this is completely untrue. While they may be experts in their scientific/clinical fields, few editors have even the basic understanding of editorial or publishing matters, including the pros and cons of peer review. This is usually not through any fault of their own, but the result of an institutional failing within medical publishing. Editors are often appointed without any clear process, there is no formal training, only recently has a Code of Conduct been devised (but few journals have adopted it) [4], and there is no way to measure whether an appointee has done a 'good' or 'bad' job. I cannot think of any other respected profession that would allow such a flawed recruitment and training process, especially when there is so much at stake. Derbyshire then says that the "status of a journal is a matter for the members of the discipline that the journal supports" but those of us within the publishing industry will know that often the only entity that really matters is the owner, as is evidenced by the constant firing of respected editors [5,6]. He also seems to be appalled at the idea of having "consumerist views" at the heart of medical research and yet it would seem to me that being patient-focussed is key to the business of healthcare (and let us not be fooled into thinking it is anything other than a business). Finally, I am deeply saddened to see the BMJ waste this opportunity to raise such important issues. All publications cover their backs by saying that the opinions expressed are those of the author and not necessarily of the journal, but in essence the BMJ has chosen not to give these issues more of an airing. I'm afraid I see that as an awful failing. In her Editor's Choice, Godlee confidently concludes "Medicine and communication are changing, and so too is the BMJ". Change is often good, but any industry must first understand where it is before it can devise where it wants to go. This book should be a significant sign-post in medical communication's journey. It's unlikely to be that if one of the world's most influential medical journals cannot see the wood for the trees. References 1. Godlee F, Jefferson T. Peer review in health sciences. 2nd ed. London: BMJ Books; 2003. [Both this, and the book being reviewed, are brimming with references to articles about peer review, almost all of which show that it is of limited value] 2. Biology Direct; http://www.biology-direct.com/ [To my mind, this is the most interesting experiment with peer review to date. Note that I have a competing interest in that I was formerly employed by this publisher] 3. Chalmers I. Role of systematic reviews in detecting plagiarism: case of Asim Kurjak. BMJ 2006;333:594-596. 4. A code of conduct for editors of biomedical journals. http://www.publicationethics.org.uk/guidelines/code [It's worth noting that Smith was instrumental in making this code happen] 5. Spurgeon D. CMA draws criticism for sacking editors. BMJ 2006;332:503. 6. Smith R. The firing of Brother George. BMJ 1999;318:210-210. Competing interests: I am the Secretary of the World Association of Medical Editors (WAME), a Council Member of the Committee on Publication Ethics (COPE), a friend of Richard Smith's (I think), a BMA member, and have been employed by the BMJ on two occasions, the first of which was reporting to Richard Smith. I was also formerly employed by the publisher whose journal I advocate in reference 2. |
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Liz Wager, Publications Consultant Sideview, Princes Risborough, Bucks, UK, HP27 9DE
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I was saddened to read that Stuart Derbyshire considers that involving patients more closely in medical journals might represent an 'erosion of professionalism within medicine'. His views on patients (which take up over a third of his review of Richard Smith's book) actually tend to reduce my trust in doctors and remind me of the patronising paternalism from which I had hoped enlightened practitioners were moving away. Smith is not calling for unqualified people to act as reviewers and decide which papers get published, but merely for some representation on journal editorial boards. According to Derbyshire, this would be 'placing the identity of the journal into the hands of novices who have no stake in the intellectual integrity of the journal'. But who gets hurt if journals publish research irrelevant to clinical practice, or dubious findings that increase confusion rather than advancing science? Surely it is patients? It seems extraordinarily insular to believe that patients do not have a stake in the integrity of journals, and dangerously naive to believe that doctors have all the answers. Competing interests: I am not medically qualified, but am a member of the BMJ's Ethics Committee and on the editorial board of Medscape General Medicine |
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Iain Chalmers, Editor, James Lind Library Oxford OX2 7LG
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Stuart Derbyshire writes: "The introduction of patients into the heart of medical research and communication can only enhance anti-professional and consumerist views and thus erode professional concern as doctors lose control of their own discipline." This complacent attitude to the state of medical research and communication could hardly be more eloquent as an illustration of one of the reasons that academic medicine has been in decline. Young minds in Birmingham University are unlikely to be prompted to come up with imaginative ways of contributing to a reversal of this decline if they depend for encouragement on a senior social scientist with Dr Derbyshire's views. Richard Smith's book challenges the research community - including journals - to assess whether the public is getting good value for its money. Derbyshire's review is the kind of arrogant response that does nothing to reassure those of us on the outside of his world that it is reformable. Competing interests: None declared |
