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First, the main reason given to justify its blanket introduction is that ‘surveys show’ that patients want rapid access. We all know that we want isn’t necessarily good for us, but before I am accused of paternalism (heaven forbid that doctors should know best how to run their practices), ask yourself this: in how many of these surveys were patients asked whether, in return for rapid access for any problem, however trivial, they were prepared to pay the prices of (a) lack of choice of doctor, (b) being triaged away from the doctor, (c) telephone advice as a substitute for a face-to-face consultation and (d) lack of follow-up care and continuity? Practices and their patients are discovering that these are the consequences of prioritising rapid access, as complaints about lack of appointments are replaced by complaints about lack of choice and continuity. There is no such thing as a free lunch. The change of focus from long-term therapeutic relationships (whose benefits are intangible and difficult to measure) to short-term interventions may have unforeseen consequences for the future health of our patients, and for our own levels of job satisfaction (and thus recruitment and retention). Only time will tell.

The World Health Organization estimates that a $60 per capita annual health spend is needed if the main diseases, such as AIDS, malaria, and tuberculosis, are to be contained. Currently the average health budget in the poorest countries is under $10 per capita. Economic crisis and austerity programmes slashed health budgets during the 1980s and it is going to be very difficult to regain the lost ground, especially with an AIDS pandemic of massive proportions. Many are hoping that PRSPs will facilitate a new dialogue between governments and users of the health services that will allow resources to be targeted at the poor more efficiently, and that government control of the health sector will improve, but, simultaneously, plans for increased privatisation of health care are sweeping Africa.
The need to address the broader health determinants One of the main problems with the delivery of health to poor countries is that health care is seen inside a box, while the wider determinants of health, such as access to sanitation, clean water, and food, are considered in different boxes. Health is all too often equated with the provision of health services -and not health outcomes. A full understanding of the links between health and its determinants at different levels is still missing. For example, the poor are more exposed to environmental hazards and natural disasters than the rich. Also missing from PRSPs is how poverty-reduction programmes fit into other programmes, such as the Global Fund for AIDS, Malaria and TB; WTO and GATS policies; and health sector reforms.
Governments need to be held responsible to their citizens and especially to vulnerable groups. Health must be seen as a human right and not as a means to economic growth, which is the way in which the international financial institutions tend to think of it. Commitments should be linked to realistic budgets and the implementation of policies should be monitored closely. Unfortunately, many feel that PRSPs have little chance of achieving any of this.
The reaction to the PRSPs comes in two forms: the optimists say it may be a window for improved dialogue with the poor in formulating a country's health policies, while the pessimists say it is no more than window dressing or rearranging the chairs on the Titanic, as Africa's health slides further into the icy sea of chaos.

Poverty reduction and health
From the journals, October 2002 ...

N Engl J Med Vol 347
1151 Why do people with eczema get so many skin infections, whereas in psoriasis they are rare? It's all to do with endogenous antimicrobial peptides, a newly discovered but very ancient system of protection for body surfaces, found in 400 million-year-old hagfish as well as higher animals. 1169 Antibiotics for otitis media? Here's a useful review suggesting we use them only if there's a fever and a bulging drum. 1227 The final vindication of the idea put forward by Geoffrey Keynes in 1922 -that lumpectomy and radiotherapy should replace mastectomy in the treatment of breast cancer. 1318 Subtotal hysterectomy is a bit simpler to perform than total, and the results are good: in fact for both kinds of hysterectomy, bladder, bowel and sexual function are normal at 12 months in this follow-up series. 1397 More about heart failure from Framingham: a declining incidence in women but not in men. Dilemmas of heart failure epidemiology are discussed in the editorial on page 1442. 1403 Physicians in the USA have been reluctant to give up digoxin in heart failure without atrial fibrillation, and the DIG study in 1997 seemed to show a small reduction in hospital admissions. But this analysis of the effect by gender shows increased mortality in women.
Lancet Vol 360 1037 Non-steroidal anti-inflammatory drugs worsen heart failure and antagonise the effect of ACE inhibitors: could the same be true of low dose aspirin? No, says this systematic review. 1071 And in the general population, NSAIDs are not associated with adverse cardiac events -this study looks at rofecoxib. 1155 Just call me CYP -the cytochrome P450 system gets abbreviated. Which is just as well, as it's so important in drug metabolism, as this complex review explains. 1203 If anyone doubted that particulate air pollution from motor traffic causes morbidity and mortality, here is a study from The Netherlands, plus one from Dublin on page 1210 and a comprehensive review on page 1233. JAMA Vol 288 1622 A review of the benefits of exercise in type 2 diabetes and hypertension. 1723 The obesity epidemic in the USA is described in three papers. 1867 Low blood folate is associated with increased risk of miscarriage. 1889 Bone densitometry is a big issue here and in the USA -here is a useful guide on how best to deploy it. 1994 Bad news for sedentary reviewers: exercise reduces coronary disease in men in a doserelated manner. 2015 A meta-analysis of the much-debated link between homocysteine and vascular disease. It seems to be mediated largely through increased systolic blood pressure.

Other journals
Arch Intern Med Vol 162: lowering blood pressure prevents dementia (page 2046). Heavy analgesic use is associated with a two-fold risk of hypertension in women (page 2204). A three-year study confirms an earlier six-month study in the Lancet: glucosamine reduces the symptoms and progression of osteoarthritis (page 2113). Men with hip fractures are usually osteoporotic but often get no treatment (page 2217). Ann Intern Med Vol 137: get ready to pronounce ximelagatran -it may replace warfarin as it needs no monitoring and prevents deep vein thrombosis after knee replacement (page 137). What and where is consciousness? With positron emission tomography you can actually watch the brain waking up (Brain 125: 2308). Headache has its own journals, such as Cephalalgia, which reports on a trial of topiramate to prevent migraine (22: 659) -it works, and tends to cause weight loss too. The Scandinavians have at last found a use for acupuncture -it seems to work for labour pains (Acta Obs et Gyn Scand 81: 943). It's a bit worrying to discover a 'common' condition one has never heard of: common variable immune deficiency 'is prone to underdiagnosis' says the QJM 95: 655 where a case series is described, mostly presenting with recurrent chest infections. Thorax 57: 880 provides welcome evidence that giving children with asthma long-term inhaled steroid treatment markedly reduces hospital admission. And Spine (27: 2291) contains yet more evidence that lumbar spine X-rays do not affect clinical outcomes in low back pain, though they increase patient satisfaction. For a (non-systematic) review of this topic, see Ann Intern Med 137: 586.

Plant of the Month: Arbutus 'Marina'
A hybrid strawberry tree, probably the same cross as Andrachnoides, and very beautiful in form, bark and evergreen leaf. The drooping clusters of tiny waxy pink flowers are replaced by the orange-red fruits throughout winter.

