Robin Goodfellow

It is mid-winter here in the air raid shelter. Mrs Robin's new greenhouse has at least got a heater but the cold chill on the hills has blown down into Robin's hospital, where clinicians are furiously arguing over whether it can survive the nuclear winter that is coming. Not only does a war loom with primary care (we don't have enough acute beds, so the GPs can't admit, so we fail to meet our contract targets, so they want to take money away, so we will have to shut beds, and so on) but the dead hand of Europe flays us with the European Working Time Directive, so all the trainees go onto shifts to cover acute medicine and lose 50% of their specialist training opportunities (when on nights and days off they cannot do clinics or attend educational sessions). Meanwhile we struggle with NICE (National Institute of Clinical Excellence) guidelines and National Service Frameworks while the nice (no pun intended) politicians talk of breaking consultants like Mrs Thatcher broke the miners. At the time, though, the UK could manage quite well without the miners. Managing without consultants, when those coming up through the system are half-trained (not to mention paying extra tax for having a degree) does not seem an option. Why does no-one see the looming catastrophe? Robin is seriously thinking (and not for the first time) of changing his name to Cassandra.

Oh yes, and à propos NICE Robin was delighted to hear its head, during a post-graduate meeting, indicate that any organization of a charitable nature that submitted evidence would be entitled to an honorarium to defray expenses. How nice. Robin has some idea of the hundreds of man-hours spent by BSR members on its submissions on biologic agents and concluded that the £200 on offer would not go very far...

Mind, it appears that the UK is not alone in having problems. Jody Lewtas details the concerns of Canadian specialists (J Rheumatol 2002;29:2251–2)[ISI][Medline] and wonders whether some of the likely recruitment problems relate to an old-fashioned perspective, while within it is understood that ‘Rheumatology has gone from a specialty perceived as babysitting patients with an untreatable chronic illness, to one well aware of the impact proper therapy can have in modifying important patient outcomes’.

Robin likes editorials, being akin to a baby bird that gets its lunch from mummy and daddy partially pre-digested. Two caught his eye—the first on a rare condition that he suspects most rheumatologists only see by accident, namely osteogenesis imperfecta (OI). Lindsay (J Clin Invest 2002;110:1239–41) [Free Full Text] discusses the evidence for using pamidronate in OI, concluding that it sets a standard against which any other treatment will have to be judged. It includes a helpful summary of the genetic and biochemical features of the condition. The second was a thoughtful piece on the ‘what's in a name’ theme (Schumacher, J Rheumatol 2002;29:2258–60).[ISI][Medline] He asks whether all early inflammatory arthritis is truly rheumatoid arthritis (RA), and if not whether that explains why those patients without specific RA features do better than those with a full house. Robin could (and would like to) start a debate here between lumpers and splitters. Do semantics matter? Why not just treat every patient with inflammatory arthritis the same? Or should we reserve our heavy guns only for those patients where the evidence for ‘true’ RA becomes overwhelming? Robin's own feeling is that this might return us to the dark ages of treating too little, too late—rather treat some too aggressively than those that matter too meanly. What do you think?

Some years ago there was a serious campaign among sufferers from juvenile arthritis to obtain compensation because steroids had stunted their growth. As Robin has said in an earlier column, treatment has moved on (having become more aggressive!) and steroids are not used so much. Thus it was interesting to see that a retrospective study from Taipei shows no effect on predicted growth with steroid use of less than one year (Wang et al., Clin Rheumatol 2002;21:363–8).[CrossRef][ISI][Medline]

We continue to wonder why patients with RA have a higher risk of cardiovascular events. Could it be because their serum lipids get deranged by RA? Park and colleagues think so (Am J Med 2002;113:188–93) [CrossRef][ISI][Medline] and have shown that treatment of the arthritis may normalize the lipids. Neat.

Meanwhile Robin continues to look at cost-effectiveness studies. The Dutch group of Van Tubergen et al. (Arthritis Rheum 2002;47:459–67) [CrossRef][Medline] sent two groups of ankylosing spondylitis out of three for spa-exercise therapy in addition to their standard treatment, and report that the cost-effectiveness and cost–utility ratios are favourable. Robin got dazzled by the numbers and is not sure whether to conclude that the group sent to Austria did better than the group treated in a ‘home’ spa, but if he was offered the choice of Baden-Baden or Buxton he would not have much difficulty choosing.

Robin is pleased to report that alternative medicine is alive and humming. One of Robin's colleagues, who suffers from intractable migraine, decided after all else failed that she would consult a cranial osteopath. First he palpated her sacrum, and announced that he could feel that her notochord was displaced. Then, as he began the treatment proper, he asked if she minded if he called on God to help (to which her response, being a Muslim, was ‘which one?’). Last he began to hum loudly, in short bursts. Somewhat unnerved by this she asked what he was doing, and was told that this produced ultrasound rays that would assist in the treatment. Now most radiologists have a fairly firm grasp of anatomy and ultrasound so this didn't wash, though it would appear she paid the fees. I think someone who claimed to feel my notochord in my backside would be told, fairly smartly, that their hand was as misplaced as their knowledge. How do they get away with it?

Finally Robin was delighted to see that his image (made by the estimable David Goode) has appeared on television. It was in the ‘Ground Force’ Christmas garden made for a school near Brighton for children with learning disabilities. For those who don't get UK television this programme makes over a garden, or weed patch, in 2 days. Sadly though Robin's statue will have to peer short-sightedly, for Mr Goode forgot to bring the spectacles.





This Article
Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
PubMed
PubMed Citation