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Raymond Courteney Tallis, Retired Professor of Geriatric medicine 5, Valley Road Bramhall Stockport SK7 2 NH
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Richard Smith's assumption that clinical science is badly compromised by the influence of vested interests, big pharma and even fraud on trials that get done and the outcomes that are reported leaves him with a good deal of explaining to do. How does he account for the extraordinary advances in health and life expectancy over the last few decades in developed countries, which are increasingly due to medicine narrowly construed? What of the progress in the prevention and treatment of cardiovascular disease much of which is due to drug treatment? Or is the human body also in hock to the pharmaceutical industry? Is myocardium susceptible to PR? Does the vascular tree respond to spin? Of course there is some bias in the construction and reporting of drug trials; some researchers are in thrall to vested interests; and a proportion of data are fraudulently generated. Science, as Smith says, is after all, a human institution. But tell me one institution that orders its affairs better. The law? Politics? Journalism? If these were regulated as effectively as clinical science, the world would be considerably better and better run than it is now. And if clinical science were not superior in respect of its pursuit of truth and effectiveness to the courts, the instruments of government or journalism, orthodox medicine would be as useless as alternative medicine, in which PR entirely takes the place of properly conducted trials. One final point, none of us is without vested interests, including, or especially, those who enjoy pointing out other people's vested interests and relish the not inconsiderable pleasure of life on the moral high ground. Competing interests: I occasionally receive honoraria for lectures and travel expenses for professional meetings from the pharmaceutical industry. |
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David M Perks, Science Teacher Graveney School, SW17 9BU
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Why is it the case that in every field of scientific endeavour the public is used as a source of legitimacy behind which professionals and institutions want to try to hide? I find the response to Stuart Derbyshire's review illustrative of a collapse in confidence within the medical profession about the capacity to act in the interests of medicine. The remarkable insight that those involved in research are human beings is put forward as if it is a revelation. Well yes science is carried out by people. But people who have a connection with the project of extending human knowledge and our capacity to act in the world. I rather think the description of human beings used to hold scientists upto account bears little resemblance to the lofty ideals of medical science. What is most surprising is not the denigration of humanity implicit within this response but more that it originated from within the medical profession itself. The crude sociological critique of science and its institutions is something I expect to find within sociology departments not within the confines of a prestigious peer review journal. The claim that peer review has been undone by the recognition that we all bring our interests to the table when we engage in any project seems to have undermined the legitimacy of any of us to claim interests beyond the selfish and private. Whilst we are all individuals we act in a world of which we are a part. It is by acting on the world stage that we gain legitimacy by holding up our ideas to the scrutiny of others. If we now admit that we can no longer be trusted to judge the actions of our peers then we have surely given up on the lofty ideals of medical science to understand and shape the world in our own interests. It would be a shame if we have abandoned the sense of common purpose medicine once upheld for humanity. The attempt to try recover a lost sense of purpose by appealing to the public will not enhance the battered reputation of medical research. It is the public who turn to the medical profession to look for their own certainties about what medicine can do for them. If peer review journals are now turning to the public for answers it can be no surprise if this leads to further erosion in the public perception of medical science. Competing interests: None declared |
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Alex Paton, retired physician oxfordshire OX10 7DJ
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The disgruntled editor’s tale Richard Smith became editor of the British Medical Journal (BMJ) in 1991 when he was not quite forty. With the brashness of youth he announced that Latin and Greek would no longer be used (thus potentially excluding many medical words) and that oldies would no longer be welcome as contributors (thereby upsetting the Establishment). That he still suffers from ageism is suggested by the relish with which he quotes a colleague: “The old guys have gone; they don’t like computers”. As a grumpy old man (like his comedian brother) I disapprove of this attitude. In 2004 according to Private Eye he “jumped ship” to become chief executive of the European arm of UnitedHealth, a giant American healthcare corporation that had allegedly been fined several million dollars back home for shady practices. This was all the more extraordinary because he had written a fighting editorial in the BMJ in1999 called “Perfidious financial idiocy: a ‘free lunch’ that could destroy the NHS”, condemning New Labour’s Private Finance Initiative (PFI). Let’s hope he has as little success with privatising the NHS as he claims to have had in running the BMJ. His mission had been to produce a popular journal that could be read by anyone, but he admits today that “the long march from being dense, dry and unreadable [not everyone would agree]…to being more like popular magazines” has not yet been achieved. Perhaps it was disillusionment that prompted a change of direction. Certainly the picture he paints in The Trouble with Medical