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Michael Patkin, retired general surgeon Royal Adelaide Hospital, South Australia 5000
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The most simple measure to improve consultations is for the patient to have a best friend with them, to help remember the questions and the answers and to reinforce recommended treatment later on. This best friend might be spouse or other close relation, neighbour, or simply good friend. During the 1980s patients who saw me as a country general surgeon for gastric bypass surgery had the same best friend with them for each of several consultations, with them while they walked 45 minutes briskly each day before surgery, and with them to reinforce the dietary advice to get them slightly lighter and fitter. Competing interests: None declared |
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Phillip J Colquitt, Technician/RN Independent Comment
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Patients should have their own room. Hospital dormitories exude a reform school atmosphere, grading the patient as unworthy of privacy, and maximising access to the patient in favour of hospital workers in training. Drawn curtains don’t eliminate sounds and smells. It’s hard to take breakfast next to another’s toilet. Single rooms would eliminate the constant bed moves within a ward and also complaints based on mixing the patients. With constant mass observation eliminated, the predictive power of medical treatment would be tested. I daren't mention a view. Competing interests: None declared |
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Stephen MW Hutchison, Consultant Physician in Palliative Medicine Highland Hospice, Inverness, IV3 5SB
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This is a subject I think and teach a lot about, and I can best summarise my main point by quoting Dr Francis Peabody, in the mid 1920s, who concluded a seminal lecture on patient care by saying "The secret of the care of the patient is in caring for the patient". We need to learn to really care, in our hearts, for people. A briefer summary could be 'Love your patient'. If we really care in that way, we will communicate thoughtfully, and investigate and treat compasionately. Some people will be hard to love, and that takes more work! Patients expect technical expertise but it is the attitude, which they notice and which conveys either care, or carelessness. Peabody, Francis W The care of the patient JAMA 1927; 88: 877-92 Competing interests: None declared |
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Christopher M Buttery, Clinical Professor Virginia Commnwealth University, USA, 23298
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Stop talking about health care when you mean medical treatment. To improve population health focus primary care on preventing chronic disease. Focus all members of a household/family on behaviors inimical to health. The chronic diseases are driven by a combination of genetics and behaviors. We have failed to guide adolescents to select future spouses based on genes so primary care must educate potential partners to strengthen behaviors most likely to result in good health. Medical interventions only prolong disease and rarely return patients to health. Medical schools must provide better training in epidemiology and medical strategy, not tactics (medical care).
Competing interests: None declared |
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Celine M Aranjo, General Practitioner New South Wales, 2208, Australia
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Since the above is so, I'd just like to say that 'cancer' as understood by many, is not a disease entity like 'the 'flu', or SARS,or HIV/Aids. 'Cancer' when considered to be a combination of diseases and disorders, could give the true concept of the word 'cancer';this in turn, should lead us to investigate the probable diseases and disorders and try to treat these BEFORE the cancer diagnosis is evident. For example, the 10 facts about cancer as put by the WHO states that chronic conditions as in chronic infections,(e.g.chronic bilharziasis,chronic lymphatic filariasis,neurocysticercosis..)are eventual causes of cancer:- uro-genital and colo-rectal...in the former,lymphoma either NHL or HL in the filarial infections,echinococcosis in the third infection, the list goes on..and when treatment is started as soon as possible for these infections,world-wide, perhaps many 'cancers' will be eliminated before they start. Competing interests: None declared |
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Derek Bell, Porfessor of Acute Medicine SW10 9NH
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Individually all clinicians aim for the highest quality of care. However, in practice, especially in acute care outcomes for patients vary by post code, hospital environment and by time of day or week. To improve this we must develop a greater understanding of why this occurs and hence remedy the problem. Publications and critical incidents often show flawed process as significant factors in poor outcomes. What can we do differently for patients? A greater emphasis on competent first assessments including a good history combined with assessment of patient need (illness severity, dependence or patient wishes) is likely to improve outcomes. We often minimise the importance of this by looking for technological solutions and we assess these core competencies poorly and at best intermittently.Often assuming these are 'easy skills'. We need to develop better systems to train and monitor patient care assessment linked to provide prompt treatment(not when convenient for the NHS) and thus move towards abolishing post code or weekday/weekend lotteries. Competing interests: None declared |