theophrastus bombastus flora medica
A RE you interested in the relationship between the arts and humanities and medicine?
In February 2002 the Association for Medical Humanities was formed at a meeting of individuals interested in medical humanities held at the University of Birmingham.
Medical humanities is an interdisciplinary approach to education, health care, and research, which includes exploring health and illness through literature, fine art, the performing arts, history, philosophy, and medical ethics. We believe it can broaden the education of health professionals and deepen our understanding of the experience of health and illness.
The Association aims to promote the medical humanities in education, health care, and research within the UK and the Republic of Ireland by providing a forum in which those interested in the field can exchange ideas, develop academic and educational rigour, and find support from colleagues. The Association is linked to the journal Medical Humanities (an edition of the Journal of Medical Ethics), which is published twice a year. The first annual conference and AGM will take place at the University of Durham in July 2003 and we plan to publish a newsletter providing regular information on initiatives, degree programmes, research results and much else.
If the Association is to be successful it will need a broad and representative membership. There are three categories of member: individual, institutional, and student. The annual subscription rates are: individual -£15, institutional -£40, student -£5. If 1 At the time of the interviews, partners in at least nine of the town's 13 practices were participating in either medico-political activities, education and training, or in some type of paid non-GMS provision. And the doctors frequently described all this as adding variety to everyday working lives in general practice, as well as providing an important connection with developments in medicine and in the delivery of medical services.
For over 60 years GPs have provided the local professional football team with a doctor, the town with police surgeons, social care agencies with medical services, and private nursing homes with medical cover. From the 1960s onwards, new posts became available within a growing range of hospital specialisms while some opportunities have declined, including medical posts with industrial companies. More recently the number of medico-political positions have grown and family doctors not only continue to represent colleagues on the Local Medical Council (LMC), but have also become increasingly involved in a range of new organisations.
The organisations that have emerged in the past decade include Renfrewshire Emergency Medical Services (REMS, the out-of-hours co-operative), the Local Health Care Co-operative (LHCC), and a number of community-based health initiatives, including Have a Heart Paisley -a project funded by the Scottish Executive. 2 As a result of their involvement in such activities, GPs know more about each other's partnerships than they would have in the past and there is evidence of an increase in inter-practice co-operation in the town. In addition, new opportunities are developing for the doctors involved in these structures. One of the key organisers of REMS, for example, has left practice to take up a post with NHS 24 (the Scottish equivalent of NHS Direct).
Such initiatives build on an earlier history of activism that involved smaller numbers of GPs and a smaller range of organisations, including the LMC and the Royal College of General Practitioners. 3 The oral testimonies suggest that there has been little rivalry between the leading activists of the RCGP and the LMC in the town. Instead, a spirit of close collaboration, mutual respect, and a common goal of improving general practice mark recollections.
While the range of 'outside interests' has been important, the paid medical posts in both the private and public sectors have also shaped the development of general practice in Paisley. Of these, it is the hospital appointments that have proved especially significant, according to the GPs. The earlier removal of family doctors from hospital posts in the years immediately following the formation of the NHS could have led to a complete division in British medicine. 4 However, as GPs with hospital appointments have argued, sessional posts have allowed for positive relationships to develop with hospital doctors and for GPs to remain in touch with hospital medicine. It is also worth noting that many of these posts belonged to the areas of medicine that have traditionally been viewed by hospital doctors as having a relatively low status (including geriatric care, dermatology, and mental health care).
Particular activities, including hospital posts, have often become associated with particular partnerships in the town and younger GPs have found themselves inheriting positions from older partners. While there are breaks in continuity, as a practice decides to give up a commitment and another takes it up, there are clear patterns of activity over time. There continue to be continuities in practices' involvement in particular outside interests. This development has contributed towards an informal specialisation of general practice. Some practitioners, for example, talk about either attracting particular patients or have patients with certain conditions referred to them by their partners, because they deal with such conditions or patients in their hospital posts.
There is also unease, with the GPs often describing outside interests in negative terms. Some younger partners engaged in the less lucrative organisational developments have found themselves in conflict with older partners who are engaged in paid work. One GP who found himself in this position characterised his practice as 'money-minded'. Another practitioner recalled a former colleague and GP trainer, who left general practice in the 1980s as a result of the pressure he felt from his partners. In part, such anxieties contribute to a shared concern that care needs to be exercised regarding the amount of time and energy expended on organisational activities, or as one GP noted, it is necessary to 'keep life manageable'. 5 Similarly, among some of those engaged in paid posts there are worries that outside interests could detract from their NHS duties. It is interesting to note that there is a recurring emphasis on the ways in which finances from external work are used to pay for initiatives aimed to help NHS patients. Working in such a mixed economy seems to produce stress and strain for the profession.  In the face of opposition the health centres were never built in Paisley. Other issues, including resource allocation, continued to face politically active GPs in the 1990s.

Community participation in primary care
Community participation in health is a practical application of the theory that 'social capital' is required for a healthy society. Primary health care can contribute to this by developing the capacity of communities to take collective decisions about the issues that influence their health.
Family doctors are essential to this process in Cuba. It is the norm (although not universal) for the doctor to live in the neighbourhood where they work, in many cases above the consultorio. In attending the d o c t o r ' s consulting room, patients are not only expected to consult for advice but to be consulted in return about their needs and health concerns. Small patient lists and strong p e r s o n a l relationships are the foundations for effectively involving the community in health.
Family doctors work closely with a c o m m u n i t y nurse, often seeing patients together. Around half of their time is designated to proactive activities, such as home visiting, health education, and needs assessment. They must provide an annual report, described as a community health diagnosis. They are also required to regularly attend neighbourhood meetings, such as those of the popular councils.
Popular councils are neighbourhood fora for discussion and decision-making. Council participants include neighbourhood associations ('committees for the defence of the revolution'), local members of 'mass movements' (such as the Cuban Women's Front), and representatives of various grupos de ayuda (support groups). The latter are set up to provide social interaction and support for vulnerable members of the community. They include, for example, 'grandparent circles', set up to provide social and exercise-based activities for older people.
A recent campaign against a resurgence of the once endemic dengue fever depended for its success on this close working between communities and health services. Family doctors were given a pivotal role so as to capitalise on their relationship with popular councils and mobilise community networks. The epidemic was eradicated within a remarkably short period of time.
Above neighbourhood level, the organisation of primary care is planned so as to provide synchronicity between health areas and local authority municipalities. Family doctors are involved at each level of this hierarchical structure, and may serve as municipal health directors. Each municipality relates specifically to one medical school, which is responsible for undergraduate and postgraduate training as well as overseeing the inspection of practices.
In the absence of this close structural relationship between health workers and communities, other Latin American countries have experimented with 'health and peace-promoting municipalities'. Common characteristics include community assemblies, health-promoting schools and making use of a wider diversity of talent in health. Lay health promoters, traditional healers, and workers drawn from anthropological and sociological disciplines, have all been effective when integrated into the primary health care team. In particular, they have helped to provide means for using community health beliefs creatively and developing culturally appropriate responses to perceived health needs, in many cases without resorting to medical technology or drugs.

Challenges to UK general practice
British general practice is perceived in Cuba to have provided an important historical M OLDOVA'S capital is Chisinau. Its centre is pleasant and leafy. During early morning jogging I see sweepers who keep the parks immaculately clean. Traffic is orderly and the lights are working, and most people are dressed much more elegantly than at home. Still, I am in a country that has become one of the poorest on earth. When I buy a beautiful, handmade chess set for £2, I realise that someone has spent over a week on it and that the shop makes a profit. I give the equivalent of 20p to an old woman begging outside a bank and she sinks on her knees. She has some change in her hands perhaps not worth more than one penny altogether -I have just given her a fortune. Almost half a million of Moldova's inhabitants are working elsewhere, mostly illegally, in Russia, Italy, Portugal, Spain. Their remittances keep their families afloat.
Moldova is a particularly sad example of the over-hurried transition from the Soviet command-and-shortage economy to one based on private profits. Regard for governance or justice fell by the wayside. It has opened up its markets but stands no chance in the new world -which is not so free trading after all. Moldova is fertile but the USA has just announced that it will raise its farm subsidies to near the levels of the European Union. The profitable sectors -weapons production and drug running -are in a part of Moldova that remains outside government control. The gap between rich and poor widened more than in most other ex-communist countries. Interestingly, countries such as Poland and the Czech Republic, where inequality rose less, are faring much better.
I am representing the RCGP, together with Kevork Hopayian, at a conference on family medicine in the former Soviet and Eastern European communist countries. It is fascinating to hear what the delegates have to say. Some countries appear to have got their acts together. Bulgaria is developing a social insurance-based health care system. To reverse a trend, it pays its general practitioners considerably more than hospital doctors. Kazakhstan has oil money to spend and is moving forward, as are Latvia and Lithuania, which are looking to Scandinavian countries for help and inspiration. Many countries have based their family practice organisation and training on European Union models.
Health care in most other countries is in a bad state. In communist countries, the status and pay of doctors is very low, compared with other professions. This has not improved in the post-communist era. We are told that in some parts of Russia, half of GP vacancies are unfilled and half of the working GPs are pensioners who will quit as soon as pensions rise. Most Russians appear to deeply mistrust the state, which had already become an instrument for privilege and favouritism in the communist years and has worsened ever since. Salvation is expected from privatisation. We are met with utter disbelief when we explain that the railways in Britain are being renationalised after the private sector made a mess of it, and that it is often preferable to be in an NHS hospital, rather than a private one, when you are acutely and desperately ill.
What did RCGP representatives do here? We gave presentations about different systems of primary care and evaluation of services, about health aid, postgraduate training, and education. But most participants knew more about the ways things are done in the UK, other European countries, and North America than in neighbouring countries.
Perhaps our roles were to be relative outsiders, helping to facilitate and to reflect. We felt appreciated and we learned much about ourselves. It struck me that in many countries the battle for ideas has been won in favour of equity-oriented social insurance or taxationbased health care systems. This has happened in spite of massive lobbying for private forprofit health care. Continuity and personal doctoring are seen as central values. It is amazing then, that we in Britain appear to be at risk of losing this in the new GP contract.
It was striking, too, to realise that being a doctor, a GP, can give that instant sense of professional brotherhood and sisterhood. It may well be a politically incorrect thing to talk about brothers and sisters in our post-Hippocratic GMC days -but dealing with life, illness, and the trust of patients remains a special and precious vocation.
Most countries without mineral wealth will continue to depend on foreign aid to pay for their health systems. Many participants appeared keen on maintaining international contacts to exchange information and to learn from experiences. There may be a role for the RCGP and it could be a truly two-way process.