Journals, by which he means the four leading general journals in the west – BMJ, Lancet, Journal of the American Medical Association (JAMA), and New England Journal of Medicine – is bleak, with never a touch of humour. The problems are spelt out in relentless and repetitive detail which makes for a depressing read, especially as most of the examples he quotes have been extensively rehearsed elsewhere. Yet in spite of what he regards as insuperable difficulties, 115 000 copies of the BMJ continue to be distributed worldwide every week, to be read, if not always with pleasure, at least with curiosity and one hopes sometimes with enlightenment. Could there be a touch of paranoia? He kicks off with the notorious case of the MMR vaccine and autism to illustrate the complexities of reporting medical research and how easy it is to get things wrong. Much is then made of randomised control trials of treatments and systematic reviews of evidence, which should be the gold standards but in fact are complicated by the placebo effect, bias towards reporting only positive results, and manipulation by those with an interest in favourable outcomes. Next there is the vexed question of peer review, the arduous process whereby papers submitted for publication are assessed with the help of expert referees, which may be no better than picking them at random; most papers rejected by one journal end up being published in another. Investigation of these sorts of problems was christened “journalology” by Richard’s predecessor Stephen Lock, but they are by no means the only issues that have to be faced by editors. Equally important are ethical matters: protection of patients in undertaking and reporting research; the seemingly intractable scandals of plagiarism and fraud (research misconduct) which provide salacious copy but which the scientific community is unable to combat effectively; and conflicts of interest – authors employed by the drugs industry, for instance, or representing patient groups with a vested interest. (Richard seems unaware of a nice example affecting himself: he praises the superiority of HighWire electronic publishing “a subsidiary of Stanford University Library” without mentioning his own association with Stanford Business School.) To give him his due though he has been instrumental in founding the Committee on Publication Ethics (COPE), a self help group for medical editors. Still, everyone is a villain: authors try to get their articles published in several different journals or divide their findings into more than one paper, so-called salami publications, so as to add to their curricula vitae (sorry about the Latin). Perhaps because he was once a television doctor, Richard is relatively kind to the media, but many scientific editors would accuse them of only being interested in the latest breakthrough. He might though have made a plea for more medically qualified journalists in newspapers and magazines. And there is no need to pity the poor editor either, because according to Richard they can be as crooked as everybody else. Yet in all of this there is virtually no consideration of readers, perhaps because on the whole they are not guilty: in a long book there is barely mention of the audience and what they think. The vision of a general medical journal then is a free for all, including of course patients (a spot of political correctness), for “contributors” rather than authors (a blog?) and preferably online. In this transparent and speedy electronic world (though a recent article of mine spent several months in the system) everyone’s opinion would be equally valid. For Richard it is an illusion that the current scientific paper is an objective artefact, rather “it is a living, human and therefore imperfect document”. And probably always will be, say I, and all the more exciting for that. Competing interests. A recent innovation in the BMJ has been a statement at the end of each article about authors’ conflicts of interest. I should therefore declare my own bias. I have contributed to the journal for over 50 years, during which time there were four editors, two of whom will go down in history. I was particularly close to Stephen Lock who brought many new ideas, including the “Hanging Committee” named, with some amusement, after the Royal Academy’s practice of choosing pictures for its annual exhibitions. Richard calls it “pretentious” and “ominous”; it was nothing of the sort, but a genuine attempt to identify the best papers by two editors and a practising doctor (myself). We would look at around 20 papers (not a dozen as Richard states, but then he admits that he was never present.) My diary records: “It’s interesting how we nearly always agree instantly, having looked at the papers completely independently; we argue about one or two only.” My memory is that we had a database of 3000 referees (Richard calls them “reviewers”) in the 1980s long before he took over. Stephen’s “small study” of the fate of rejected articles actually involved the tedious job of locating 1000 papers. What is more he had already extensively researched peer review (the subject of his Nuffield Provincial Hospitals Trust fellowship in 1985), and had also taken on the challenge of research misconduct. Little of this is apparent from Richard’s account: the impression the reader gets is of his own carefully orchestrated struggle, a single handed David against the forces of reaction. Alex Paton Physician Smith R. The Trouble with Medical Journals. London: Royal Society of Medicine Press,2006 This review appeared in The Health Summary (THS)2006;23(11): 13-5, and is submitted with permission of the editor. Competing interests: I worked for the BMJ for many years |
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Stuart WG Derbyshire, Senior Lecturer School of Psychology, University of Birmingham, B15 2TT
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The responses to my review of Richard Smith’s book (1) have been largely negative, suggesting incompetence, arrogance and an unwarranted complacency. Let me briefly respond to my critics.
