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Views & Reviews Review of the Week

Observations from on high

BMJ 2008; 336 doi: (Published 08 May 2008) Cite this as: BMJ 2008;336:1073
  1. Colin Douglas, doctor and novelist, Edinburgh

A new book of medical musings on topics ranging from basic science to cheese willhelp clever doctors pass the time, Colin Douglas finds

This collection of medical musings comes with a veiled warning in its foreword: the pieces first appeared as columns in the Quarterly Journal of Medicine. Not in the BMJ or the Lancet, and definitely not in any of the cheery throwaways whose columnists are the medical equivalents of Private Eye’s immortal Phil Space and Polly Filler. No, they first appeared in the QJM; and the QJM, we are reminded in the foreword, has a core readership of fairly senior and fairly academic physicians. So, the usual stuff of the lesser sort of column—the week’s odd case; the easy dig at management; the facile reflection along the lines of “aren’t our patients sometimes dim”—simply will not do. Fairly senior and fairly academic physicians have their standards, which we must assume are fairly high.

I hope these 50 pieces lived up to them. They certainly show evidence of serious effort. After a few hundred words of a piece about bed wetting, our attention is drawn to the relevance and utility of the theory of logical types first proposed in Bertrand Russell and Alfred North Whitehead’s Principia Mathematica almost 100 years ago. Helpfully, for the less senior and less academic of us, its essence is summarised before we move on to learn of its relevance to Bateson’s theory of humour. Its relevance to bed wetting is, of course, the main point, and eventually we get there too; although after all that foreplay the outcome is anticlimactic—a sensible, even obvious, course of action is neatly justified. But thinking like this no doubt helps clever doctors pass the time in a mundane 10 minute appointment.

The author—at various times a GP and an analytic family therapist and on occasions a patient and a family man too—ranges widely. The collection has pieces on evolution, on basic science, on history taking, on postmodernism, on travel medicine, on personal illness, on teaching and supervision, on cheese and choice and health care, on some failures of our NHS, and on much else besides. There is observation well done and scholarship that reaches into odd and sometimes interesting corners.

If the collection has a general problem it is that too much of it comes mulched with a rich psychoanalytic compost: glosses, reflections, and assertions that to the broad agnostic church of British medicine today might seem nothing more than the quaint disputed orthodoxies of a dwindling sect. And in these circumstances two and a half pages of quite small print on the case of Anna O and her hundreds of hours with Breuer might be a real risk. How quaint and distant it all seems now, and wherever did it take us?

But there are high points. A piece entitled “Weasel Words” begins with a better than average NHS jargon word game around those toe curling job advertisements decked out with goodies such as “exploring new realities” and “promoting sharing risk through integrated delivery.” Firstly the author amiably mocks such nonsense, then he skewers it for what it is: “this pervasive deceit in the public services” with its “corruption of language, corruption of thought, and corruption of action.” Ouch. Now he’s almost as good and as tough as Orwell. People might reply to those advertisements, but have they any idea what they might end up doing if they got the job?

And he’s good too at the personal. We are mortal, and first we get ill. Launer does it in style. His account of an electrocardiography technician’s best efforts variously to control, ignore, and diminish him while confidently confusing him with another patient is a model of its kind: both as NHS worst practice and in the description of it. If only it could have been included in the offender’s annual appraisal folder, much good might have come of it. On fatherhood too he shines. Twins are a complex and rewarding challenge, and he covers it well: from the first exposure to well meaning gratuitous nonsense from strangers, through the early literature (Shakespeare had twins, which explains a lot), and on to the intricate science of zygosity, by then, in the context, fairly painless.

But in one or two pieces the art overwhelms the matter. One in particular struck me as intriguing, if only because its ideal audience might be small or minuscule. How many devotees of the sonorous paratactic rhythms of the Old Testament might also be fans of the majestic force of evolution? Aren’t these interest groups much at odds these days? But perhaps Launer, with his account of phylogenesis in a pastiche of Genesis (“And the deuterosomes are also in the likeness of worms. And we are of the deuterosomes, because when we are newly formed in our mothers’ wombs, yea, our anuses are open even before our mouths . . .”) has happened upon an unlikely means of at least getting them to sit down and reason together. I certainly hope so, but I won’t hold my breath.


  • How Not to be a Doctor

  • John Launer

  • RSM Press, pp 108, £24.95

  • ISBN 978 1853157523

  • Rating: **

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