Years ago Katharine Hepburn declared she would not allow herself to be treated by a physician under the age of fifty. Ageism in reverse. Remember though, her father had been a doctor. Recently we have heard much about evidence-based medicine and its importance in securing satisfactory treatment outcomes for patients. This late emphasis suggests that up to now doctors have been bumbling along in a skills and knowledge vacuum and that politicians, bless them, are here to rescue the sick public. Yet evidence base, especially in the treatment context seriously took off with A Bradford Hill's promotion of the double-blind trial which is not a process panacea but few would doubt its beneficial effect in measuring treatment outcomes. Nor would we want to disinvent the Internet for accessing information and databases like Medline and the Cochrane Library. It is another tool. Nothing more, nothing less.

There is however, and there always has been, a temptation for us as medical practitioners, especially when in our early prime, to think that ours and ours alone is the era of the true cutting edge: the new, the only, Medical Enlightment; that all that's gone before is perhaps well intentioned but....er..sorry.. a bit primitive (naturally). But, thank God, it is now on track. Would that this were the whole truth. The Internet and its search engines are not without their imperfections. One recent study of web-based information on the treatment of depression found that the quality of the 21 popular websites examined was poor.(1). Something else which might dent any hubris tendency in British medicine's state of the art was Wilmshurst's concern for quality of clinical skills, and therefore lack of clinical competence, to the detriment of patient care, among those who hold honorary clinical appointments.(2) Although some subsequent correspondence questioned his claims, he has answered them rather emphatically and more commentators agree than disagree with him.(3)

Further in support of Wilmshurt's assertions, I was astonished to find in an editorial from a professor of psychiatry et al (as it happens, also in the BMJ) on the treatment of bipolar affective disorder, that ECT went wholly unmentioned.(4). Electoplexy has a remarkably safe and impressive treatment record, often life-saving in deeply disturbed patients, both in mania and depression. This is something that few psychiatrists with ten or twenty years experience at psychiatry's coalface would deny. Neither, of course, would they abjure the adjunctive effectiveness of psychotropic medication.

Kate Hepburn had a canny point in valuing, for her, the importance of the physician's mature clinical experience. But lest junior doctor's become demoralised they should keep in mind Professor Mshgeni's explanation of why God could never get a chair at a university: "He has had only one major publication. It carried no references and was not published in a properly refereed journal. There is some doubt about whether He wrote it Himself. And the international community has found it very difficult (indeed impossible) to replicate the results of His work."(5)

Dermot J Ward FRCPI FRCPsych

Independent consultant psychiatrist

1 Hill AB. Statistical methods in clinical and preventive medicine. 1962. Edinburgh, Livingstone.

2 Wilmshurst P. Devaluing clinical skills. BMJ 2000;320: 1739.

3  Wilmshurst P. Author's reply. BMJ 2000;321: 1351.

4 Young AH, Macritchie KAN, Calabrese JR. Treatment of bipolar affective disorder. BMJ 2000;321:1302-3.

5 Lean J. Now it's time to save the humans. The Independent 1998;10 May:17.