Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Proportion or Percentage?
- Peter O Pharoah (15 March 2004)
-
Investigations to treat or to answer ?
- Ruchir D. Trivedi (15 March 2004)
-
Life is Real
- Dr Lynne Wrennall (16 March 2004)
-
Editor's Non-Choice or Who is needling whom?
- Michael O'Donnell (16 March 2004)
-
Original papers are now published online first
- Richard Smith (16 March 2004)
-
Re: Original papers are now published online first
- Adam Jacobs (17 March 2004)
-
The Young Know Everything
- BM Hegde (17 March 2004)
-
Re: Re: Original papers are now published online first
- Mark A Edgar (18 March 2004)
|
|
|||
|
Peter O Pharoah, Emeritus Professor Dept of Public Health, University of Liverpool, Liverpool L69 3GB
Send response to journal:
|
Dear Richard, As usual I enjoyed reading your Editor's Choice this week but why do you use 'percentage' when 'proportion' is more appropriate. "The percentage of patients who saw 10 or more doctors varied from 17% to 59%" surely reads better as "The proportion of patients who saw 10 or more doctors varied from 17% to 59%". After all 'percentage' is a specific form of 'proportion'. Yours sincerely, Peter Pharoah Competing interests: None declared |
|||
|
|
|||
|
Ruchir D. Trivedi, MMedSci student in Nephrology University of Sheffield, Northern General Hospital
Send response to journal:
|
Dear Sir, Richard Smith's continuing comments on present situation is stimulating and thought provoking. To my surprise, many diagnostics are done at modern health care trusts to solace patients and relatives before informing futile outcomes. Investigations are repeated for answering questions rather than unwinding clinical vignette. Consultants and junior staff calculate how many investigations are not ordered rather than what constructive they have done from already available investigations. Modern day medical practise revolve around pleasing patients and more than that saving our skins. As such, inquisitive relatives are hard to confront, unless we have whole range of specialist opinions and sophisticated results. I believe, patients not only require correct information about their illness, but at the same time require day to day progress and our primary impression of their condition and future. Most end of life decisions are made when already more than enough had been done for the patients. We somehow believe that, if patients and their relatives see for themselves that so much is being done they can satisfy themselves and perhaps not litigate us. How much we should do and how far one can go in treatment of chronic incurable disease is a very difficult issue to address. What to tell, when to tell and how much at a time, are difficult issues for doctors to decide. Our attitudes are shaped by the initial experiences we have in hospitals and they are very difficult to change. Timely decisions direct resources effectively and reduce sufferings. I am appreciating the change in doctors’ attitude towards tackling difficult patients. We want to do so much for the patients in spite of knowing its outcome, as we believe more futile attempts to salvage the situation push an individual to accept final jolt. This might prepare them for eventuality. We talk death when we have to and when it is seemingly visible. I do not wish to comment on this situation but I am afraid of loosing my primary duty of doing no harm and always doing benefit to my patients. Purist argue that additional investigation just to answer their questions even when overall diagnosis is evident, still go along with the notion of doing no harm. I disagree with this thinking. Being a patient, I would like to be told everything by my doctors promptly rather than waiting for a scan report or MRI. Even when we defer such conversation, considering that we want to give them full details, we fail to realise that patients are dying in apprehension and uncertainty till reports are available. Information without investigations can not be accurate and clinical impressions are not unequivocally perfect. When these facts are told to patients they can accept any change in their diagnosis and prognosis with relative ease. Unnecessary pressures are being put for prompt, accurate information & present day situation is a natural defence reaction of the system. Most patients walking out of their first out patients’ consultation lack adequate information. In a bid to provide more information to our patients, it is provided very late. Most investigations are still done to answer irrational questions by difficult accusive relatives rather than to treat. Ruchir Trivedi Competing interests: None declared |
|||
|
|
|||
|
Dr Lynne Wrennall, Fellow University of Liverpool L69 3BX
Send response to journal:
|
