Fourteen-twenty

For the last 100 years the sequence of the doctor-patient interaction has been History-- Examination -- Investigation -- Management . The Irish physician Lindsay collected his wisdom in 1923, which gives a good idea of of the practice of medicine at a time when Investigation had yet to make an impression - then as it was for eons before. The care and attention paid to symptoms and signs is incredible. Imagine deducing the size of the stomach by testing where one can still hear the sounds of the beating heart transmitted like a drum? Modern investigations have, quite rightly, rendered many medical signs obsolete. We often talk about what will be next to come - better scanners, molecular sensors, greater marvels. I wonder what will be next to go - symptoms?

We are longitudinal creatures. As HG Wells wrote in the introductory exposition of The Time Machine, ' any real body must have extension in four directions: it must have Length, Breadth, Thickness, and—Duration '. We know this in clinical medicine, where the most valuable ingredient of diagnosis, prognosis, and therapy is often time. And yet much of observational medical research is cross-sectional - we compare two groups at the same time, condensing all nuance of an individual's life-course into the variance of the group. N=1 trials are of increasing interest because they take full advantage of the fact that intra-individual variation is almost always much less than inter-individual variation. Plus they more directly answer the question we really care about - will this intervention help this person? A great recent example was the SAMSON study , which looked at side-effects reported by patients taking statins to lower cholesterol. Despite the significant benefits of statins...

There are two problems with experts; they either talk about the things they know , or the things they don't .  Michael Gove's statement that ' people in this country are tired of experts ' entered the historical and political lexicon as a Brexit soundbite, and was supposedly symptomatic of an era characterised by populist, post-truth, and anti-intelligence movements. I have concerns about this interpretation. When I realised that the phrase was being mockingly employed by middle-class liberals over dinner party discussions, with a derisory tone to the word 'people' suggesting it may as well be interchangeable with 'proletariat', I felt uneasy. Firstly, what did Gove actually say? This is the least important part of this discussion, but worth dealing with upfront. In an interview with Faisal Islam on Sky News on 3rd June 2016 he said ' I think the people in this country have had enough of experts ... [interruption] ... from organisations with acronyms...

Fatigue is a common and disabling symptom that affects many people with multiple sclerosis (MS). I have been suggesting that patients try drinking a daily cup of high-flavonoid hot chocolate, off the back of this interesting trial . Some doctors balk at the idea. Why? This was a well-designed, albeit small, feasibility study which showed a small but significant effect of a very low-risk (even enjoyable) intervention on a common and disabling real-world symptom.  Compare this to the drug amantadine, which is listed in textbooks as a treatment for MS fatigue but in the real world is rarely effective or tolerated. In fact a recent well-designed trial reported that amantadine was overall more harmful than placebo and no more effective. Real-world effects matter. Patient-reported outcomes matter. We need to reflect this in clinical trials.