Increasing complexity

“The thing about back pain is that it's mostly mental, right?” So says John McEnroe, the tennis player, as he comments on a Wimbledon match that (naughtily) I'm watching while writing this. Perhaps McEnroe reads the BMJ, where as the years pass back pain does indeed seem to be changing from a condition thought of primarily in physical terms to one considered to be predominantly psychosocial. Now we may be about to watch the transformation of menorrhagia.

A group from Edinburgh and Glasgow has studied how it is that women with menstrual problems, particularly menorrhagia, get to hospital clinics (p 24). This is important because most of these women are likely eventually to have hysterectomies—despite organic disease being rare. Many of the women did not think that they had heavy bleeding, yet doctors had referred them for heavy bleeding. This tendency for menstrual complaints to be defined as heavy bleeding intensified within the clinic, accelerating the probable progression to hysterectomy. The authors suggest that the considerable variation in referral rates for menorrhagia may be less to do with uncertainty on how to treat the condition and more “fundamental uncertainty about the concept of menorrhagia.”

Gynaecologists who find their traditional concepts becoming more complicated might have some small sympathy with the University of Nottingham, which has found that its public life has become much more complicated since it decided to take £3.8m from British American Tobacco. I resigned my position at the university after BMJ readers voted that I should do so, but now a proper professor has also left, a student of the year has declined his prize, a member of the European parliament has quit, and the Nottingham paediatricians have sent a letter of protest to the vice chancellor. We move the debate forward today with an editorial that takes an international view of the relation between tobacco companies and universities (p 1). Many have taken the tobacco shilling, but others—including the leading academic hospitals in Boston and the University of Sydney—have a declared policy of not taking money from tobacco companies. We urge other universities in Britain and elsewhere to do the same.

Finally, I'm writing this at the BMA's annual meeting, which is filled with discontented doctors (p ), and so I was very taken by a doctor writing the following. “Although it is extremely hard work, an emotional roller coaster, and not financially rewarding, I'm so glad to be here ” (Career Focus, Classified Supplement, http://bmj.com). Where could this doctor be? The answer is The Gambia—on a scheme organised by the Royal College of Paediatrics and Child Health.