ary Care Conference -'Lessons of -21 June 2002
context for the emergence of a biopsychosocial theory of health. Both systems share much in common, not least a national health service, free at the point of need, accessed through a registered family doctor. Cuban family medicine is evolving, however, in a direction that diverges considerably from recent historical developments in the UK.
Clearly, the political, cultural, and societal demands differ greatly. While there are far more GPs to go around in Cuba, their income is astonishingly small compared with that of British GPs. The challenge of responding to the relentless marketing that drives rising consumption of medical technology is largely absent in Cuba. The Cuban experience, however, raises many valid challenges for UK general practice.
Home visiting and needs assessment by GPs in Cuba are seen as the basis for responding to the lived experience of communities in setting the priorities for primary care locally. This contrasts with strategies promoted in the UK to manage 'patient demand', such as telephone consultations, nurse triage, and avoidance of home visits. Can we respond adequately to needs as perceived by our patients when we increasingly meet with them on our own territory and on our own terms?
Active participation in neighbourhood organisations is seen as a core element of quality medical practice in Cuba and not a pastime for the devoted few. Can 'methods' for community consultation by Primary Care Groups in the UK ever become part of a practitioner's core concerns without such a network of personal relationships with key community members?
Cuban GPs are local residents in the areas where they practice, sharing the same neighbours, shops, schools, and amenities. While this is true in many affluent neighbourhoods in the UK, the same cannot be said for most deprived communities. Do we unwittingly contribute to the Inverse Care Law when the future of our own children does not depend on the advancement of the community in which our patient's children are being raised?
The Cuban model represents GPs as actively responding not only to medical needs, but to the social, housing, and environmental concerns of their patients. The bureaucracy surrounding such concerns in the UK is perceived to be a major and unnecessary burden on GPs. In disengaging ourselves from this so as to focus on defined medical services, are we also attempting to abdicate our responsibility to work with patients and communities in making healthier lives possible? Peter Cawston Cosme Ordonez Moldova essay 'I was thought and called very stupid and obstinate. ' Elizabeth Fry Journals, 23 August 1828 D YSLEXIA is a debilitating disorder which affects about 3% of children (which means approximately one in each classroom). It is a syndrome which, despite variation, displays a recognisable pattern. 1 It is independent of social class, 2 it tends to run in families, 3 and has a ratio of males to females of about four to one. 4 Some dyslexics may have special talents. 5 Post mortem examination and, more recently, brain scan techniques, 6,7 have shown that the brains of dyslexic individuals are differently organised, having abnormalities in the language areas of the cortex.
There is possibly some malfunctioning of the cerebellum, 8 which would explain why some dyslexics are clumsy or have poor handwriting.

Elizabeth Fry (1780-1845)
Among the historical figures who overcame the problems of dyslexia was Elizabeth Fry. Her major contribution to society is commemorated today by the recent selection of her portrait to appear on our £5 notes.
Elizabeth Fry, who was a Quaker, was the child of a Norfolk banking family. 9,10 She began her prison work in 1813 when she entered Newgate prison in London. There she faced 300 fighting, gambling, halfnaked and often drunk women, all imprisoned in a space of 190 square yards. She possessed remarkable speaking skills and organisational ability, encouraging others to help her to establish a school for children who accompanied their mothers to prison. Order replaced chaos and her success became the talk of London. She travelled throughout Europe advising on penal reform and establishing committees of local ladies to visit and inspect their prisons.
Elizabeth Fry became involved in other philanthropic activities, establishing libraries for the coastguard and navy and forming 'Friendly Societies', which encouraged the poor to save. Through her formation in 1840 of the 'Institution of Nursing Sisters' she made a major contribution to nursing reform, which is at last receiving recognition. 11 Dyslexia: importance of early diagnosis If dyslexia is recognised early (say, by the age of seven or eight years), its negative effects can largely be prevented. If diagnosis and aftercare are denied, however, the price can be very high. The undiagnosed dyslexic may be accused of laziness or of 'not trying' and may be subject to all kinds of stresses. 12 In extreme cases the result may even be a custodial sentence. This tragic result is often owing to the necessary intervention falling between four stools; representing parents, teachers, general practitioners, and educational psychologists.
Despite the gap of two hundred years, the evidence as to whether Elizabeth Fry was dyslexic will be presented as a reconstruction of her likely responses to questions or simple tests put to her in a doctor's consulting room today.

The consultation
When informed that the patient is a poor speller the doctor should immediately consider the possibility of dyslexia. Lack of intelligence and/or educational opportunity must be excluded. This can certainly be done in Elizabeth Fry's case: her education, thanks to her caring Quaker parents, exceeded that offered in many schools today.
Sometimes there is comorbidity with dyspraxia, with attention deficit hyperactivity disorder (ADHD) or with Asperger's syndrome.
As part of the diagnostic procedure the doctor may wish to use the Bangor Dyslexia Test. 13 This test is suitable for use with both children and adults, and, apart from its diagnostic function, it can serve as a way of helping dyslexic individuals to talk about and come to terms with the things that have put them under stress. We lack information on how Elizabeth Fry might have responded to many of the items in this test; we do not know, for instance, whether she would have shown any uncertainty over 'left' and 'right' or whether she would have had difficulty in repeating tongue-twisting polysyllabic words, such as 'preliminary' or 'statistical'. However, the present-day doctor may well find the patient's responses to such questions interesting and informative.

What is your problem?
The commonest early manifestations of dyslexia are lateness in learning to read and difficulty with learning to spell. These, however, need to be related to other signs, and a diagnosis needs to be made on the basis of the total picture.
Response: there is no evidence as to whether Elizabeth Fry was late in learning to read. With regard to her spelling, however, her private unedited journals of approximately 500 000 words 14 give overwhelming evidence that she was a poor speller ( Figure  1 gives an example of her writing at age 17). Examples of the many spelling errors in her journals include 'impreshon' for impression, 'intomit' for intimate, 'peeple' for people, 'drayhths' for draughts, and 'whent' for went.
Her journals are in total contrast to the standardised literary style in contemporary publications, where both grammar and spelling are identical to what is found today. supported.

Apart from the spelling, what is your writing like?
Some dyslexic children have very untidy handwriting, and some have considerable difficulty in learning grammar and punctuation.
Response: An examination of Figure 1 shows that punctuation consists of an occasional dash, the sentences rambling on. This example of her handwriting was specially selected -in much of the journal it is barely legible. Even in middle age, she admitted to being 'a poor scribe'. (Untidy handwriting on its own is, of course, not an indicator of dyslexia; it has been suggested that, if it were, a disproportionate number of medical doctors might be diagnosed as dyslexic!). Conclusion: Diagnosis of dyslexia is supported.
Are you slow at getting things done? Slowness (e.g. at completing homework) is a feature of many dyslexic children.
Response: Elizabeth Fry writes 'I have observed today how slow I am doing things ... I have so much slowness in my composition'. In another passage she comments on how slow she is in comparison with her sister, Richenda. Conclusion: Diagnosis of dyslexia is supported.

Do you have any problems remembering things?
Many dyslexic children tend to forget instructions -for instance, they may not remember what homework has been set. Immediate memory can be tested by asking them to repeat random digits -both forwards and in reverse order. They also may find difficulty saying the months of the year, particularly if they have to say them backwards.
Response: Elizabeth Fry writes 'I am so forgetful … I receive an idea quickly but it soon vanishes'. Conclusion: Diagnosis of dyslexia is supported.