Dear Editor Writing condolence letters is probably the most difficult writing one can undertake. We fall back, aware of the difficulty, it is easier to avoid. It is so easy to get it wrong. I don’t just mean by patronizing, but there is something worse, a fear of being presumptuous, of trespassing upon memories which are personal, private and in which people are entitled to their own opinion. Never is one’s own memory more properly inviolate than when death has taken someone we love. Memory is what we retain of the person who is gone. We want to share our memories, we don’t want to have them invaded. But I want to say Richard that I am sorry to hear that your Dad has died and I do appreciate the honour you have paid us in sharing the experience with the people who read what you want to tell them. I didn’t know your Dad and I can’t interpret him. I can only appreciate him. In the intangible gifts that pass from parent to child, you obviously apprehended spirit and guts as your weapons of choice. You built and defended something rare and remarkable, a democratic forum. Some of the most important conversations of our time have come to life in the forum you have built. Thank you for your Dad’s life and what he brought. Thank you Richard for allowing freedom to happen. Regards Competing interests: Not a single clinical trial on liberty or immortality! |
|||
|
|
|||
|
Michael O'Donnell, Journeyman writer & doctor Loxhill GU8 4BD
Send response to journal:
|
Yesterday, Monday 15 March, The Independent newspaper published a full-page article claiming that “the biggest trial of acupuncture outside China … is published today in the British Medical Journal.” The results were “strong enough” we were told, “for researchers from the Royal Homeopathic Hospital in London, who helped to organise the trial, to urge the NHS to consider an immediate expansion of acupuncture services paid for by the taxpayer.” The study, as The Independent describes it, involved 401 patients and was not “blinded”. Dear editor, I have scoured the contents page of this issue, published not yesterday, as The Independent claimed, but on March 13, and found no such report. Maybe you are planning to publish such a study in which case your publication has been pre-empted by a “leak” in a less critical medium. Could this strange episode be in any way related to the imminent publication of the German mega-trials of acupuncture, involving some 500,000 patients? These studies were partially “blinded” in that patients were randomly allocated to groups treated with “real” acupuncture or “sham” acupuncture (needles stuck into non-official acupuncture points.) Preliminary results are said to show that, though sham and real acupuncture both achieved better results than standard medical care, the results with both were much the same. If these preliminary findings are substantiated, those of us of scientific bent - as opposed to homeopaths - are likely to conclude that the placebo effect of having needles stuck into you with impressive ceremony is much the same whether they be stuck into sites defined by ancient Chinese texts or sites chosen at random. Competing interests: None declared |
|||
|
|
|||
|
Richard Smith, Editor BMJ
Send response to journal:
|
Michael O'Donnell was not alone in wondering where the paper on acupuncture had appeared. Another friend--highly sceptical of the claims made in the newspapers--kept turning the pages of last week's paper edition of the BMJ convinced that the study must be there somewhere. But it wasn't. The paper was published online yesterday--as one of our "Online firsts." We are close to publishing all of our original research online first. The paper will not appear in the paper journal for a couple of weeks. We clearly need to do a better job of promoting this new facility to both readers and the media. Richard Smith
Competing interests: I'm the editor of the BMJ and accountable for all it contains online and off. |
|||
|
|
|||
|
Adam Jacobs, Director Dianthus Medical Limited, London SW19 3TZ
Send response to journal:
|
Perhaps I could make a small suggestion for one way in which the BMJ could do a better job of promoting the 'online first' facility to readers. At the moment, the link to online first articles on the BMJ website's home page is a rather subtle one near the bottom of the page. On my computer screen, it is off the bottom of the screen and I have to scroll down to see it. Perhaps if the link were moved to the big blue box of links in the middle of the screen more readers would be aware of the facility, assuming they visit the website in the first place. Competing interests: None declared |
|||
|
|
|||
|
BM Hegde, Retired Vice Chancellor Mangalore, India
Send response to journal:
|