Worsley suggests the popularity of plastic surgery, highlighted in the same edition of the BMJ (2), might reflect self interest rather than beneficence. It might, but what other profession would so openly decry the pursuit of self interest and bring their profession to account for such brazen selfishness? Moreover, “even” plastic surgeons are likely to be driven by a genuine compassion towards their patients. Ilangaratne suggests that there are plenty of fit patients willing to serve on editorial boards and that the absence of less fit patients will not be a problem. It is strange, but apparently necessary, to have to make the obvious point that patients are defined by sickness, they are not defined by their editorial, medical and scientific prowess. Moreover, the patients who will certainly not sit on editorial boards are children, old people, the weak, the infirm, those with chronic illness, mental handicap, people who can’t speak English and those that have better things to do; in other words, most of the patients seen by doctors in the NHS and around the world. Tamber agrees, possibly, that the medical profession includes some positive fundamentals but he cautions that much can rest on a publication. Certainly it is true that doctors are under more moral pressure to do right by their patients than they are to do right by their journals and so professional standards face slippage when submitting papers to journals. But what is the solution to this? Tamber, along with Ilangaratne and Wager want to put patients onto editorial boards because patients get hurt when dubious findings are published. The problem, of course, is that patients lack the expertise to spot and prevent the publication of dubious findings. What patients can do is introduce personal and anecdotal evidence that will result in “emotion driven” publishing, which will further erode professional standards and further displace medical professionals who publish from “their” journal. Tamber tries to justify the involvement of patients as enhancing a patient centred approach but he is over reaching. Patients want confident doctors who can provide good health care; being patient centred shouldn’t mean making patients responsible for scientific medicine. Chalmers suggests I am complacent. I am not. I am distraught that doctors are sacrificing their autonomy and allowing, even encouraging, their professional values to be smeared despite good evidence that medicine has provided immense gains for humanity. Demanding reform from a moral high ground built upon poorly representative events such as the MMR debacle, the Shipman murders and occasional instances of fraud will provide for change but to what end? Tallis has elsewhere described in detail that a defensive medicine based on hostility and distrust will breed the mantra of, “first, cover your ass and damn the harm” (3). Perks usefully reminds us that peer review is not just a practical exercise in sifting out bad papers from good but is a statement of our collective belief that fellow medical professionals can judge the work of their peers. Yes we are human beings, but our pursuit of better understanding and better treatment for our patients means that we commit to the scrutiny of each other in the knowledge that such scrutiny will improve our practice for everyone. Turning to the public, however, will only confuse and demoralise all involved. Finally Paton provides his own review of Smith’s book, which is far more critical than mine. Paton suggests that Smith makes everyone a villain but that is not quite true. Contemporary villains are those who uphold professional autonomy and defend the principles of medicine as being essentially good and honourable. 1. Derbyshire SWG.Medical Journals: past their sell by date? BMJ 2007; 334:45. (6 January) 2. Zaman MJ. We don't need another 400 plastic surgeons. BMJ 2007; 334:44. (6 January) 3. Tallis R. Hippocratic Oaths. Atlantic Books, 2004; Horton R. Second Opinion: Doctors, Diseases and Decisions in Modern Medicine. Granta Books: London, 2003. Competing interests: None declared |
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Jay Ilangaratne, Founder www.medical-journals.com
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In his reponse Derbyhsire states, "Tamber, along with Ilangaratne and Wager want to put patients onto editorial boards because patients get hurt when dubious findings are published.". It should be clear to any reasonable person that I did not either directly or indirectly say that patients should be put into editorial boards "because patients get hurt when dubious findings are published". It is not clear why Derbyshire felt necessary to misinterpret my comments like this.Finally, he need not be so "distraught" because in reality, doctors are not sacrificing their autonomy.I appreciate that Derbyshire is not part of the medical profession. Competing interests: Have responded to this topic before. I have had many dealings with Dr Smith when he was the editor,BMJ. I am a patient. |