Is there a similar problem in the family?
In about 50% of cases of dyslexia there may be affected relatives. Is there anything you are especially good at? Many dyslexic children are especially gifted at art, and some may even become poets or writers.

Response
Response: Two of Elizabeth Fry's daughters note that 'she certainly always possessed more genius and ready quick comprehension, than application or argument'. Conclusion: Her life confirmed unusual ability.

Summary of diagnostic findings
The case for saying that Elizabeth Fry was dyslexic rests not on any one sign on its own but on the different signs taken in conjunction. Particularly relevant are her poor spelling, her sometimes indecipherable handwriting, the absence of punctuation, her self-reported slowness and forgetfulness, and the 'genius and ready quick comprehension' mentioned by her daughters. The repetition of words in the sentence just quoted is also a tell-tale sign.
Critchley and Critchley 15 specifically mention a variant of dyslexia that 'may present itself in the guise of atrocious, barely legible handwriting, coupled with a mild degree of spelling disability and unorthodox punctuation'. These words precisely describe Elizabeth Fry's literacy problems.

Management of the dyslexic child
Dyslexic children need plenty of encouragement, as in many cases their selfesteem is likely to be low. Being set to memorise spellings, dates, etc. is difficult for them and unrewarding. This is what Elizabeth Fry wrote at the age of 48: 'What great care is needful … not to force children to learn too much as it not only injures them but gives a great distaste for intelectual persuits [sic] -the instruction should be adapted to their condition and communicated in an easy and agreeable way'.
In some cases dyslexic children may feel encouraged if they are told of dyslexics who achieved lasting fame, for instance, Hans Christian Anderson, Thomas Alva Edison, Michael Faraday, and William Butler Yeats. Among contemporary eminent dyslexics are the actress, Susan Hampshire, and the racing driver, Sir Jackie Stewart.
Parents should be encouraged to tolerate such irritations as forgotten messages, missed appointments and school books left at home. Dealing with these problems is a matter of common sense. A word processor with a spellchecker, and a calculator may prove invaluable.
Contacting the school is the desired course of action, with subsequent referral to an educational psychologist being sometimes indicated. The address of the British Dyslexia Association is: 98 London Road, Reading RG1 5AU. Special techniques are now available for helping dyslexics with their literacy problems, and parents should press that persons brought in to help their children are suitably qualified. suggested to me that 'constructive post modern thought' was, in essence, an oxymoron. Not so, states the introduction by the series editor, who distinguishes this constructive (or reconstructive) approach from deconstructive or eliminative postmodernism. I counted ten different words ending in '-ism' in the introduction alone, which lets you know what you're in for. There is a striking plurality of -isms. I was therefore very grateful for Ian McWhinney's brief and lucid foreword, which summarises both the intentions behind the book and its main arguments and conclusions.

T R Miles Richard Huntsman
Modern medicine has been on shaky philosophical ground for some time now. Founded on Cartesian dualism and the rationality of the Enlightenment, it has achieved a huge amount for mankind over the past century. Le Fanu, in The Rise and Fall of Modern Medicine, describes these achievements in fascinating detail, but concludes by attacking the 'intellectual falsehoods of the Social Theory and the intellectual pretensions of the new genetics' (page 405). The undermining of clinical judgement by evidence-based medicine, and the hubristic greed of the pharmaceutical industry, he suggests, is turning us all into patients, or at least consumers of drugs. In the process, public and private health systems are being bankrupted.
Illich, writing in 1976 about social iatrogenesis and the invention and elimination of disease, predicted it all. In trying to eliminate suffering, we doctors inevitably create more, as we have engendered in our culture the deeply rooted misapprehension that all suffering is avoidable. This is a profoundly unhealthy belief.
Furthermore, while we in the West become medicalised, the health problems of developing countries, victims of the global market, are sidelined by modern medicine. As Solomon Benatar tell us, 87% of international healthcare expenditure is spent on 16% of the world's population. Ninety per cent of research expenditure is spent on diseases causing 10% of the global burden of disease.
So, if these are just some of the problems, does this book offer some solutions? Foss starts with a detailed discussion of the limitations of the reductionist mechanistic view of medicine. The views that the mind is only matter, that all complex processes are reducible to a large number of simple processes, and are ultimately explicable in terms of 'physiology gone astray' are attacked on scientific and philosophical fronts, and found wanting. His 'successor model' rests on two premises. One is that the human body, or mind-body, is a selforganising system rather than a mechanism. The other is that, within this organism, energy flows are separated from information flows. Energy transfers effect predictable, long-recognised physiological or pathological processes. Information transfers affect many parts of the organism simultaneously, releasing the potential within the organism -body and mind. Because we are reflective, self-referential beings, able by the exercise of will to affect our own physiology and pathology, these effects are complex, unpredictable, and contingent on the unique characteristics of the individual organism, and on the social milieu within which that organism lives. Information is transferred by 'memes', selfreplicating psychosocial information units passing from mind to mind. Thus instead of immunology, we have psychoneuroimmunology; instead of pathophysiology, we have pathopsychophysiology, and so on. Neurolinguistic programming techniques seem to employ these information flows in a carefully calculating way.
In the development of the theory, there is an acceptance that, as Bernard Williams says, the Enlightenment is intellectually This model, says Foss, is 'infomedicine', the successor to biomedicine. Perhaps it should be infobiomedicine? It will come as no surprise to family doctors, who have been quietly working with this model, expressed through intuition and judgement rather than in academic language, for decades. Foss acknowledges his debt to McWhinney, whose Pickles lecture of 1996, 'The importance of being different', still represents the best summary that I know of the essence of general practice. He also quotes Kuhn's remark that paradigm shifts come from the edges of a discipline, not the centre. It's hard to imagine such a profound shift coming from an interventional cardiologist. Recent analyses of medicine in terms of chaos and complexity and postnormal science can be subsumed within the infomedicine model, as can Dixon and Sweeney's study of the human effect in medicine.
Will this approach help to address the issues of hubris, medicalisation and injustice discussed above? Probably yes, if the concepts move beyond academia, where they currently rest, and are incorporated into the delivery of health care, based on an expanded ethic incorporating interpersonal ethics, public health ethics, and the ethics of international relationships; the model suggested by Solomon Benatar. This perhaps, should be the basis for the postmodern global order discussed in the foreword.
Is infomedicine really a science? I can't think of a test of falsifiability that might answer that question, but there may well be one. It's intriguing, however, to read about a scientific theory purporting to explain How Things Really Are (apologies to Richard Rorty), which also claims to be postmodern. Perhaps the Truth is still Out There.

John Gillies
'Here be angels' 1 not the kind with gilt dinner plates on their heads stuck with vicious looking knives shooting ray-gun fire no, the kind who wears a purple angora cardie while crocheting blankets from cloud who wraps you in wings as big as a hug until you forget what colour knickers you possess never mind are wearing the kind who winks, eyes crinkling laughter at the corners, until you laugh at yourself too, for being pompous; the kind who teaches you how to lean into the bend when you ride pillion 1 Heather Hawkins/voyaging 'The angels' share' They roll around drunk in the aisles of the distillery cellar after everyone's gone to bed, legless (or wingless?) on whisky sniffed through the wood, straight into their blood, or whatever pumps through their hearts -'quintessence' I supposeprobably mostly whisky.

For David
Our toes touch as we sit crocheting cloud into fields and snowflakes each as big as a blanket; patchworked together, they mound over our laps and cuddle our backs.
Through the gap created by our unravelling of the cumulus which pillows our feet I can see the world we have wovenand all is well all is well all manner of things are well.