Dear Editor, Your emotional "Editor's Choice" brought to mind the following saying of Oscar Wilde (1854-1900): “The old believe everything, Middle age suspects everything, The young know everything." Surprisingly, most of what we do to the dying patients in the last few days(few hours) in the terminal care units has never been audited using controls or placebo! The Swan-Ganz catheter is a good example. The uncritical critical care is, probably, consuming most of the medical care budget of advanced countries. Thank God, the only thing that the poor in this world get as free bonus is peaceful death even though, in life, they are at the receiving end of every single malady that man is heir to. The poor pay for their poverty with their lives, but thankfully, they die in peace without having to undergo the torture of untested interventions of no proven value. It is not surprising that the death rate fell down significantly when doctors went on strike in Israel a couple of years ago! The divine interventionalists better keep this in mind. Yours ever,
Competing interests: None declared |
|||
|
|
|||
|
Mark A Edgar, Honorary Projects Coordinator Dove Cottage Day Hospice, Leicestershire LE14 4EX
Send response to journal:
|
Dear Editor
I write with regard to the final report of the Independent Review of Paediatric Neurology Services in Leicester. Richard Smith, editor of BMJ, wrote advising me that the BMJ editorial team by accident did not cover the release of that report- it got missed. Mr Smith invited me to send a rapid response on the subject. Accordingly, I submit this statement. The report of the Independent Review of Paediatric Neurology Services in Leicester was presented to the public in October 2003. It sets out an account of how the situation at the University Hospitals of Leicester NHS Trust consequent to the high rates of misdiagnosis of childhood epilepsy made by Dr Andrew Holton had been allowed to develop. The Review, commissioned by Professor Lindsey Davies, the Regional Director of Public Health for the Trent Region, and having the status of a statutory Private Inquiry under Section 2 of the NHS Act 1977, took 18 months to complete. The Review Panel's key conclusion was that "insufficient weight was attached to the accumulation of concerns about Dr Holton's practice" and that "the response of the Leicester Royal Infirmary NHS Trust and the University Hospitals of Leicester NHS Trust to the issues and concerns raised by the clinical practice of Dr Holton could, and should, have been more decisive at an earlier stage." The Panel concluded that a move to external review of Dr Holton's clinical practice should have been pursued with vigour by May 2000; a decision taken in Leicester Royal Infirmary in the autumn of 2000 not to proceed to external review was, in the Panel's view, a serious error of judgement. One significant aspect of the way by which concerns emerged around Dr Holton's practice was the role played by local paediatricians who were not employed by Leicester Royal Infirmary, in particular the consultant community paediatricans in Leicester. The Panel was impressed by the clarity with which the consultant community paediatricians identified the issues for consideration, noting that they were increasingly able to form a collective view that strengthened their joint resolve to take decisive action. The Panel concluded that concerns expressed by the consultant community paediatricians were not given the weight they deserved, noting that the fact that the initial concerns around Dr Holton's practice arose from clinicians within the community Trust in Leicester, rather than the acute hospital Trust, appears to have diminished their impact. However, although recognising the role played by clinicians whose employment lay external to Leicester Royal Infirmary, the Independent Review Panel does not comment upon the approach taken by that arm of the NHS which, at the time concerns were emerging around Dr Holton, had responsibilities for external monitoring, for challenging poor performance and for intervening to correct situations in which clinical services were assessed as struggling or failing; namely, NHSE Trent Regional Office. The Regional Director of Public Health for NHSE Trent had been alerted to the emergence of concerns around Dr Holton in March 2000.(Personal correspondence: letter from Professor Lindsey Davies to Dr M A Edgar, December 22nd, 2003) However, the Independent Review report does not present any account of actions taken by the NHSE Trent Regional Office in the light of that alert during the course of the subsequent 14 months leading up to Dr Holton's suspension in May 2001. Indeed, the Director of Public Health for NHSE Trent is not listed as having been interviewed by the Independent Review Panel. In this regard, the Panel's report differs in content from the reports of inquiries carried out by the Commission for Health Improvement. The examination of the role played by relevant organisations responsible for external monitoring is a significant component of CHI's systematic investigative approach. Dr M A Edgar
Competing interests: None declared |
|||