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Clifford G. Miller, Lawyer, graduate physicist, former lecturer in law BR3 3LA
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Dear Sir, When "Peer Review" Means "Not Peer Reviewed" As a former editorial board member of a journal, peer review is, as I have always understood it, the process by which the peers in the scientific community pass judgement on the work of others. Why does the BMJ call refereeing what it is not? Whilst one or two people might cast their eye over a paper before it is published, perhaps with rigour and perhaps not (and there is no test for the reader to tell which) that is not peer review. A refereed paper has not been tested against scrutiny of a sceptical and critical audience at large. Further, even after publication many papers are still not so scrutinised - perhaps because there are so many of them and others have not the time to do justice to the task. So calling a paper "peer reviewed" is one of the most misleading descriptions in publishing today. Worse still, in my professional work some of my brothers in law think that the conclusions of a "peer reviewed" paper are sacrosanct when they are likely to be the least reliable part of the work. ___________________ To contact Clifford Miller go to www.cliffordmiller.com Competing interests: None declared |
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Richard Smith, A cat of a different stripe Clapham SW4 0LD
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I’m grateful to the BMJ for reviewing my book on medical journals, even though the reviewer thought it was tosh. He may well be right--who am I to judge?--but the Lancet was more favourable. I’ve reflected on how it happened that I went away to write a book about medical journals, to which I’d devoted most of my life energy, and came back with a book that was effectively a “j’accuse” against journals. One of the many beauties of life is that we don’t understand our own motivations--even when we think we do. But I have developed a range of theories on how it happened. My conscious theory is that I had time to look at the evidence and that the evidence showed mostly defects. A semiconscious theory is that I was approaching the subject from an ethical point of view--as I was supposed to be writing a book on publication ethics--and an ethical analysis points you towards problems. The simplest theory is that I was indulging my iconoclastic streak, one of my strongest characteristics. Or it’s perhaps that as a follower of continuous improvement I’m trained to be interested in what’s wrong. “Every defect is a treasure,” says the philosopher, because it gives you an opportunity to improve. “If every defect is a treasure then in medicine we are sitting on King Solomon’s mines,” says David Eddy. Certainly, I’ve always been terrified of complacency. Maybe it’s simply that the closer we are to an institution the more we are aware of its defects. Leaders of the BMA will understand this, and, famously, those who admire the law and sausages should never watch either being made. It could be nothing more than the fact that a book (or film) needs to have a central argument. Once you’ve started down an argumentative track you need to keep building it. But my main reason for sending this rapid response is that I’ve been reading John Berendt’s book on Venice, “The city of falling angels.” It was in a 15th century palazzo in Venice that I wrote my book. Berendt’s book is very readable but not in the same league as his masterful book on Savannah, “Midnight in the garden of good and evil.” But in his Venice book I came across these quotes which may explain the book I wrote. “What is true? What is not true? The answer is not so simple, because the truth can change. I can change. That is the Venice effect.” Count Marcello “Venetians never tell the truth. We mean precisely the opposite of what we say.” Count Marcello “In Venice, no matter what you say, everyone will assume you’re lying. Venetians always embellish, and they take for granted you will, too. So you might as well. Because, funnily enough, if they discover you’re someone who tells the truth all the time, they’ll simply write you off as a bore.” Rose Lauritzen I don’t mean that I’ve lied. I simply mean that in Venice the truth is elusive--as, I’ve always thought, it is everywhere. Richard Smith Competing interests: I'm the author of the book that was reviewed and a former editor of the BMJ. |
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