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Living Proof: A Medical Mutiny

Article in The BMJ · April 2002

DOI: 10.1136/bmj.324.7341.855

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BOOKS • CD ROMS • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS

Living Proof: A Medical Living Proof is in two sections. Firstly, time to try alternatives or to prove
diary entries cover Gearin-Tosh’s initial themselves “good” outliers on the sur-
Mutiny diagnosis and the turbulent year that vival curve before being rushed into
Michael Gearin-Tosh followed. At times this sensitive, articulate chemotherapy.
Scribner, £14.99, pp 327 man’s thoughts and his interplay with an Although the principle of giving treat-
ISBN 0 7432 0677 0 accompanying cast of friends rival journalist ment only when it is needed is sound,
John Diamond’s book C: Because Cowards Get Gearin-Tosh’s arguments are zealously
Rating: ★★★★
Cancer Too (BMJ 1998;317:825). Living Proof impractical. For acute leukaemias and many
is also a wonderful study in neurosis, and a solid tumours the sole therapeutic oppor-
warning to doctors about the futile cycles tunity may be lost in delay. In addition
our hastily chosen words engender in Gearin-Tosh, perhaps not surprisingly given
susceptible people. his background, is often wooed more by
After seeking seven different medical narrative than by scientific argument. Alter-
opinions Gearin-Tosh discovers, almost by native practitioners are not all repressed
default, that he has rejected orthodoxy. The seekers of truth and to give them carte
fact that he remained well throughout blanche is naive.
months of prevarication clearly influenced Despite these faults Living Proof ’s asser-
him retrospectively to embrace as the sole tion that we should investigate those who do

A
series of articles about Living Proof
and its author—an Oxford English reason for his survival the “mild” alternative well and not dismiss them as quirks is unde-
tutor “battling” myeloma through therapies that he had been dabbling with. niable. Perhaps it is the only way to replicate
diet rather than chemotherapy—appeared (He doesn’t state this explicitly, however.) their successes. Setting himself up as the
recently in the Times. Any doctor reading Eight years of coffee enemas later he definitive outlier, updating his medical
them could be forgiven for prejudging remains triumphantly alive. details regularly on a website, Gearin-Tosh’s
Gearin-Tosh as an academic revealing noth- In the second section, Gearin-Tosh challenging “Explain me” ultimately stands
ing more than his ignorance of bell-shaped discusses what exactly he thinks he is “living out as laudable, brave, and a little awe
survival curves (which show that it’s totally proof ” of. He sidesteps some critics
inspiring.
possible to live longer than the average and immediately by stating that it is not the diet’s
still not be cured). Yet one message to glean effectiveness that has been proven, but Ross Camidge clinical lecturer in cancer
from both the press coverage and this book rather the “one size fits all” mentality of therapeutics, Edinburgh Cancer Centre, Western
is that we shouldn’t believe everything we medicine that has been proven wrong. General Hospital, Edinburgh
read in the papers. He argues that patients should be allowed drcamidge@talk21.com

Allowing Dignity in Death another Harold Shipman, think again. Moor But there is something unnerving about
was arrested for providing good terminal Moor’s telling of his story, and that is his
Dave Moor complete lack of negative emotion. This is a
care for a dying patient. He had done what
Privately published just about every doctor in the United man who seems unable to express fear,
ISBN 0 9540799 0 6 anger, or hate. At most he describes mild
Copies available at £10 each Kingdom has done at some time or another,
and will continue to do. It took nearly two irritation. Here is a doctor who when
including postage from
hounded by the press on what was
Michael Irwin, 15 Hovedene, years for the prosecution to bring him to
Cromwell Road, Hove, East essentially a trumped up murder charge can
trial and just 69 minutes for the jury to find
Sussex BN3 3EH only describe the people around him—and
him not guilty.
the circumstances in which he finds
Rating: ★★★ Moor and his wife wrote this account himself—in warm terms. Everybody is just
from the notes they kept during the two years “doing their job.” The narrative may be clear
leading up to and throughout the trial. and Moor’s eye for detail accurate, but his
Although they could probably have found an range of emotional expression seems alarm-
established publishing house to take it on, this ingly narrow. The last line in the book is “I
book was published privately. It’s a surpris- would be the first to admit that it was Hell.”

