Medical journals and the “real world”

BMJ 2002; 325 doi: (Published 06 July 2002) Cite this as: BMJ 2002;325:g

Medical journals are often accused of being remote from the real world. They present the results of trials conducted on highly selected patients in ideal circumstances. They view the world from London, Boston, or Chicago unaware that in Peioria or Harrogate patients don't turn up, won't comply with treatments, and scoff at “patient centredness” and that the local hospitals are falling down and run by people who until yesterday were running sewage plants. Well, this issue has a whiff—even a stink—from the real world.

The BMJ has published many studies suggesting that serum screening for Down's syndrome in pregnant women is more effective than screening based on age, but an audit of over 150 000 deliveries suggests that may not be true (p 15). The models in support of serum screening assumed that 5% of mothers were over 35. In fact, 15% are. An editorial considers why eradication of Helicobacter pylori often fails in ordinary practice (p 3). The answer seems to be growing antibiotic resistance. Antibiotics have traditionally been prescribed for children with acute otitis media, but systematic reviews suggest that there is little benefit (p 22). But it's hard in the real world to suggest to parents that antibiotics are not indicated. Now a further review suggests that it may be worth giving them to children who have high temperatures or who are vomiting—although even then it may be worth waiting for 24 to 48 hours.

Selected patients with stroke can probably be helped with thrombolytic drugs if seen quickly and if they undergo computed tomography. A multicentre study from Britain shows how hard this is to achieve in the real world. Only 37% of patients arrive at hospital within three hours of their stroke. Computed tomography was requested within three hours of arrival in hospital in 22% of patients but undertaken in only 8%. Ideally, all patients with serious illness would be admitted quickly to hospitals with the full range of services. But many people live a long way from such hospitals, and, says a report from the Royal College of Physicians, patients in at least 30 “isolated” hospitals are at increased risk because of the lack of intensive care (p 8). The realpolitik of reconfiguring such hospitals is terrifying—at least to politicians.

Any notion of the real world is philosophically questionable (why, for example, are my dreams less real than what I do during the day?) and certainly relative. In the United States—unlike in the vast majority of countries—they have thought it acceptable to execute mentally retarded prisoners. Now the Supreme Court has ruled it unacceptable (p 9). But consider the real world of Sierra Leone described in the obituary of Arthur Osman Farquar Stuart (p 47), the “people's doctor” of Sierra Leone. “What a relief,” he wrote, “to be free of the soldiers who would cut a pregnant woman's belly open to settle a bet whether she was carrying a baby boy or baby girl.”