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elizabeth m witherington, clinical assistant nottingham university hospitals
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What our patients really, really want is to know that when they are bloody ill (learning how to recognise this diagnosis needs to be reintegrated into undergraduate curricula), they will receive a decent standard of care at a hospital reasonably near their home. The single most important thing that we can do to improve patient care is to learn how to communicate medical information when we entrust our patients to another doctor. We may have delivered the highest standard of care ourselves, but unless we tell the next doctor how we have meddled with medication, we contribute to risk and potential harm. Increased fragmentation of care has led to fragmentation of thinking. The most vulnerable patients (BMJ 2007;334:1016-1017, doi:10.1136/bmj.39201.463819.2C Multimorbidity's many challenges) are at greatest risk from our failure to communicate properly at transfers of care. Safe transfers of care require information about -how ill the patient is now -how ill they have been during the most recent episode -what has changed, diagnostically -what has changed, therapeutically, and why -what monitoring is required for each of these changes, when it is required, and who is required to do it This is not a new subject, and it is not sexy, but if we communicate properly it could reduce a lot of misery, reduce risks and possibly save lives. Competing interests: topic editor, transfers of care, www.saferhealthcare.org.uk |
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Gösta E Eliasson, GP Falkenberg SE-311 37 Sweden
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Today medical care is complicated and there are many investigations done at the primary health care centre. This means allocation of resources. GPs can do many things. The question is what is most important. Patients are mostly satisfied with their care, given that they have came inside the walls of a health care centre. But to be able to see a GP becomes more and more difficult. Walk in centres and NHS direct could be a substitute, but the personal relation will suffer from these organisational fixes. Real quality improvement would be to make availability to a personal GP priority number one in health care. All other tasks should be subordered this. Competing interests: None declared |
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Eluzai .A. Hakim, Consultant Physician St.Mary's Hospital,Newport, Isle of Wight,UK,PO30 5TG
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Properly carried out,Health Education empowers the patient with information about risk factors for commom conditions.Conditions directly related to Alcohol consumption,Cigarette and recreational drug smoking, Obesity and Road traffic accidents, for example, continue to increase in our emergency Departments placing enormous strain on Health Resources. These problems may be dealt with cost effectively through appropriate strategies to educate the public and patients to minimise exposure to these factors and hence reduce morbidity, mortality and improve quality of life.Many obese patients do know that judicious exercise reduces cardiovascular risk and obesity, choosing instead to visit a Doctor for a prescription!Education is to date the most powerful weapon on our hands in Healthcare which must be distinguished from treatment.There are more people who need Healthcare than treatment.I have encountered heavy cigarette smokers who resisted outpatient clinic advice against smoking by saying,"Don't patronise me;I have smoked all my life and Iam well" More structured educational material would help in this situation. Competing interests: None declared |
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David I Ben-Tovim, director, Redesigning Care and Clinical Edipemiology Units flinders Medical Centre, Bedford Park, South Australia 5042
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The most important thing is to believe that it is true. That being admitted as a patient in a modern hospital is second only to cardiovascular disease as a source of preventable mortality and morbidity: And that this is so world wide, and that nothing that we have done so far has changed that risk. If we really, truly believed in the evidence (which of course we do not, not really) we would agree that trying to do what we do now, but doing it a bit better is not going to be enough. In fact, it is that kind of thinking that is the problem. It assumes that our basic approach is fine, we just need to work a bit harder at it. If around one in ten patients leave hospital with a patient safety event, the problem goes much deeper than any top five, ten or twenty interventions can fix. From the patient viewpoint, care in hospital or primary care is a process made up from a sequence of activities from registration through to specific treatment and exit. We have to get the right step, to the right patient, at the right time, at the right place, and get it right first time, at every point along the journey. Biomedical thinking is not about how care is actually delivered. It is about what should be delivered at a restricted number of steps. But no one ever got better from a should, only from an is. We have to learn from people who understand about improving processes and who really care about quality (in places like modern manufacturing and service industries), and understand that we are members of a team, and that its the teamwork, stupid, that will make the difference. Competing interests: None declared |
