Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
BP Self-monitoring: Beware of the pitfalls!
- William CW Wong, Wong WCW (5 September 2005)
-
RCTs are not always the "gold standard"
- Kath H Checkland (4 October 2005)
-
Applauding one Woman's Rebellion against Quetelet
- Peter Morrell (15 October 2005)
|
|
|||
|
William CW Wong, Assistant Professor in Family Medicine Hong Kong, Wong WCW
Send response to journal:
|
Dear editor, I totally agree with Bakx et al (1) and McManus et al (2) that self- monitoring of blood pressure should have some roles to play in hypertension management. In our study, we found that ownership of electronic BP machines was widespread in Hong Kong.(3) However, those machines that were available to and used by the general public poorly agreed with the gold standard and there were large variations in how often and under what circumstances the machine had been used. Therefore, making Grade A (4) electronic BP machines available at general practice clinics could be a solution to promote better BP self control at the expenses of convenience and greater autonomy of home monitoring. Alternatively, information on their performance should be made more available to the doctors and the general public, and patients who decide to embark on home monitoring should be trained in the techniques and advised on what to do when the readings are abnormal. 1. Bakx JC, van der Wel MC, van Weel C. Seldf monitoring of high blood pressure. BMJ 2005; 331: 466-7. 2. McManus RJ, mant J, Roalfe A, Oakes RA, Bryan S, Pattison HM and Hobbs FDR. Targets and self monitoring in hypertension: randomized controlled trial and cost effectiveness analysis. BMJ 2005: 331: 493-6. 3. Wong WCW, Shiu IKL, Hwong TMT, Dickinson JA. Reliability of automated blood pressure devices used by hypertensive patients. J Roy Soc of Med 2005; 98; 111-3. 4. O¡¦Brian E, Waeber B, Parati G, Stassen J. Myers MG. Blood pressure measuring devices: Recommendation of the European Society of Hypertension. BMJ 2001; 322: 531-6. Competing interests: None declared |
|||
|
|
|||
|
Kath H Checkland, GP and post doctoral research fellow Eyam Surgery S32 ??? National Primary Care Reserach and Development Centre M13 9PL
Send response to journal:
|
Whilst agreeing with the main thrust of this editorial, I was irritated by the unthinking assumption that the answer to all research questions lies in randomised controlled trials. RCTs can only tell us about average effects across populations. Until genetic research can begin to provide us with individualised response profiles, then for drug effects this kind of information is the best we can do. When we are dealing with human behaviour, however, we can do better. As a GP in an affluent area I have some patients who have purchased their own BP monitoring machines. In my consultations with them I do not want (or need) evidence from RCTs that tells me that ON AVERAGE, across a population, x% of people will do better with home monitoring. What I need is a detailed knowledge of the patient (are they very anxious and likely to become obsessed and panicky about their blood pressure, or are they the kind of person for whom being in control is a positive experience? Will knowing their BP motivate or frighten them?) and the time to discuss with them the implications and the evidence about blood pressure and health. It is disappointing that an editorial in the BP is perpetuating the unthinking dogma that RCT evidence is always "the best". RCT evidence can answer some questions; investigating human behaviour is often better done in other ways. Kath Checkland Competing interests: None declared |
|||
|
|
|||
|
Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University, UK
Send response to journal:
|
Kath Checkland says "I was irritated by the unthinking assumption that the answer to all research questions lies in randomised controlled trials. RCTs can only tell us about average effects across populations. Until genetic research can begin to provide us with individualised response profiles, then for drug effects this kind of information is the best we can do. When we are dealing with human behaviour, however, we can do better." [1] As she goes on to say, "in my consultations with [my patients] I do not want (or need) evidence from RCTs that tells me that ON AVERAGE, across a population, x% of people will do better with home monitoring. What I need is a detailed knowledge of the patient." [1] In the context of a recent BMJ discussion on another thread [2], her comments above reveal her as conforming very closely to the concept of the "good doctor" who is keen to tailor treatment to each individual patient rather than "perpetuating the unthinking dogma that RCT evidence is always "the best"..." [1] which in this context means the vexatious application of what she calls "average effects across populations," [1] or one standardised mode of treatment for all. She also very nicely illustrates my contention that the "'good doctor'....is both a competent and caring doctor of great skill and also one who individualises treatment to your own specific needs, rather than treating you as just another case of ABC," [3] for the approach which she advocates rebels somewhat against the "standardisation based upon averages of millions [Quetelet's 'l'homme moyenne']...an approach [which] cannot of necessity build into its therapeutic equations the huge variability inherent in each person." [3] For, as she also insists, "when we are dealing with human behaviour, however, we can do better." [1] It is most heartening to see that there still exist such 'good doctors' as Kath Checkland, who are also intelligent and and brave enough to question "unthinking dogma." [1] Her comments reveal some glimmer of a welcome rebellion against Quetelet, who Auden might have had in mind when he wrote: The average of the average man
We do not live as averages but as individuals; this applies as much to our sickness as to our health. Sources [1] Kath Checkland, RCTs are not always the "gold standard" BMJ e- letter, 4 October 2005 http://bmj.com/cgi/eletters/331/7515/466#118349 [2] see article and e-letters of: REVIEWS: Domhnall MacAuley Rebuilding Trust in Healthcare; What is the Real Cost of More Patient Choice?; Patients, Power and Responsibility: The First Principles of Consumer-Driven Reform BMJ, Jan 2004; 328: 54. http://bmj.bmjjournals.com/cgi/content/full/328/7430/54? [3] Peter Morrell, Good doctor and science are incompatible categories, e-letter, BMJ http://bmj.com/cgi/eletters/328/7430/54#117340, 26 Sep 2005 [4] W H Auden, New Year Letter, 1940, in Collected Poems, London: Faber and Faber, 1994, p.234 Competing interests: None declared |
|||