It takes two to tango
For the Lindsays I'd like to dance with you, angel: one firm hand in the small of my back, one pair of wings arched over us, and a halo, soft as lamplight, to guide the way; we don't know the steps (perhaps there is no choreography to the music of the spheres) but your naked feet touch my feet.
I'd be afraid if you were a seraph, so awesome and yet so bashful: two wings to cover his face, and two to cover his genitals and two more to fly 1 -A cherub wouldn't do eitheronly going on wheels in straight lines, with all those faces, and all over eyes 2 we'd never know which way to go. Now I want to sleep, angel in spoonsme breathing into golden hair cushioned by one wing, the other draped over; dreaming I'm in heaven.

reflection
T HIS review is about a systematic effort to evaluate the work of a group of primary care practices that employ anthroposophic medicine and show some unusual features. The research addressed three questions: What is anthroposophic medicine, as interpreted by doctors and others working in general practice? How is it organised and delivered within primary care settings in the United Kingdom? What impact does it have on patients, both in terms of clinical outcomes and patient responses?
Six general practices and primary care teams and a 16-bed residential unit were evaluated. They share a common source of inspiration in principles proposed by Rudolph Steiner and use clinical methods and treatments derived from both conventional and complementary medicine. Their patients are registered under the National Health Service, but most of the practices have developed charitable resources, which pay for additional staff and structures or special forms of treatment.
Anthroposophic medicine is an extension of conventional medicine. It is based on the beliefs that each individual is unique; that scientific, artistic and spiritual insights may need to be applied together to restore health; that life has a meaning and purpose; that the loss of this sense may lead to a deterioration in health; and that illness may provide opportunities for positive change and a new balance in a life.
It aims to provide a means by which people can develop their own latent capacities. It involves a variety of therapies including, for example, art and music therapy, eurhythmy, massage, and counselling as well as anthroposophic medicines. It offers opportunities for work and for social rehabilitation. Its study must be based in a multifactorial and multilevel view of human health and illness -a huge challenge to scientific method.
Answers to the three research questions were provided mainly through a descriptive, qualitative approach. No comparison with the work of other practice teams was attempted. That would have been too ambitious, requiring the research group to surmount a cluster of barriers to achieve valid comparisons. Some of these barriers could not even have been foreseen without the sort of exploratory study that has now been carried out. Nevertheless, it might be expected from work done elsewhere 1 that patients in a practice where, for example, they are generally seen by one GP throughout the whole treatment programme and have received an initial consultation of at least 45 minutes, would report positively on their care and that they might prove to be more 'empowered' (the criterion of quality proposed and elaborated by Howie 2 ).
Although mainly descriptive, this study does pilot three before-and-after comparisons of the effects of treatment: first, a qualitative assessment of physical, psychological and behavioural outcomes, through interviews in which patients were asked about effects they had felt or observed; secondly, two separate questionnaires completed by patients about their health (both currently used in primary care research). These research methods were chosen because they most closely represent patient priorities for their lives and health care, addressing their own concerns rather than imposing standard questions which may not be relevant to them. The three types of assessment gave consistent results in terms of physical and, to lesser degree, psychological outcomes. There was evidence of benefit to patients with chronic conditions, but it was not possible to disentangle the effects of anthroposophic treatments from other influences, such as the supportive relationship and the amount of time offered. The number of patients was small and there was no control group. As the authors point out, the study demonstrates only that it is feasible to use these tools for this group of patients and practices.
This detailed and thoughtful report of 150 pages focuses on anthroposophic medicine, but this particular problem can be seen as representative of other multidimensional or complex problems in primary care. Indeed the evaluation of primary care overall, particularly the central role of the clinician-patient relationship, faces similar methodological challenges. Is it realistic to single out the care of one illness when so many patients have more than one at the same time? Or one form of treatment when more than one at the same time is common practice? Does the intentional neglect of other influences on a patient than the one selected for study lead to misleading conclusions and inappropriate practice? Such problems of research method -and the choice of ways forward -are faced and discussed by the authors. One conclusion stands out -that quantitative evaluation is cogent, but inadequate. Combined with qualitative and descriptive work, it gains both meaning and usefulness.
I hope that this difficult task will not be abandoned at this point.

On quality and quantity
T HERE is no single issue more important to the improved health of the nation than the drive for quality, to whose mast the RCGP has firmly Blu-tacked its colours. Top quality clinical medicine is -or should be -within the intellectual reach of every doctor. And a steady narrowing of the gap between aspiration and reality is -or should be -the experience of every voting tax-paying patient. We know pretty much how it is to be done. Non-threatening incentives to promulgate best practice. A ratcheting-up of the present 'minimal competence' level of summative assessment. Replacing the culture of blame with a culture of cooperation and common sense. Vocational training based in general practice. And so on. Investment, time, resources. The long haul, the big picture, the non-partisan vision. Pursue the drive for quality, and the nation's blood pressure will soon be impeccable, its cholesterol level beyond reproach. Patients in their droves will scarcely have time to scribble a 'thank you' note to their GPs before they're up on the operating table having their veins done.
On the other hand, there is no single issue more important to the improved health of the nation than the drive for quantity, to whose mast the Department of Health has firmly nailed its colours. Nailed? Would that it were anything so flimsy. Riveted, welded, superglued. The logic is at first sight irresistible -more care for patients requires more appointments and more time, and hence more doctors. More doctors means more recruits, faster training, fewer failures, fewer dropouts. But since we apparently need about another 6000 GPs by a week on Tuesday, they are not going to be delivered by what we've come to regard as the normal channels.
So the chicanery has already started. The press gangs have set to work recruiting GPs from Spain and Austria, wooing them with fables of that healthcare paradise which is the UK. The (so far) very few who have been seduced will have their expectations quickly downsized to British levels and will be fast-tracked into practice in the most disadvantaged areas. Deaneries are already under pressure from the DoH to lower their selection and training standards, and one at least has been told that the answer 'no' is unacceptable. The embryonic Postgraduate Medical Education and Training Board (from whose title the word 'Standards' has interestingly been quietly dropped) will have most of its 25 members appointed by the Secretary of State, to whom alone it will be accountable.
For some reason I find myself remembering a little scene I saw being played out at my local garden centre this morning. Judging by the scrum around the wallflowers, you'd think they were giving away a crate of Beaujolais nouveau with every half-box. The adults were tight-lipped and ruthless, elbows flying, trolleys cutting swathes through the competition like the war chariots of Boadicea. But the under-fives were having a whale of a time. The centre has rather a nice take on the shopping trolley; some of them, for the use of parents with imaginative children, are got up as toy cars. While the grown-up pushes towards whatever it is the grown-up wants, Junior is seated behind a red plastic steering wheel. The wheel, of course, is connected to nothing at all. Nevertheless, 'Brrmm brrrmmm!' goes the kiddy, engrossed in a private fantasy of power and control, steering vigorously to the left in the direction of the preserves and biscuits. And the other shoppers smile indulgently. But today the wallflowers were over there, to the right.
Quality and quantity agendas, as currently formulated, are irreconcilable. 'Better equals fewer' and 'more equals worse' are simultaneous equations with no solution. Unlessbrainwave! -the College, which continues to cherish the hope that MRCGP will become the entrance standard to unsupervised practice, can increase the exam's pass rate to 185%. That should do it. But otherwise the College's policy of 'promoting excellence in family medicine' may make us the enemies of the Department, whose imperative is to do a quick paint job on the NHS in time for the next election. Diplomacy, persuasiveness, and an unblinking gaze are required of our leaders, and we should pray for them now as never before. In the short to medium term, our quality agenda puts us potentially in the same relationship to government as a hedgehog to a truck.
We can console ourselves that hedgehogs, as a species, multiply and survive, while trucks ultimately turn to rust. Meanwhile, though, it would be sad if the last that was heard of us for a bit was a happy 'Brrmm brrrmmm!' dying away on the indifferent air.

College Constitution
The Honorary Secretary presented the proposals to introduce new constitutional documents for the College and formally moved the two resolutions on the agenda, which were seconded by Dr John Toby.
Concern was raised by Sir Denis Pereira Gray that the wording of Article 14 of the Supplemental Charter, which set out the rights of honorary fellows, was inappropriate as it did not confer a right on such fellows to attend College general meetings. Although this provision had not been changed from the existing Charter and Ordinances, following further debate, the Honorary Secretary proposed an amendment to the wording of the Article, which was seconded by Dr Philip Evans and agreed by the meeting. The amended Article read as follows: '14. An honorary fellow is entitled to attend general meetings and to receive all general notices sent out by the College to its members and to participate in the activities of the College as decided by the Council, but shall not as such rank as a member of the College. Persons previously elected as fellows ad eundem are deemed to be honorary fellows for the purposes of this Article.' The substantive resolutions were then put to the meeting separately. The President asked the meeting to vote on each and on a show of hands the first resolution was passed nem con thus fulfilling the requirement for support by twothirds of those present and voting. The second resolution was then approved nem con.

