Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Best friend as support at consultations
- Michael Patkin (18 May 2007)
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One's own room
- Phillip J Colquitt (18 May 2007)
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Real patient care
- Stephen MW Hutchison (18 May 2007)
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Prof
- Christopher M Buttery (19 May 2007)
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This issue is dedicated to early cancer detection
- Celine M Aranjo (19 May 2007)
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Getting it right - timely assessment and treatment
- Derek Bell (19 May 2007)
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Communication, communication, communication
- elizabeth m witherington (19 May 2007)
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Availability comes first in primary care
- Gösta E Eliasson (19 May 2007)
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Health Education
- Eluzai .A. Hakim (19 May 2007)
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its the teamwork, stupid
- David I Ben-Tovim (20 May 2007)
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Just ask if they smoke...
- Chris Del Mar (20 May 2007)
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'Full presence' and compassionate intention
- Leila Kozak, PhD (20 May 2007)
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Patients as participants in their care
- Peter M Lapsley (21 May 2007)
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ICE, ICE, Baby......
- John A Spencer (21 May 2007)
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An ostrich of an initiative
- GRAHAM WATT (21 May 2007)
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CBT for depression
- Tony Kendrick, Jeannette Lynch (21 May 2007)
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Professor C.A.B.Clemetson's Legacy
- Michael D Innis (21 May 2007)
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Most important? Heathy living.
- Bill Cayley (21 May 2007)
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ICE is nice, but needs to be ICES
- Joanne M Shaw (22 May 2007)
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Look at the bigger picture. Look beyond the consulting room
- M Justin S Zaman (22 May 2007)
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Availability
- anthony clift (22 May 2007)
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carer's response
- Anne M Chatterley (22 May 2007)
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Emphasize the positive
- W. Bruce Thompson (22 May 2007)
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Focus on COPD disease management
- Erik W.M.A. Bischoff (23 May 2007)
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Effective Communication
- Theo Schofield (23 May 2007)
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Integrated ICT for patients and health professionals
- Tom Fahey (23 May 2007)
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Providing information for patients: some considerations.
- Elizaveta Naumova, Professor Yury Shvarts (25 May 2007)
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Look at why we have a problem
- Glenn Stewart (25 May 2007)
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A fair and rapid asylum process
- Jean P Fisher (25 May 2007)
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The metacontext needs everyone's attention.
- Steven Ford (25 May 2007)
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Opportunistic advice
- Janet Boaler (25 May 2007)
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consultation skills
- Elizabeth A McClure (25 May 2007)
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The whole person
- Katherine H Checkland (25 May 2007)
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Screening for gallstones. Saving lives and budgets.
- David Flook, Rochdale Road, Oldham, OL1 2JH (25 May 2007)
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Addiction
- Steven A. Burr (25 May 2007)
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Studies needed on older patients with multimorbidity: take the challenge!
- Els Licht (25 May 2007)
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Making a difference
- Jonathan R Benger (26 May 2007)
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IN DRIVER'S SEAT
- PRANAV KUMAR (27 May 2007)
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Alcohol history
- Trevor G Stammers, Twickenham, TW1 4SX (28 May 2007)
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Your Health Depends On You
- Hugh Mann (29 May 2007)
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Holistic care at the end of life
- Wendy-Jane Walton, Shrewsbury SY2 6DL (30 May 2007)
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End of life care in the elderly
- Alex Williamson (31 May 2007)
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Listen
- James Hickman (31 May 2007)
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Motivational interviewing
- Adrian H Sie (31 May 2007)
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health care is much more than just medical care
- Melissa K Raven (31 May 2007)
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Families
- Simon Fountain-Polley (31 May 2007)
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Liverpool Care of the Dying Pathway
- Philip R Williams (31 May 2007)
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Trust, Sincerity of Purpose
- Dindukurthi Sudhakar (31 May 2007)
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Respect and communication
- Alison J Melvin (31 May 2007)
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The Final Frontier
- Colin J Greaves (31 May 2007)
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Occupational Health in the Consultation
- Antony S Willman (31 May 2007)
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Poverty and diseases are overwhelmingly connected.
- Dr. Naseem A. Qureshi (31 May 2007)
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Listen and touch
- Pedro Solberg (31 May 2007)
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too many tests/investigations
- Vaidyanathan Gowri (31 May 2007)
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Diagnostic errors and patient care.