I
n 1999, Dr David Moor was tried for ingly good read. Surprising, because most of But as a reader, this was the first time I had
murder and acquitted. He was accused it is a meticulous blow by blow account of the any inkling that his calm exterior had really
of abusing the doctrine of “double been pierced at all during the ordeal.
case as it unfolded in court and I hadn’t
effect” (which allows a doctor to administer Dr Moor died prematurely in October
expected to find it as riveting as I did. I found
drugs to relieve pain and suffering, even 2000, just 18 months after being acquitted. I
though the dose used may hasten death). the early chapters hard work. But later, as he
can’t help wondering if the emotional stress
But before you summon up thoughts of finds his rhythm, Moor becomes a natural
of his Hell—so conspicuous by its absence in
storyteller and there are moments of high
this book—finally caught up with him.
drama and suspense, particularly as the pros-
Items reviewed are rated on a 4 star scale
ecution’s medical evidence is pulled neatly Abi Berger BMJ
(4=excellent)
and methodically apart. aberger@bmj.com

BMJ VOLUME 324 6 APRIL 2002 bmj.com 855

reviews

The Epidemiology of less than 10/100 000 in Italy and France.

There are differences in sex ratios in
BOOKCASE Diabetes Mellitus: An childhood type 1 diabetes—a large excess in
d Amid the ongoing debate over the International Perspective girls in Slovenia and an equal but opposite
increasing use of recreational drugs and excess in boys in Portugal. Diabetic neph-
Ed Jean-Marie Ekoé
whether or not to decriminalise cannabis
John Wiley and Sons, £120,
ropathy is rapidly declining in some
comes a new edition of Drug Notes, a set
pp 454 countries (in Sweden, it is virtually disap-
of booklets providing information on a
drug’s history, its health effects, legal status, ISBN 0 471 97448 X pearing). There are also two populations of
prevalence, and supply (Drug Scope, £1.50 African-Americans with type 2 diabetes—
Rating: ★★★★
per pamphlet, tel: 01235 465500). Titles one with and one without insulin resistance.
include heroin, cannabis, cocaine and There are pithy, readable sections focus-
crack, ecstasy, ketamine, and GHB ing on the major diabetic complications (for
(gammahydroxybutyrate). The booklets example, nephropathy and neuropathy).
adopt an informal style (although without Special praise is due to Karvonen et al for a
too much “street” language) and would be superb perspective on the global epidemiol-
useful for anyone coming into contact with
ogy of diabetes; to Banerji and Lebovitz for
people who may use recreational drugs.
They are well written and include short insights into type 2 diabetes in African-