Welcome
The President welcomed everyone to the meeting and referred to the Mace Procession which customarily opened the meeting and which on this occasion had been led in by the College piper, Dr Ronnie Seiler.

Appointment of Honorary Fellows
Dr Sheila Adam, Professor Sir Ian Kennedy, Professor Bengt Linder, Professor Roger Strasser, and Mrs Sarah Thewlis were appointed to Honorary Fellowship and presented with their Fellowships by the President.

Presentation of Awards, Medals, Prizes and Scholarships.
The President presented and announced Awards and Scholarships as set out in the booklet Awards and Fellowships 2002, tabled at the meeting.

The Rose Prize
The President announced the Rose Prize , a new award jointly supported by the Worshipful Society of Apothecaries and the RCGP for a project on the history of medicine. The award would be presented once every two years and the first such occasion would be in 2004.

Appointment to and Presentation of Fellowships
The meeting appointed to Fellowship those members whose names appeared in the booklet Awards and Fellowships 2002, tabled at the meeting.

James Mackenzie Lecture
Professor Mike Pringle, University of Nottingham, presented the James Mackenzie Lecture 2002, entitled 'A Dog's Life'.

Annual Report of Council 2001-2002
The Chairman of Council, Professor David Haslam, presented the Annual Report of Council for the year 2001-2002 and highlighted major events. The report was adopted nem con.

Accounts for the Year 2001-2002 and Auditors' Report
The Honorary Treasurer, Dr Tony Mathie, presented the Accounts for the year ended 31 March 2002. He also presented the report from the College's Auditors. The Accounts were adopted nem con.

Auditors
Messrs Buzzacott were proposed and appointed as Auditors until the 2003 General Meeting. The meeting also authorised Council to agree arrangements for fixing the remuneration of the Auditors.

Annual Membership Subscriptionreduced subscriptions -Amendment of Bye-Law
The Honorary Treasurer introduced an amendment to Bye-Laws 2.(A), the effect of which was to delete the words 'and has been a medical practitioner with full registration from the General Medical Council for less than 10 years' in the first sentence. This wording had proved to be confusing and had offered no benefits to any significant number of members.
It was resolved that Bye-Law 2.(A) be amended to read as follows. 'One-half of the Full Subscription Except as provided for in sub-sections (v), (vi) and (vii) hereunder, any Fellow, Member or Associate who on 1 April of any subscription year has a gross income from all professional services of £20 000 or over per annum, and has, on that date, been a Member or Associate of the College for less than five subscription years, shall pay onehalf of the full annual subscription. Gross annual income will be based on the previous year to 31 March. The five-year period will commence from the date of completion of vocational training or the first date of College entry, whichever is the later.'

Spring Symposium 2003
The Spring Symposium 2003 will be held in Bristol.

Date and Time of 2003 Annual General Meeting
The Honorary Secretary announced that the 2003 Annual General Meeting would be held on Friday, 14 November 2003, commencing at 2.00pm.

Concluding Remarks
The President thanked everyone for attending the AGM and reminded the meeting of some of the very many successful events that had been held during the College's 50th anniversary year which was concluding that day.

neville goodman
Boxes T HERE are 22 consultants in our department. All of us received a cardboard box through the post. It measured 18.5 x 13.5 x 5.5 cm. Inside was another box, a marvel of paper engineered with complex tucks and flaps, and inside that were just two pieces of paper. One was a prepaid postcard, the other a gatefolded picture of some anaesthetic equipment. Some of us opened the box, but most of us, forewarned, threw it in the bin.
So a mailshot of our department took up 0.03 cubic metres of space, first in the post office, which presumably gained something from the 44 pence it cost to deliver each box, but then in our post room, which can ill afford to have to deliver a pile of completely unnecessary and unsolicited rubbish. There are 2500 consultant anaesthetists in this country. Storz, the company responsible, took up 3.5 cubic metres of NHS space. I hope the advertising genius who thought up the idea is downsized.
I throw all advertising arriving on my hospital desk unopened into the bin. In our department, one of us sits on the equipment committee and another on the drugs and therapeutics committee. If they think we need something, they read about it, or see it, and ask the rest of us. We are generally happy to take their advice, and I don't intend buying my own private anaesthetic machine, nor my own drugs. I'm sure this is true for my colleagues, and for almost all other consultant anaesthetists. As clinicians we are threatened with all sorts of guidelines for best practice. Some of these are consensus statements, thrashed out with much dissent and argument. There is nothing wrong with dissent. Medicine, despite what some people would like to think, is often an uncertain discipline. But there is much wrong with imposing consensus. Whether we wish to argue with NICE that best practice demands ultrasound for the insertion of elective central venous lines (and I am only too happy to use ultrasound if my trust will buy the equipment and train me), only an idiot would think it was best practice to waste trees, energy, and the precious time of NHS staff by posting empty boxes around the country.
In the wake of the consultants' rejection of the gravely flawed contract, Alan Milburn is busy slagging us off as greedy. He is threatening to appoint 'junior consultants' so that he can continue his 'modernisation'. What happened to the insistence that we must be properly trained? His bullying and lack of logical thinking about health care are more obvious by the day. He needs the consultants. Why doesn't he take out his aggression on the people who waste our time posting us empty boxes?
Nev.W.Goodman@bris.ac.uk B ACK in 1998, the year I closed my practice in Strasbourg after several years of trying to remake myself as a French doctor, a remarkable novel appeared on the stalls: it gave vent to my own mood of frustration, sorrow, and disbelief that Europe's grande nation could expect its GPs to work under such economically straitened and socially isolated conditions. What was that old chestnut about the British being a nation of shopkeepers? -It was the French who seemed unable to conceive of social relations in terms other than those imposed by the market.
More remarkably, La Maladie de Sachs, Martin Winckler's second novel, found a huge public. Awarded the Prix de France-Inter (by a radio jury) that year, it went on to become a bestseller and has since sold more than 600 000 copies. A sober film adaptation was made the following year by Michel Deville, and the novel has appeared in an excellent American translation by Linda Asher as The Case of Doctor Sachs. Martin Winckler (born into a medical family in Algiers in 1955 as Marc Zaffran) has seized the opportunity offered him to speak up on behalf of his public: his radio slot, Odyssée, can be heard every morning on France Inter. His latest book -C'est grave, Docteur? -is a tour of the body in lay language. He is a man with a mission, and he makes no bones about his dislike of the French medical establishment: 'doctors', he roundly declares, 'are cowards'.
Winckler's defence of the patient's point of view may initially seem surprising in a country such as France, where patients are free to shop around for a doctor -any kind of doctor. The morality is the market's: patients demand, doctors oblige -when Sachs refuses to prescribe a lipid-lowering drug to one crusading client the rebuke is rapid: 'Who does he think he is? After all I know better than he does what I need. Who's the patient anyway?' In many respects, France remains a conservative, rigid, and even mistrustful country, and its old scholastic habits have survived perhaps most comprehensively in its disease palaces -the hospitals. At the bottom of this medical hierarchy are purblind GPs. Forty years ago, they might have been small-town notables; now they're lucky if they find a rung standing in for the priest-confessor of earlier times. Other habits die hard. France was one of the last countries in Europe to allow patients access to their hospital dossiers (in 2000), and even today doctors are chary about giving patients bad news, especially of cancer. Morphine, too, remains underused (see why in the 'Little Medical Afflictionary' below), while the consumption of antibiotics and psychoactive drugs remains sky-high.
Martin Winckler is an engagingly open writer. He has translated and written about American TV series and polars (detective novels), and their influence is discernible in the pace and framing of his book. His fictive 'conscripts' in La Maladie de Sachs include Mesdames Queneau (the nurse), Borgès (the cleaner) and Matiouze -all fetish writers of his, the last presumably a long-lost relative of the American expatriate Harry Mathews. Sachs' name nods to Oliver Sacks, the well-known American neurologist. Even the pen-name Winckler is a tribute: to the eight-year-old deaf-mute in Georges Perec's W or Memory of Childhood. One of France's greatest recent writers, Perec  was a tireless compiler of lists and inventories, and his interest in what he called the 'infraordinary' -routine actions and quotidian events -is carried over profitably into Winckler's work.
At the heart of his novel is that odd, ambivalent, involuntary thing called the doctor-patient relationship, although under French conditions it sometimes feels like a heart cut out. Some doctors might talk down to their patients, but Sachs' patients address him in the second person singular. This is a clever narrative strategy: it puts Sachs under scrutiny, and lends an oddly objective touch of intimacy to his dealings with them (voice-offs are used in the film). Sachs comes across as intelligent and caring (no over-prescriber), a bit stiff in his decency perhaps; he often fails to see how much the treatment he doles out is mutual. Interestingly, the ideal doctor he aspires to be comes from Balint's The Doctor, the Patient, and the Illness, the 1950s study that helped establish British general practice as a discipline uniquely positioned to surmount the mind-body divide. That was a generation ago, of course: it is doubly ironic that market liberalism is making British medicine more 'French' by the day.
Though La Maladie de Sachs seems to want to escape the adversarial politics that have characterised France since the war, it actually continues a 20th century French genre, the medically-inspired study in alienation. Where else are doctors perceived as outsiders in their own society? And what a transformation from the saviours of society who put a better foot forward in Zola and Balzac! For that reason alone it will be interesting to see what Winckler does next -whether his humanism is robust enough to develop in the land of many -isms or whether it succumbs to the politics of the person, which is no politics at all. This is particularly true of the texts in this collection. Not only are they a repository for my own anger and arguments against the medical establishment, but they also preserve the outlines of characters, dialogues and forms I've made use of later when writing my books.

