BMJ  2008;336 (12 April), doi:10.1136/bmj.39546.558148.47

Editor's Choice

Editor’s choice

Think again

As medical aphorisms go, "common things are common" is pretty trite. But we do well to remember it, especially when deciding whether one thing causes another: if both things are common, think again. Last year a series of studies in the New England Journal of Medicine suggested a link between bisphosphonates and atrial fibrillation. As Sumit Majumdar writes (doi: 10.1136/bmj.39513.481065.80), it was only a matter of time before osteoporosis, its treatments, and cardiovascular events would be linked. But a large population based case-control study in this week’s BMJ finds no evidence that women taking bisphosphonates are more likely to develop atrial fibrillation or flutter (doi: 10.1136/bmj.39507.551644.BE), and Majumdar concludes that the risk, if it exists at all, is vanishingly small and is unlikely to offset the benefits of fracture prevention.

Atrial fibrillation is certainly common. As Steven Lubitz and colleagues remind us in their Clinical Review, it’s the commonest arrhythmia in clinical practice and causes considerable morbidity and mortality (doi: 10.1136/bmj.39513.555150.BE). Catheter ablation is increasingly popular for patients whose rhythm isn’t medically controlled, especially where ectopic pulmonary vein foci are to blame. Although evidence on long term outcomes remains poor, data suggest that patients with symptomatic drug refractory atrial fibrillation do better with catheter ablation than continuing medical treatment.

Among complications of the procedure, pulmonary vein stenosis remains important and is too often overlooked as a cause of respiratory symptoms in the months after the procedure, according to P Kojodjojo and colleagues (doi: 10.1136/bmj.39457.764942.47). They report on three patients in whom it took several months and a slew of unhelpful investigations before the real reason for haemoptysis, chest pain, or shortness of breath was identified.

Meanwhile, the experiment that is the NHS reforms in England continues apace. Whether we need it or not we will have a constitution in time for the NHS’s 60th birthday in June, says Rudolf Klein, because the junior health minister Ara Darzi proposed it, the prime minister endorsed it, the BMA supported it, and the secretary of state for health is busy working on it (doi: 10.1136/bmj.39545.432407.59). Exactly how it will enforce patients’ rights and responsibilities, and how it will balance national standards with local decision making, remains to be seen. Uncharacteristically, in this case Klein recommends rhetoric over precision.

Tony Blair’s reforms may have cut waiting times for planned care, but Chris Ham says we need a different approach for disease prevention and chronic care (doi: 10.1136/bmj.39532.445197.AD). Instead of competitive commissioning by primary care trusts, which anyway is not going well, he suggests clinical integration, in which general practitioners and hospital specialists would work together to commission and provide the service. The problem is how to do this without yet more wide scale restructuring.

Finally, however we select the next generation of doctors—and Celia Brown and Richard Lilford think cognitive ability is still the best way (doi: 10.1136/bmj.39517.679977.80)—we need to foster in them a passion for reflective learning, say Erik Driessen and colleagues (doi: 10.1136/bmj.39503.608032.AD). Teaching this constructive self criticism should be second nature to most of us: "As in consultations with patients, the skill is to listen well and ask open questions."

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