I
n 1978, Dr Kelly West published his Americans; and to Ekoé and Shipp for a fas-
narratives from users that offer an insight
monograph on the epidemiology of cinating compilation regarding the enigma
into the often very powerful effects of the
diabetes and its vascular complications, of malnutrition-related diabetes.
various substances.
earning himself the name of “father of Since each review stands on its own, one
d Despite affecting more than 520 diabetes epidemiology.” Almost a quarter of
million people worldwide, hepatitis B and can dip into this volume at any point to sat-
a century later we have a worthy successor to
C are often poorly understood. Hepatitis isfy a particular curiosity. All of the chapters
this text. And, if ever there was a need for a
B and C: Management and Treatment are as up to date as they can be in a multi-
compendium of current epidemiology of
(T Poynard, Martin Dunitz, £19.95, authored text and provide guides to the fer-
diabetes and its complications, it is now.
pp 148, ISBN 1 84184 077 7) has very ment and richness of current studies in this
Diabetes mellitus, as readers will quickly dis-
short chapters—often only a few pages rapidly changing clinical arena.
long—with frequent subheadings and cover if they didn’t already know, is a world-
wide pandemic straining medical resources One hopes that this is just the first
excellent illustrations, all of which go to
and capacity. edition of what will become the definitive
make this near pocket sized book easy to
read. Particularly useful are the chapters Within the covers of this book are textbook in the field.
on immunomodulating drugs and insights from the studies of diabetes in
comparisons between them, which are not different populations. For example, the inci- Robert Matz professor of medicine, Mount Sinai
such heavy reading as they may sound. dence of type 1 diabetes in children is over School of Medicine, New York
This book will appeal to specialists, but 35 in 100 000 in Sardinia and Finland but robert.matz@mountsinai.org
the simple uncomplicated approach
makes it appropriate for a wider audience.
d Elderly Medicine: A Training Guide Assisted suicide In the past 20 years, we’ve seen the rise of a genre of writing in
(G Rai, G Mulley, eds, Martin Dunitz, £45, which patients recount their personal battles against illness. Jeff Aronson calls
pp 430, ISBN 90 5823 234 4) is an these stories “autopathographies,” and is compiling the definitive list of such
evidence based volume covering the whole tales (http://bmj.com/cgi/content/full/321/7276/1599).
field from social gerontology and If Aronson included patients’ internet diaries, his list would grow
management of Parkinson’s disease to how WEBSITE exponentially. How would he begin his search? One place would be the
to be a successful consultant. The authors
use questions as subheadings on which to OF THE Personal Documentary Center (http://home.earthlink.net/∼hevern/
hang facts and this gives the book a lively WEEK diaries.html), which chronicles personal testimonies on the internet.
feel to make up for its lack of colour and Why do patients want to tell all? For many, it is a cathartic release of
illustration. End of chapter key points and emotions that patients fear might be toxic if repressed. But for Nancy Crick,
self assessment questions mean that the a 70 year old Australian woman with bowel cancer, self expression has become
book works well as a revision aid. a political tool in a campaign for the right to die.
d Gynaecology: Integrating Crick says she can no longer tolerate the chronic pain and diarrhoea that
Conventional, Complementary, and are a constant part of her life. For a brief time in Australian history, she could
Natural Alternative Therapy have requested physician assisted suicide in Australia’s Northern Territory. An
(A Ostrzenski, Lippincott Williams & act permitting such assistance, The Rights of the Terminally Ill Act, took effect
Wilkins, $69.95/£53, ISBN 0 7817 2761 8) on 1 July 1996, but it was overturned by the federal parliament in March
provides a novel approach. It is an evidence 1997. And now, at the time of the fifth anniversary of the act being repealed,
based reference book that details both Crick is planning to end her life by taking an overdose, surrounded by her
conventional and alternative treatments to
loved ones.
all the gynaecological disorders and
Crick wants the act reinstated, and to argue her case she is keeping a diary
diseases. Conventional therapy is, however,
very much in the driving seat and often no of her suffering in the run up to her suicide (www.protection.net.au/
specific alternative treatment is nancycrick/). Her diary entries are intended to make us feel uncomfortable, so
recommended. Where there are alternative that we might get a glimpse of her agony. On 16 February, she wrote, “Today I
recommendations—for example, for rose at 4am to visit the toilet, stayed there till 10am.” Under a photo of the
urinary tract infection or prevention of Gavin toilet, she writes, “Welcome to my world.”
cancer—they are all evidence based and Yamey Crick would have been heartened by a recent BMJ editorial
provide interesting reading as a deputy editor, (http://bmj.com/cgi/content/full/323/7321/1079) arguing that physician
companion to the rather densely presented wjm—Western
assisted suicide should be legalised. Others, however, were horrified (see p 846).
conventional material. Journal of
Medicine But whatever our views, a series of high profile cases around the world is
Alex Vass BMJ gyamey@ forcing us to acknowledge that patients want a greater say in decisions at the
avass@bmj.com bmj.com end of their lives.

