Polythenia gravis: the downside of evidence based medicineBMJ 1995; 311 doi: http://dx.doi.org/10.1136/bmj.311.7021.1666 (Published 23 December 1995) Cite this as: BMJ 1995;311:1666
- Down End Research Group
- Correspondence should not be addressed
The impetus for this case report and study protocol was the admission to hospital of a senior physician with a fractured neck of femur. On the night of the accident the patient had got up to pass water and slipped on a pile of journals still in their plastic wrappers which were lying on the floor beside his bed. The history revealed gradually increasing nocturia compatible with age related benign prostatic hyperplasia. On direct questioning he admitted that he had recently performed a bone densitometry measurement on himself and found a slight reduction of bone density compatible with a male menopause some 10 years earlier. He also admitted that he felt an increasing sense of guilt and inadequacy associated with an inability to keep up with the journals. On the DEWLAP index 1 he scored moderately high for his age. His JASPA score (see table 2 was 5, consistent with a mound of journals kept by the bed, avalanching both under the bed and across the room. The oldest journal in the pile was nearly five years old, and the JOCA (journal cumulative age) index (total number of journals mutiplied by the age of each one) was in excess of 100.
The patient made an uneventful recovery after surgery and returned to clinical duties in three months despite being in moderate continuous pain and receiving regular analgesia; his walking distance was only 30 yards. Follow up at this time by the orthopaedic consultant briefly recorded an “excellent result,” and the patient was discharged from clinic. Paradoxically there was a significant improvement in his DEWLAP score, perhaps because he was no longer able to get up to London (to attend meetings of college committees) and because ward rounds were abandoned after the first two patients because he could not limp any further. Despite his pain and disability a dramatic overall improvement in his affect was also noted. This followed his decision, after his stay on the orthopaedic ward, to donate all his journals (unread) to needy doctors in Third World countries. His JASPA score fell to 0 after this decision.
We have named the condition described above “polythenia gravis.” We believe that this may be the first of many cases that will subsequently be seen as the average age of doctors rises, the number of journals proliferates, and as continuing medical education preys on doctors' sense of inadequacy and leads to chronic insomnia, with ever growing piles of journals beside the bed. More importantly, we believe that this case of polythenia gravis may be the tip of an iceberg, both in terms of numbers and as the first and most easily recognised in a cluster of conditions that make up a previously unrecognised adverse consequence of evidence based medicine.
The trial protocol we describe is aimed at looking at possible management of the problem before it has even been fully defined. We believe this fulfils exactly the spirit of the government's new initiative towards funding relevant medical research related to prevention rather than treatment.
Proposed trial protocol
Title—A randomised controlled trial comparing clinicians receiving VBJs (very boring journals) with those receiving a periodical of choice (POC) using a Zelen's double consent randomisation design with the JASPA score as the outcome.
Aims of study—Primarily to reduce the JASPA score in doctors at risk; secondarily to halt the incipient epidemic of polythenia gravis.
Study group—All clinicians who claim to read any journals.
Outcome measure—JASPA score.
Power of study—Mean overall reduction of 30% in JASPA score. Sensitivity 80%; specificity 80%. 250 subjects required in each arm.
All doctors entering this trial will be randomised either to the VBJ group or the POC group. Exclusion criteria are those doctors who claim not to read any journals. At the insistence of the local ethics committee the POC is to be Private Eye, not Penthouse as originally proposed.
A feasibility study showed that all but one doctor had a strong preference for being allocated to the POC arm. We therefore rejected a subject preference trial, fearing a veto by a statistician when we sought publication. We propose therefore a modification of Zelen's double consent randomisation, which involves informing trial participants of their group allocation some time after randomisation. In this case only the control group will be informed (in case they wonder what is going on). The control group will continue to receive their VBJs as before, but they will be informed that they are now part of a study and will be asked to complete a JASPA questionnaire. They will be offered £2000 as compensation (not payment) for the time involved in completing this two minute checklist. They will not be required to read the journal.
For the duration of the trial the POC group will not be told that they are entered into a trial but will instead receive a copy of Private Eye wrapped inside the outer cover of a standard VBJ and then placed in a standard polythene wrapper. It is possible that some clinicians will complain about this treatment and will write to the editor of that journal. Their number is expected to be extremely small and therefore no account is taken of this in the power analysis. Clinicians in the POC group will also be asked to fill in a JASPA questionnaire at the begining and end of the study. Total compliance is once again anticipated by sending, at the same time as the JASPA, a plain brown envelope containing a letter from the merit award committee requesting a curriculum vitae and emphasising that a candidate's cooperation with local management and national research are looked on most favourably when names for a merit award are being selected. No further problems with compliance are anticipated.
The purpose of this trial is to show that not only do journals break necks of femurs but they also produce a generalised global sense of angst in clinicians. We feel that the unread journals themselves have a pernicious effect on the general health of doctors and that the recent thrust towards evidence based medicine will put even more doctors at risk of a raised JASPA score. A significant fall in JASPA score in the POC group during the study would be a strong indication that medical journals are at least in part responsible for the overall malaise in the medical profession at the moment. If this is shown to be the case then we would recommend that publication of all medical journals should be monitored by Ofmag (office of management of medical angest and guilt). A journal should receive a full licence only if its publishers can show that the JASPA score of clinicians who receive their journal is either unchanged or reduced by its arrival on their doorstep. We would further recommend that each specialty should be allowed only a fixed number of journals (the number to be determined by a Delphic consensus). Journal publishers would have to bid against each other for access to these “slots,” supplying a manifesto of journal contents aimed at showing why the JASPA score would fall. Furthermore, clinicians should be allowed to receive only a fixed number of journals (again depending on specialty). Persistent attempts by a consultant to take more journals than allowed would result in a referral to a JAM (journal angst management) psychologist.
Only in this way will it be possible to nip in the bud what we see as a pernicious epidemic which may yet bring the medical profession to its knees.
Conflict of interest No author has any interest in this paper, nor will they take any responsibility for its conclusions. No author will use this paper to try to obtain promotion within their department, nor will they quote it in their departmental HEFCE returns. All have promised not to quote it when trying to obtain research grants nor to use it in any other unethical way.
The authorship of this paper consists of a group of clinicians, non-clinicians, and lay people. Of the three clinicians, two are psychiatrists and the third is a non-physician C merit award holder (the least deserving). The non-clinicians are a psychologist (sitting on a number of major grant giving bodies in medicine) and a public health doctor sunk deeply in audit. The three lay members are an anthropologist studying human resource use, a jeweller living off human resource use, and a lawyer currently writing a new constitution to ensure fair distribution of these resources.