Marc Zaffran, Martin Winckler
In my eyes, all writing is a part of a whole, not a succession of literary pieces whose genre dictates their value. Whether medical translations or novels, essays about television series or autobiographical jottings, all texts count. I don't draw up a hierarchy. It's not my job to do that. But I have my preferences, based for the most part on what I feel when I read. I believe in the value of intuition in literature, just as I believe in the value of intuition in medicine. In that, I feel myself to be closer to English-speaking doctors, who accord great importance to proven facts but never stifle their own sensitivity or that of the people they care for. Paradoxically, it's because they take account of pain 'objectively' -by considering it as an aspect of disease in its own right -that they have no difficulty in relieving it.
French medicine, on the other hand, prides itself on being 'neutral and benevolent' although a doctor is neither. A doctor is not a robot, but the double of the person he is treating. That's the main source of my anger as a writer. By prohibiting caregivers in training from voicing -indeed from feeling -their most disturbed emotions and making them believe that they constitute an elite distinct from the rest of the population, by turning a deaf ear to what their patients say or filtering it through their diagnostic grids, by elevating lying by omission into an ethical rule and treating patients as incompetent majors, French medicine is responsible for the extraordinary gulf which has been dug between it and the population.
One of the principal signs of this gulf is the overspecialisation of a majority of practitioners, and their disdain for general medicine. Not so much for GPs themselves, but for the conditions under which they practise, the type of relations they establish with their patients, their daily struggle against social, political and bureaucratic factors which have nothing to do with the diseases described in manuals but everything to do with the sufferings of those who consult them. When I wrote those words, it occurred to me that should that phrase and the pages which follow it ever be read by colleagues, I would receive scores of threatening letters. The violence and rebelliousness expressed in this part of the novel were not A doctor isn't necessarily someone who's always patient.
Sometimes he's fed up to the back teeth with repeating the same old thing about the pill, coughs and colds, vaccinations, coughs and colds, 18-month checks, coughs and colds, bronchites, coughs and colds, back pain, coughs and colds, cancers-which-aren't-but-which-are-farmore-common-than-cancers-which-arereally-cancers (but you know how it is with everything that you see!), coughs and colds, fitness certificates for sports, coughs and colds, sore throats, sore ears, purulent noses, recurrent sore throats and corns on the feet.
A doctor isn't someone who works for the happiness of mankind, but because being a doctor is a job. A doctor isn't someone who likes people to be ill, he's someone who'd like to treat only people in good health. A doctor isn't someone who likes handing out medications; if he does it's because the laying on of hands doesn't do any good. A doctor is someone who wants to strangle parents when they threaten to give their kids jabs if they don't behave themselves. Because a doctor is someone who feels sympathy for some of his patients, and dislikes others.
In short, if you didn't know (and if you'd forgotten, it's not a bad idea to remind you of it) a doctor is an individual like any other. He has a car that doesn't start, problems with the tax man (yes, I know, there are problems with the tax man we'd all like to have...), an inflammation of the

[Comment Soigner son Médecin]
that some literary genres are inherently noble, and others not. Writing is a tool. It can be used to represent the world or to question it any of many ways. Some -and I'm one of them -believe that the completion of a text, its range, are intimately bound up with its form as well as its content. Formalism doesn't make a text. Empty ideas remain empty whatever the vocabulary or the syntax. But, the most potent ideas are futile if the spectator isn't caught up by the text. If the text hasn't been worked on in order, reciprocally, to make the reader work.
I've been writing for ages, but I've never really had a 'big' literary project. I was writing, that's all. Text after text. But the same is true of writing as of any artisanal activity, of any practice. When you're not afraid of experimenting, you learn a lot. First and foremost, how to master your instrument. To play it without having to think about it.
I've been very lucky, and this collection shows it: in meeting after meeting, experience after experience, I've tried lots of things in the 20 years I've been writing. Different themes, different forms, different publics. In doing so, I've attempted to get as close as I could to the writers I most admired -those who had no prejudices when it came to writing. But the purpose of this permanent experimentation, subconscious no doubt, was to acquaint myself with all the describable and indescribable feelings my profession of physician might stir up in me.
As some readers will observe, many of the texts reprinted in this collection announce, sometimes years in advance, some of the characters or central themes of La Maladie de Sachs. The most astonishing thing was that before rereading them, I couldn't remember having invented 'Madame Renard' when I worked on the review Prescrire, and I couldn't recall having previously written a text presenting Balint groups. No more, as it happens, than I remembered having written, in my diary, that 'one day, I would have to learn how to do TOPs', ten years before writing up this same experience in a novel called La Vacation. Things like that happens because I forget what I write.
The whole point of a collection of texts is not to show retrospectively what a prolific or inspired writer you've been all these years. As far as I'm concerned it's a way of reminding yourself of the person (writer, physician, citizen) you've been and continue to be. A tree sheds its bark but its layers persist. Under the skin of the forty-year-old there's still the rebellious boy, the untried physician, the apprentice-writer. I know they're there, but I sometimes have the need to find them again, to look them in the face.
I write in order not to forget who I am.
l concentrationnaire] exaggerated: the stories which gave rise to it are part of my own experience, even though I haven't lived all the stories I cite in my role as doctor. Two years have slipped by, and despite the huge number of letters, signings and meetings which have followed on from the publication of my book, the hard landing I'd expected hasn't come to pass. If the book had stayed samizdat, it would have been easy to imagine that, lacking the time to read it, doctors would have remained unaware of its existence and contents. However, the book has sold more than 400 000 copies, most of my mail comes from caregivers of all types, it is now recommended reading in medical schools, and I'm invited to talk at postgraduate medical meetings, nursing conferences and to students in their lecture rooms. The number of readers who've asked me to sign the book for a parent, friend or acquaintance who happens to be Antibiotics [Antibiotiques]: medications for lowering fever. Always a source of tiredness, they should never be taken with milk (makes your stomach turn). Very common cause of allergy.

Cholesterol [Cholestérol]
: modern equivalent of the ancient gods. When it climbs, sacrifices have to be made (no more butter, meat, sugar); when it falls, one indulges (no more medication). The intellectual process is the product and conjunction of knowledge, intuition, hunches and sometimes amazing revelations, and may be compared with the resolution of a crossword puzzle in which symptoms are the horizontal definitions and signs the vertical definitions. The doctor is able to call upon three diagnostic tools: blood tests, appeals to specialists, and hospitalisation.

Diagnosis 2 [Diagnostic 2]:
(by extension) capacity possessed by a physician to resolve crossword puzzles more or less reliably, i.e. to provide an explanation for everything including an inexplicable death (Example: 'He has a good nose for diagnosis.').

