The rhythm method

The weekly print BMJ has a familiar rhythm, which those of you who start at the front and work steadily to the back may recognise.

At the front—indeed, most of the way through—we have lots of serious stuff. This week, for example, several articles consider the complexities of diagnosis. Wytze Laméris and colleagues studied 11 diagnostic imaging strategies for acute abdominal pain (doi:10.1136/bmj.b2431). Although computed tomography after radiography was the most sensitive investigation, they conclude that radiography followed by ultrasound, with computed tomography reserved for people with negative or inconclusive ultrasound results, is the best strategy, with good sensitivity and less exposure to radiation. In their accompanying editorial Adrian Dixon and Christopher Watson set these findings in the context of advances in imaging, increasing surgical specialisation, and pressure on beds (doi:10.1136/bmj.b1678). “It will become untenable for a patient to stay in hospital with an undiagnosed abdominal problem because of a lack of access to modern imaging,” they say. Imaging will direct patients to the right surgical specialty, and it will save time by preventing patients from languishing in beds while being observed.

Yet time is still available in primary care, and is a powerful diagnostic tool, suggest Susanna Almond and Nick Summerton in their discussion of the “test of time” (doi:10.1136/bmj.b1878) Used wisely, it helps “protect the patient from the harm of unnecessary investigations and the ‘cascade’ effect of unexpected abnormal results generating further tests.” In their companion article on acute diarrhoea in adults Roger Jones and Greg Rubin show how (doi:10.1136/bmj.b1877).

But despite the carefulness of these strategies, clinicians often stay wedded to a wrong diagnosis, in the face of counterevidence, and in his Analysis article Ian Scott aims to explain why (doi:10.1136/bmj.b1860, p 22). It’s our cognitive psychology. The same mental processes that allow us to think very efficiently can let us down in over 40 different ways.

Political and organisational thinking often seems less precise than clinical reasoning, and no less problematical. Nigel Hawkes, for example, muses on how stubborn Britain’s inequalities remain—and how little health care can do about it (doi:10.1136/bmj.b2604). And Jeanne Lenzer reveals how lax regulation of medical devices is (doi:10.1136/bmj.b2321).

But then you reach the back of the BMJ—and some iconoclast undermines it all. This week there are several candidates: Liam Farrell invents Dante’s 10th circle of hell (for patients with certain expectations) (doi:10.1136/bmj.b2644) and Theodore Dalrymple suggests merit in an 18th century debate on whether the ancients or the moderns were best (doi:10.1136/bmj.b2410). He thinks Hippocrates might have the edge. But my prize goes to Tom Jefferson for his review of the book Dread: How Fear and Fantasy have fuelled epidemics from the Black Death to the Avian Flu (doi:10.1136/bmj.b2610). This is a tale of fear—and the people who profit from it; and for Jefferson it explains his puzzlement at “why and how a relatively benign disease such as flu [has] been turned into a fund raising, raging monster…”

For readers who start at the back of the BMJ the whole experience is, of course, the other way round.