856 BMJ VOLUME 324 6 APRIL 2002 bmj.com

 reviews

PERSONAL VIEW SOUNDINGS

The role of role avoidance A painful experience

I
’ve only recently heard of the term “role senior house officer when all I wanted was I was on an Airtours flight from Florida
avoidance.” Looking back I realise that an opinion on a patient. And perhaps most recently when medical assistance was
it’s a strategy I’ve been using for a long galling of all, being turned down for a GP called for. The patient had benign
time but one which has remained nameless rotation at a hospital at which I had worked prostatic hyperplasia and was in
until now. Perhaps I should explain. I am a previously and from which I had good refer- retention. Since we had another seven
doctor who stammers and have just ences, just because I stammered. All these hours to fly, holding on was not an
embarked on a course at the City Literary experiences fostered in me the belief that option. He needed a catheter, so I was
Institute in London in what is called “block reassured that the plane’s inventory of
somehow I wasn’t a “proper” doctor, that it
modification.” Those of you who are familiar medical equipment included catheters
would be far easier to avoid being a
with stammering therapy will know what and collecting bags. But I then found
stammerer at all.
this entails. For those of you who aren’t, it is that there was no lignocaine gel, no
To do this I’ve created a doctor lubricating jelly, and no gloves.
based on the work of a number of American
persona—authoritative, knowledgeable, per- Performing a catheterisation without
speech pathologists, including Charles Van
Riper and Joseph Sheehan, and basically haps slightly brusque even, and usually gloves or anaesthetic was not pleasant,
comprises three stages—identification, avoiding eye contact for fear of seeing a but the lack of lubricating jelly proved a
desensitisation, and modification. reaction in my listener. In this role I can be bridge too far, so when the patient
The identification stage involves looking considerably more fluent than I normally started screaming I deputised some
at both the overt and covert aspects of stam- am. I can’t deny that this strategy has served antiseptic cream as an ersatz lubricant.
mering, and the “iceberg model” described me well in the short term. It has enabled me As the catheter was non-retaining, I
by Joseph Sheehan is useful for this to function effectively as a doctor for several advised the greatly relieved patient not
purpose. Just visible above the waterline are years despite having a stammer. So why to drink any fluids for the rest of the
the overt aspects of the stammer—the change it, you may ask? flight and to attend accident and
outward struggle, as it were. However, below Well, I believe that block modification emergency on his way home. I then had
the waterline lurks the often much larger therapy is only going to be truly successful if to remain on alert for the next seven
covert component—the feelings of anger, I can disassemble my role avoidance strategy hours. Before disembarking I was asked
resentment, frustration, and poor self image. and be more open and honest about the fact to sign a form indemnifying Airtours
It is these that result in avoidance strategies that I stammer. This is the difficult part—old against any claim arising from the
to lessen the discomfort associated with procedure and was offered a bottle of
habits die hard. Coupled with this is a need
speaking situations, and right at the top of wine as a gesture of appreciation.
to work on some of my beliefs, and I have
the hierarchy of avoidance is role avoidance. I had expressed my concerns to the
made some headway already in this respect.
Although something of an abstract concept, steward, but having heard nothing after a
Attending a self advocacy course for people few weeks I contacted Airtours. The
the essence of role avoidance is the use of
who stammer at the City Lit last year and company’s flight officer explained that
tricks or techniques to achieve fluency and
thereby avoid taking the role of a stam- more recently going to the British Stammer- Airtours usually received inflight medical
merer, which as a doctor would be ing Association’s annual conference in advice from an institute in the United
unacceptable. Liverpool have both had a profound impact. States and the airline’s medical officer
From the moment I entered medical Meeting other stammerers who are both assured me that gloves had been present
school and throughout my career it has eloquent and intelligent, and listening to in the equipment box—I just hadn’t
been apparent to me that medicine favours their often inspirational stories, has filled me found them. He said that he had done
outwardly “flawless” individuals. The embar- with the sense that I can be an excellent doc- hundreds of catheterisations and had
rassed looks of the panel as I struggled my tor who, by the way, just happens to never used lignocaine gel. In a
way through medical school interviews. The stammer. subsequent letter, he insisted that the
nervous laughs of my colleagues as I did company’s equipment was standard to all
presentations. The “do something about Paul Reynolds general practitioner, Hanwell, airlines, and that “the catheters are self
your speech” comment from the surgical West London lubricating, and being small and
atraumatic do not need lubrication or
local anaesthetic.” Really?
As a doctor, I had no choice but to
respond to the patient’s needs, and
without that choice I was forced to
perform a difficult procedure with
inadequate equipment. The poverty of
the Airtours response was depressing,
especially considering how much money
I had saved the company; if a doctor
hadn’t just happened to be on board, the
plane would have had to return to
Florida. Maybe in future Airtours should
take one fewer passenger and a bit more
equipment, and maybe omit those
magical self lubricating catheters. I won’t
be travelling with Airtours again—not
without taking my own lubricating jelly.

Liam Farrell general practitioner, Crossmaglen,

County Armagh

BMJ VOLUME 324 6 APRIL 2002 bmj.com 857

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