BMJ  2006;333 (12 August), doi:10.1136/bmj.333.7563.0-f

Editor's choice

Diminishing returns

There's lots of clinical stuff in the BMJ this week—chosen because we think it will help doctors make better decisions.

From their randomised controlled trial of antibiotics for acute conjunctivitis, Everitt and colleagues (p 321) conclude that the best strategy is delayed prescribing (a prescription to be collected at the patient's discretion after three days). Remco Rietveld and colleagues conclude that withholding antibiotics for such minor complaints can be considered harmless in Western countries, where the incidence of complications has declined sharply in the past decades. Antibiotics may thus be reserved for more serious conditions, such as infective endocarditis—linked nowadays in the West more to intravenous drug misuse, degenerative valve disease, and nosocomial infection than to rheumatic fever. Rhys Beynon and colleagues advocate a multidisciplinary approach in their clinical review (p 334).

Meanwhile there's good news for one old drug and bad news for another. Wallenborn and colleagues help to rehabilitate metoclopramide as a treatment for postoperative nausea and vomiting (p 324), while Verhamme and colleagues report that spironolactone nearly trebles the risk of upper gastrointestinal events (p 330).

This is perhaps the sort of stuff that Tara Hunt thought she'd be focusing on after discovering, in an unexpected epiphany at the age of 26, that she wanted to be a doctor. Instead, after several happy years studying medicine and getting into debt, she finds her enthusiasm dampened and her pride in her profession confused (p 359). "When did it all become about getting published, about audits and research, points on your curriculum vitae, and ticking the right boxes?...Shouldn't I be busy updating myself on published best practice rather than trying my best to get published?"

Readers may sympathise but, as Nick Black and John Brown point out (p 312), there's more to best practice than just giving the most effective treatments. The only way seriously to improve outcomes, they say, is by delivering care more efficiently. To do this we need meaningful and accurate measures for productivity, something they fear we don't yet have. Hardest of all is to be sure that measures take account of the humanity of care as well as procedural and clinical outcomes. Better data on the process and outcomes of care should be collected routinely, they say.

Ultimately what we need in health care, says Stephen Black, a management consultant, is not more resources but more and better management (p 358). "Investing more in better organisation, good managers, and appropriate IT may be a far more effective way to improve the working lives of doctors and nurses than recruiting more doctors and nurses."

Fiona Godlee, editor

(fgodlee{at}bmj.com)

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Relevant Articles

Health care productivity
Nick Black, John Browne, and John Cairns
BMJ 2006 333: 312-313. [Extract] [Full Text] [PDF]

Infective endocarditis
Rhys P Beynon, V K Bahl, and Bernard D Prendergast
BMJ 2006 333: 334-339. [Extract] [Full Text] [PDF]

More and better management is the key to fixing the NHS
Stephen Black
BMJ 2006 333: 358. [Extract] [Full Text]

I just wanted to be a doctor
Tara Hunt
BMJ 2006 333: 359. [Extract] [Full Text]

Spironolactone and risk of upper gastrointestinal events: population based case-control study
Katia Verhamme, Georgio Mosis, Jeanne Dieleman, Bruno Stricker, and Miriam Sturkenboom
BMJ 2006 333: 330. [Abstract] [Full Text] [PDF]

A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice
Hazel A Everitt, Paul S Little, and Peter W F Smith
BMJ 2006 333: 321. [Abstract] [Full Text] [PDF]

Prevention of postoperative nausea and vomiting by metoclopramide combined with dexamethasone: randomised double blind multicentre trial
Jan Wallenborn, Götz Gelbrich, Detlef Bulst, Katrin Behrends, Hasso Wallenborn, Andrea Rohrbach, Uwe Krause, Thomas Kühnast, Martin Wiegel, and Derk Olthoff
BMJ 2006 333: 324. [Abstract] [Full Text] [PDF]

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