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Chris Del Mar, Dean Bond University, Queensland 4229
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There’s indirect[1] and direct[2] evidence that the NNT (treat here meaning provide anti-smoking advice) for smokers is about 10 - 17 to prevent a death from smoking-related disease. It will be much lower for smoking-related morbidity. That’s a pretty good hit-rate — and since smokers are about 30% of our general practice population, case-finding is not difficult. We have to overcome the problem is that this is undetectable in practice, unlike many clinical activities for which success provides immediate positive feedback to the clinician. Hence the need for proxy measures for primary care to target. 1 Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 1994;309:901-910. 2 Rose G, Colwell L. Randomised controlled trial of anti-smoking advice: final (20 year) results. J Epidemiol Community Health 1992;46:75- 7. Chris Del Mar Dean, Health Sciences and Medicine, Bond University, Gold Coast Australia 4229. Competing interests: None declared |
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Leila Kozak, PhD, Investigator/Senior Project Manager University of Washington, School of Medicine, Seattle, WA 98109, USA
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I agree with Dr. Hutchinson’s statement (“Real patient care”). As he says, “we need to learn to really care, in our hearts, for people.” To accomplish this ‘real patient care’ we need to train providers beyond communication skills – we need to train them in the practice of being “fully present” and attuned with their compassionate intention. This quality of presence that the provider may bring to the interaction and the conscious projecting of a compassionate intention can make a huge difference not only on patients but in the quality of life of providers. This sense of presence and intention also has the power to transcend cultural/language barriers. Competing interests: None declared |
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Peter M Lapsley, Patient editor BMJ, BMA House, Tavistock Square, London WC1H 9JR
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Like many patients, I wish to be an active partner in my healthcare, collaborating with clinicians to achieve acceptable outcomes. That can be thwarted by doctors’ slavish adherence to evidence-based guidelines and protocols, and by poor explanation of risks and benefits. The rigid requirements of evidence-based medicine deter doctors from taking account of patients’ lifestyles and, thus, of the quality of patients’ lives. A recent survey by the Royal College of Physicians Patient & Carer Network found that risk-benefit communication was taught in only a minority of specialties. If patients’ needs are to be met, both those things must change. Competing interests: I am the BMJ's patient editor |
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John A Spencer, GP & Professor of Medical Education Newcastle University (NE2 4HH) & Adelaide Medical Centre, Newcastle (NE4 8BE)
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If GPs (nay, all doctors) consistently and systematically elicited their patients' ideas, concerns and expectations (ICE), the effect on patient satisfaction, diagnostic accuracy, inappropriate help-seeking behaviour, quality of care of, for example, long term conditions and functional illness, and concordance (to name a few outcomes), and possibly even on job satisfaction, could be momentous. Competing interests: None declared |
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GRAHAM WATT, PROFESSOR OF GENERAL PRACTICE UNIVERSITY OF GLASGOW G12 9LX
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This initiative is important but addresses only half of the problem - identifying the most effective interventions in primary care. To improve public health, we need to consider not only what is effective for individuals, but also how many people are eligible for the intervention. What needs to be compared is the product - just as supermarkets make mega- profits based on small margins for large volumes of sale, primary care improves population health by doing simple things for and with large numbers of people. The inverse care law is alive and well, 36 years after its initial formulation, as the availabilty of good medical care continues to vary inversely with the need for it in the population served. It is not so much a "law" as the result of the policy, maintained throughout the history of the NHS, of rationing medical manpower in primary care - in the war-time sense of everyone having equal access to a general practitioner. Thus general practitiioners, and resources tied to the numbers of GPs, are distributed equitably in terms of population numbers, but inequitably in relation to population health need. In England, this situation is getting worse rather than better. All this boils down to less time in the consultation for patients with higher levels of need - an endemic situation which can only be resolved by professionals and patients adapting to lower levels of expectation and aspiration. Such practices are further behind in the transition from reactive to anticipatory care. When the most effective interventions have been identified and ranked, we shall still be no further on in addressing why such interventions are less likely to be delivered in deprived areas. As Tudor Hart also said, "intellectual opposition to injustice is only the beginning of social understanding". We need fewer ostriches, and more owls, who are not only wise, but can see the whole picture. Graham Watt