Family [Famille]
: universal pathogenic medium, resistant to antibiotics, vaccinations and to all therapeutic methods invented in the last six thousand years (see Family Doctor).

Fever [Fièvre]
: symptom which justifies: 1. wrapping babies in three pullovers and twin covers (to avoid them catching cold); 2. calling the doctor at night (in order to be sure of finding him at home); 3. prescribing antibiotics (in order to avoid a complication); 4. issuing a sick note for the mother (in order to ensure that baby doesn't develop an allergy to antibiotics).

Illness [Maladie]
: the sum total of unpleasant phenomena that brutalise the body and mind of a patient, and whose cause, development and nature is codified, described and indexed in all good medical treatises. An illness is often a hydra with several heads. Whether it affects the body (physical diseases), psyche (psychiatric diseases), both (a real mess) or neither (psychosomatic diseases), its origin is either external (measles, dysentery, malaria, chemical pollution, radioactivity, family conflict), internal (resentment, guilt, frustration, cancer) or mixed (that's life...).

Family doctor [Médecin de famille]:
species currently in the process of disappearing. After rapid mutation in the last 50 years, the supposed focus of the family doctor's attentions has acquired a LITTLE MEDICAL AFFLICTIONARY [Petit afflictionnaire medical] a doctor, or even for their own doctor, is considerable. Not only is The Case of Doctor Sachs the highest-selling novel in 1998 (and one of the highest-selling in 1999), it is probably the medical novel most read by doctors since André Soubiran's Les Hommes en blanc (Men in White Coats).
Although most of the expressions of sympathy have come from GPs, many of whom recognise themselves in the dialogue and experiences recounted in the novel, I've also received many letters, and not a few warm handshakes, from specialists or hospital doctors met during my tours. And not once have I experienced any sign of hostility or the least reproach about Bruno Sachs' wild utterances.
This silence doesn't catch me unawares. Hospitals might have been terrible places 50 years ago (have a look at Soubiran's novels), but that was no longer quite the case 25 years ago and the situation has surely changed since then. For the better, it is to be hoped. And despite that, not a single indignant letter, no outraged reaction, no complaining letter to the Regional Medical Council (it is well known that doctors complain about their colleagues at the drop of a hat, which is precisely why they're afraid their patients might one day do the same...).
On the other hand, I received an astounding letter from a 70-year-old historian and philosopher, a specialist in concentration camp history who had shortly before undergone an operation for a cancer of the oesophagus: he described his stay in hospital as being something like a concentration camp. 'With one exception', he added, 'there I could have thrown myself against the barbed wire and have ended my misery in a salvo of machine-gun fire.' The reason for the silence of the caregivers is not, I believe, because they're indifferent to what I've said. When their reputation is on the line, hospital doctors are too touchy to overlook what's said about them in a work with a large circulation. What takes the wind out of the sail of any commentary, I believe, is that hospital doctors are well placed to know that, here and there, hospitals are indeed more a source of suffering than of care. Having become specialists by inclination or necessity, they're aware of not having all the skills needed to respond to the entire gamut of symptoms expressed by the patients in their bed. Caught between the burden of administrative duties, the chronic lack of medical staff, the falling number of house officers and budgetary restrictions, they are perfectly aware of the fact that they are unable to shoulder completely their triple mission as caregivers, teachers, and researchers. For some, care comes after the clinical trials. For others, teaching is sacrificed for an efficiently running department. Furthermore, some hospital doctors lack, and lack by a mile, the proper attitude to the persons they are supposed to be looking after. Their blank spots have nothing to do with their degree of competence, but are part and parcel of in their general attitude to patients. Not everybody likes those he or she has to treat: this is as true of hospital doctors as of other health care personnel. But why are they doing the job then? And not only that, but on what grounds do we allow them to do the job? Why do we allow colleagues to behave abjectly without saying a word? Why do we let alcoholic surgeons operate without so much as lifting a finger? Why do doctors hesitate to blow the whistle on colleagues guilty of behaviour which is at least questionable, if not criminal?
Let it not be thought that this is just a matter of challenging other doctors or drawing attention to exceptional situations. Awkward personal questions are something each one of us should be asking.
Those of you reading this article, medical colleagues -have you read the hospital patient's charter? All of it? Have you had your patients read it? Have you discussed it with them? Have you set up analgesic protocols that can be administered night or day by the nursing staff? Do you accept to be called outside your on-call period or your contracted time in order to talk about a patient you usually look after? How many times have you sat down at a patient's bed this week? How many times have you taken their hand? Do you set time aside in the day for meeting families? Is it your practice to talk frankly to your patients or do you lie to them as a matter of principle 'so that they don't abandon hope'? Do you find yourself saying things to the family that you wouldn't say to the patient? And inversely? Do you always explain the different diagnostic or therapeutic options to your patients before setting them in knee that prevents him from doing his ten kilometres three times a week (but not his home visits) a forehead that's losing its hair, a brother-in-law who had a bout of renal colic last night, friends who come to tell him their life story when they're worried about their health or their relationship, children who say that they've got tummy pains when they come home in the evening, relatives dying in hospitals where they don't know a soul. In short, compelled to be a doctor all the time, a doctor sometimes feels like doing something else.
So, when you think about it, he has just as many problems as you, this man. A few more perhaps. For you, the crick in the neck that came on this morning on getting up is almost a godsend, you won't have to go to work today, and then it'll go, in three days the last twinge of it will be gone. Whereas he'll still be a doctor once your neck is cured and you've forgotten his existence and thrown away his prescription. Because being a doctor is incurable! Now a doctor is someone who gets worn out if treated badly. For a doctor to be useful, operational, well-performing, and if he's to last a long time too, he needs to be handled gently. Are you going to consult him? Are you quite sure you've nothing serious? Well, make a little effort! Smile at him when you come in for the consultation, that will cheer him up. Ask him for explanations by making it clear to him that it's just to inform yourself, and not to annoy him: that will set him at ease. Tell him that you don't necessarily need treatment if it's not necessary: he'll have the illusion that you've been cured simply by seeing him. Advise him to take holidays (without saying that he looks tired, that will annoy him). In three words: look after him.
He'll be eternally grateful to you and, with everything that you see, you never know when you might need a doctor… motion? What would you say to a patient who asks you to let him die in peace? Do you take the quality of life of your patients into account when you decide about treatments? Have you ever said things to a patient that you regretted? Have you ever felt the need to offer an apology to a patient? Have you done it? Have you ever asked whether one of your patients has died because of something you did? Have you talked about it to a colleague, to someone close, to your mother or father? Do you ever ask the auxiliary nurse about the welfare of the patient whose tray she has just picked up?
Have you set time aside, in your department roster, for a discussion group that would allow all the members of the health team to express their views? Are you or have you ever been part of a Balint group? Do you know what a Balint group is? Have you already undergone a course of psychotherapy yourself to help you cope with the difficulties of the job? Do you ever weep when carrying out your tasks? When you get home? Do you ever get the urge to pack it all in? Do you have a hobby outside medicine? Does your professional life spill over into your private life? I could continue this list indefinitely. I don't believe there are 'good' or 'bad' responses to these questions. I don't believe either that they all have to be answered. But I do think that the surest bulwark against the development of the hospital as a concentration camp, against the subconscious sadism we are all capable of, against the confusion between patients and study subjects, between health care and trial protocols, lies in asking ourselves every day some of these questions, or indeed any questions which come to mind and shake our certainties.
The surest bulwark against the violence of medicine, this violence we are all capable of showing through fatigue, obscurantism or mere oversight, is not just our awareness, but more especially keeping open our doubts and methodically questioning the way we act.
All the proof I need is this anecdote, which was told to me by a hospital doctor a year ago during a postgraduate meeting. One of the doctors present asserted loud and clear that the treatment of pain was properly provided in every French hospital department. One of his colleagues raised his hand and said: 'That's not true, and you know it. I underwent arthroscopy a few weeks ago. I received a regional block and everything went well. But three hours after having been wheeled out of the theatre, it started to hurt like hell. I asked the sister to give me some painkillers but she replied that the anaesthetist had gone without leaving any instructions, that there was no question of disturbing the duty doctor for a thing like that, and that all I had to do was go to sleep and it would pass. I was in agony until the following morning.'