Sunday, 18 February 2007

More press coverage

An article by Christina Patterson in The Independent. Reviews by Lisa Appignanesi in The Observer today, and David Shukman in The Mail and Hanif Kureishi and William Leith (p. 62 of magazine) in the Telegraph (Saturday 17 February). There's a feaure in March edition of Harpers and an interview with us in The New Scientist.

We're pleased that coverage has been so positive. But there have been two less favourable reactions. Darian featured on Sky News (Saturday 17) and was pitched against an irate doctor, who based on a perusal of the press release took us to be trying to dictate to GPs how to practise.

The Sunday Times carries a review of our book by Theodore Dalrymple. In a bizarre series of claims about our views, we hear that "the authors depict surgeons almost as necrophiliacs" and that we believe "that hypoglycaemic attacks are the consequence of diabetes rather than of the treatment of diabetes". For the latter claim I can only imagine he has misunderstood our discussion of a case study by Rosine Debray:
In another case, a diabetic man experienced a hypoglycaemic episode while speaking with a therapist. This dangerous deficiency of glucose in the bloodstream, which had often sent him into a diabetic coma in his past, had occurred while he was describing his son’s first communion. As he spoke, he became pale, trembling and confused. Reaching for the glucose he carried with him, he was unable to open the packet, fumbling and lacking the coordination necessary to handle it. (p. 67)
On weekends, the patient would spend all his time working flat out on restoring a country house. He would systematically neglect to modify his insulin dosage, although he knew full well that this would be necessary given the physical exertions he was subjecting himself to. The result was frequent hypoglycaemic episodes as well as diabetic comas, occurring almost always on weekends. (p. 274)
Type 1 diabetics have a balancing act to perform between providing their bodies with sufficient insulin to extract excess glucose from the blood, while ensuring that their food intake maintains sufficient levels. Hypoglycaemia may result from the insulin side of the balance tipping too far. As our first extract records, the treatment for this is to ingest glucose. This balancing act would become all the more difficult during an intense period of physical exertion. Perhaps we might have avoided misunderstanding by adding that the patient also neglected to control his food intake. But if Dalrymple is so keen to find fault, he's sure to find it.

His critique of our understanding of diabetes comes after this:
Having emphasised, indeed overemphasised, the role of psychology in the production of illness throughout the book, the authors ask whether it would not be better if the basic training of doctors were in literature and philosophy rather than in the natural sciences (David Corfield is a philosopher by training). The answer, I think, is a resounding no. While I would prefer my doctor to be cultured rather than a philistine, and to have a wide outlook, I would, even more, like him to have some grasp of physiology and biochemistry...
It would seem strange in a book which dwells probably much longer than most editors might have wished on the details of the immune system, the heart and the formation of tumours, that its authors would be advocating that doctors not be trained in physiology and biochemistry. And of course we don't. What is at issue is the balance to be struck in doctors' training. In view of the research reported in our book, and don't forget nearly all was carried out by medical professionals, we suggested that more time be devoted to improving trainee doctors' understanding of humans as people, especially those intending to become GPs. At present this allocation is vanishly small. This could be organised through a literature course, or perhaps better, through one which takes in books written by doctors such as Michael Balint's The Doctor, The Patient and His Illness and James Lynch's Broken Heart: Medical Consequences of Loneliness.

In a final blast, we read that
The authors do not appear to understand the limitations even of their strongest evidence. No doubt people often contracted smallpox at the lowest ebb of their lives rather than at the peaks of their existence; nevertheless, smallpox was eradicated by immunisation, not by empathy or the talking treatment.
A curious passage. Having seemingly agreed with us at the beginning of the review about the complexity of illness, we stand accused of a psychological reductionism nowhere maintained in the book itself. Indeed it seems to be Dalrymple who relapses to a simplistic psychological/medical dichotomy. Immunisation is a fascinating topic. Although deaths from many disease were declining through public health measures introduced before vaccinations were designed, clearly we have them to thank for the eradication of smallpox. But immunisation is not a simple mechanical process. Did you realise how your reaction to a vaccine can depend on the time of day it is given to you (page 215)? Or that your response to a flu vaccine can be increased by sessions of 'mindful meditation' (page 285).

Doctors who have given us their private opinions have been overwhelmingly positive. I fear, however, that what we hear and read in the media will be counterattacks from those who have taken us to be aggressively critical of the medical profession. Is dialogue impossible nowadays?

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