Competing interests: None declared |
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Tony Kendrick, Professor of Primary Medical care University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST., Jeannette Lynch
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Depression is one of the greatest burdens facing all health economies, over and above the considerable personal costs[1]. Total economic costs are estimated to exceed £25 billion per year (2% of GDP)[2] largely due to the loss of 91 million working days[3]. The incidence seems to be increasing[4] and with it the use of antidepressant drugs: prescriptions rose by 36% between 2000 and 2005 to 7.3 million items per quarter, the 4th most expensive area of prescribing[5]. Many patients do not wish to take antidepressants however and the risk-benefit ratio is not as favourable as psychological therapy. Guidelines recommend CBT based treatments as appropriate alternatives[6], but despite this, access to such treatments remains limited[7] and should be increased as a matter of urgency. 1.World Health Organisation E. Mental health: facing the challenges, building solutions. 2005. 2.Layard R. Mental health: Britain's biggest social problem? RL414c, 1-33. 2004. 3.Layard R. The case for psychological treatment centres. RL447 (2nd update), 1-10. 2006. 4.Mental Health Foundation. Statistics on Mental Health - fact sheet. 2003. 5.Prescriptions Pricing Authority. Drugs used in Mental Health. 2005. 6.Depression: management of depression in primary and secondary care. 1- 328. 2005. National Istitute for Clinical Excellence, National Clinical Practice Guidelines. 7.Lovell, K. Richards, D. 2000. Multiple Access Points and Levels of Entry (MAPLE): Ensuring Choice, Accessibility and Equity for CBT Services. Behavioral and Cognitive Psychotherapy, 28, 379-391. Competing interests: None declared |
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Michael D Innis, Director Medisets International Home 4575
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Dr. Clemetson : "To reduce the risk of Barlow's disease,(misdiagnosed as SBS) we should consider the following: (1) Postponing inoculations for infants who are premature or ailing in any way, even with an upper respiratory infection; (2) reconsidering the wisdom of giving as many as six inoculants, all at once, to infants at eight weeks of age; (3) administering 500 mg of vitamin C powder or crystals, in fruit juice, to infants before inoculation; and (4) giving additional ascorbic acid by injection to any infant showing a severe reaction such as convulsions or a high-pitched cry." http://en.wikipedia.org/wiki/C._Alan_B._Clemetson Competing interests: None declared |
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Bill Cayley, Assistant Professor, UW Health Augusta Family Medicine, University of Wisconsin 207 W Lincoln, Augusta, WI 54722 USA
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Healthy lifestyles are the foundation of healthy lives. Several previous responses wrestle with the tension between medical treatment (with interventions, drugs, etc) and education for healthy living (exercise, smoking, etc). In the individual doctor-patient encounter, both have a place. However, the area that we need far more clinically applicable research and improvement in practice is understanding how to both assess patients' life-style risk factors, and understanding how to motivate for health-ful change in three basic areas: eating, exercise and smoking. The more we can focus on healthy living, the more we will prevent help prevent disease in the long-term, and the more we will implicitly convey to our patients that we view health as more than just pills and technology. Bill Cayley, MD bcayley@yahoo.com Competing interests: None declared |
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Joanne M Shaw, Vice-Chairman, NHS Direct 207 Old Street, London, EC1V 9PS
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I fully support Dr Spencer's contention that clinicians should follow the ICE framework. Decisions made by doctors are better when informed by patients’ Ideas, Concerns and Expectations. But treatment decisions should not be made by doctors alone - patients are also decision-makers. For example, it is the patient who decides whether, when and how to take the medicine once prescribed. And as we all know, around 50% of medicines for long term conditions are NOT taken as prescribed. Shared agreement is needed for patients to buy into and follow treatment decisions. ICE is nice but needs to become: Ideas, Concerns, Expectations and Shared decision. Which is why training doctors in shared decision-making with patients, along with the use of ICE, would make such a difference to personal health. Competing interests: None declared |
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M Justin S Zaman, Research Fellow in Epidemiology/Specialist Registrar in Cardiology University College London WC1E 6BT
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A nutrition transition has occurred amongst populations in high- income nations [and soon lower-income ones...] in which not only is energy intake per person higher but also a higher proportion of that energy is derived from added sugars and fat. (1) The obesity epidemic is comparable to the tobacco epidemic. (2) Evidence that increased tobacco consumption results from trade liberalisation (3) and global marketing (4) are potentially applicable to the obesity epidemic. Health behaviours are not “lifestyle” variables, governed largely by individual choice and therefore a matter of individual responsibility, but are socially patterned and reinforced in groups. To create an environment in which individual behavioural initiatives can succeed, major shifts in population behaviour through public health policy are necessary. Reference List (1) Drewnowski A. Fat and Sugar: An Economic Analysis. J Nutr 2003; 133(3):838S-8840. (2) Chopra M, Darnton-Hill I. Tobacco and obesity epidemics: not so different after all? BMJ 2004; 328(7455):1558-1560. (3) Bettcher D SCGE. Confronting the tobacco epidemic in an era of trade liberalization. Commission on Macroeconomics and Health, editor. WG4:8. 2001. Geneva, World Health Organization. Ref Type: Report (4) Collin J. Think global, smoke local: transnational tobacco companies and cognitive globalisation. In: Kelley L, editor. Health impacts of globalisation: towards global governance. New York: Palgrave, Macmillan, 2006: 61-86. Competing interests: None declared |
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anthony clift, College Medical Adviser M24 4DZ
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100 words BMJ General Pactice has suffered from being proactive (campaigns for immunisation, birth control, smoking cessation etc) rather than reactive to patents needs. This has led to inordinate work loads, destroying access to the GP just when its needed . Stop all remunerated targets, which seem to have dominated practice as they are major income producer. Rely on doctors to give appropriate advice when seen. GPs are becoming inaccessible, especially out of hours and visits, but many callouts are a chance to educate the patient in use of the NHS. Make small charge for all GP consultations, with appropriate relief for the elderly and chronic sick. Competing interests: None declared |
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Anne M Chatterley, carer parent's home HP23 4AF
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Doctors need to talk to each other especially when sharing the care of a patient or transfering the care to another department/hospital. It is frustrating to have tests repeated because the 'new' team cannot access the previous results or accessing them takes too long, is too difficult or, as I heard twice recently, the new team prefer to do their own tests as they know the staff who carry out/process those tests (this suggests they do not trust other colleagues work which does not fill the patient with confidence if they return to the care of that team). What you tell patients needs to reflect the fact you are aware of what your colleagues have said, this is not to say you have to agree with what they said, just be aware and if necessary explain why your conclusions differ. Competing interests: None declared |
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W. Bruce Thompson, GP 28 Church Walk, Lurgan, N.Ireland. BT67 9AA
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For many years NHS patients have had great incentive to maximise their illness behaviour. The introduction of the Disability Living Allowance (DLA) provided a paycheque for the professional patient, whilst increased waiting lists neccesitated exaggerating symptoms to get priority treatment (or any treatment at all). Getting better costs the patient money. The reduction of waiting times will allow timely intervention to those who need medical help and weed out the malingerer. Why not stop DLA payments and use these funds to encourage wellness not illness behaviour - free leisure centres, parks, cycle paths, school games facilities - the list is endless. Competing interests: None declared |
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Erik W.M.A. Bischoff, GP trainee and PhD student Department of General Practice, HAG 117, Radboud University Nijmegen, The Netherlands
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COPD prevalence and COPD-related mortality and morbidity have increased enormously during the last decades and caused an expanding burden on health care systems worldwide. International guideline committees have pronounced their concerns about the further increase in COPD prevalence. The major part of COPD-related costs can be attributed to the increase of exacerbations, which have a significant impact on patients’ health status. In my opinion, health care professionals and researchers should focus on how to improve health care or disease management for patients with COPD. How can we help patients to prevent and to react efficient on exacerbations? How can we improve the use of medication among COPD patients? How can we help them to change their lifestyle (e.g. stop smoking, exercise programme)? Although more and better research on this topic is needed, there has to be also a willingnes | |||