- Giuseppe Lippi (31 May 2007)
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reflection
- Joaquin Averbach (31 May 2007)
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Solid foundations
- Brian P McNicholl (31 May 2007)
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Better care
- Moahmed Salim Merchant (1 June 2007)
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Talk about reproductive health
- Douwe A A Verkuyl (1 June 2007)
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Better quality of life and appropriate treatments
- Roberto G Romanelli (1 June 2007)
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voting for sexual health interventions
- Gerda Pohl (1 June 2007)
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Re: Health Education
- Peter J Mansfield (1 June 2007)
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Community based team care for the elderly
- Barry J. Goldlist (1 June 2007)
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Helping patients follow self-administered treatments
- R Brian Haynes (1 June 2007)
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Integrate outside the clinic
- Christopher J Burns-Cox (1 June 2007)
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Dignity of the Patient
- Satyendra K Tyagi (1 June 2007)
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The importance of diagnosing the transition of "living with" to "dying from"
- Clive E Bowman (1 June 2007)
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Time, understanding and reassurance
- John A Evers (1 June 2007)
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The patient as a resource
- William G Kernohan (1 June 2007)
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Making a difference
- helene a brandon (1 June 2007)
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The Cardiovascular Center of Excellence
- William H Bestermann Jr (1 June 2007)
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Motivating Self Care and Change in Patients
- Pamela J. Lockwood (1 June 2007)
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Recognition of neurodevelopmental disorders
- Richard J Purvis (1 June 2007)
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Caring for somatising patients.
- Sani Abdel- Aziz Hlais (1 June 2007)
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Build Patient Self-Care Capability
- James E. Schlosser (1 June 2007)
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Medical basics, tobacco cessation, healthy diet, exercise, good insurance.
- Stephan D Thome (1 June 2007)
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Re: Emphasize the positive
- B Shah (1 June 2007)
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Patient empowerment and corporate responsibility translates to good health
- Paul R O Nyatigi (1 June 2007)
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Stop smoking!!
- ANDREA PELUCCHI (1 June 2007)
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Check Check and Check
- Dr Jayaraman Nambiar (1 June 2007)
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Prevention is the thing
- ADOLFO PRECIADO SOLÍS (1 June 2007)
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Register of adverse events
- Manuel Praena (1 June 2007)
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Educate, advice, motivate your patient
- Prof. Enrique J. Sánchez-Delgado, M.D. (1 June 2007)
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Pain, a problem neglected.
- William G Notcutt (1 June 2007)
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Quality and culture
- Aureo Muzzi (1 June 2007)
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standardization of care
- Matthew Garber (1 June 2007)
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I wish I knew!
- Andrew N Crowther (1 June 2007)
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Vaccination
- Inge Axelsson (1 June 2007)
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Care and be bothered
- Ashis Banerjee (1 June 2007)
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Targeting Overweight in Children
- Mukesh Kapoor (1 June 2007)
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More time for Patient - Doctor Interaction!!
- Himanshu Kataria (1 June 2007)
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Adequate time for communication
- Fotios Drakopanagiotakis (1 June 2007)
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Promote Breastfeeding
- Prakash Manikoth (1 June 2007)
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Youth Mental Health - An overdue opportunity to improve public health
- Patrick D. McGorry (1 June 2007)
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Lets all work together
- Elizabeth Cottrell (1 June 2007)
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Prevent iatrogenic infection and make procedures safe
- James D Newton (1 June 2007)
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An ill for every pill
- Luca Mascitelli (1 June 2007)
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Doctors' practice should be changed first
- Aung Maug (1 June 2007)
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Think about prevention
- carolyn V Brown (1 June 2007)
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Time - Yours, is of the essence.
- Robert O. Cannon, MD, MPH (1 June 2007)
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Exercise!
- Stan Baltsezak (1 June 2007)
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Jobs, Jobs, Jobs
- David Brookman (1 June 2007)
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Health Education is the best approach
- Mohy K El Masry (1 June 2007)
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Adverse Drug Reactions: A public health problem but nobody’s job
- Susan E Jordan (1 June 2007)
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Physical Activity & Exercise: A service for National Health
- Mark E Batt (1 June 2007)
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Saving the patient's backside (and your own)
- John Kennelly (1 June 2007)
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Systems and Culture
- Rob Z Torok (1 June 2007)
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Behavioral change is the most effective intervention
- Brian Stello (1 June 2007)
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Patient Held Records
- Rupert Gude (1 June 2007)
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Life beyond illness
- Rebecca Scott (1 June 2007)
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Making a difference: now it is self improvement and techniques’ turn to explore as new health care interventions.
- Syed Abdul Mujeeb (1 June 2007)
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Health education
- Sawsan Talib Jamal (1 June 2007)
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Consent
- R Mohindra (2 June 2007)
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Re: Physical Activity & Exercise: A service for National Health
- Robert D Southward (2 June 2007)
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co ordinating with business houses
- katpadi varadarajan arulalan (2 June 2007)
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Connect to communicate
- Woody Caan (2 June 2007)
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suggestions
- Alessandro Calderan (2 June 2007)
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Professional Competence, Communication skills, Follow up,easy availiblity to patient.
- Dr Rajender Singh Chauhan (2 June 2007)
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Diet and Exercise
- Maura Murphy (2 June 2007)
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Childhood pulmonary diseases in developing economies
- Cristan Q Cabanilla (2 June 2007)
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Re: Integrated ICT for patients and health professionals
- Mithun Barik (2 June 2007)
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Computers are our friends!
- Kate E. Koplan (2 June 2007)
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Proper communication with the patient
- Chandra Sekhar Devulapalli (2 June 2007)
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Save Your Life
- ARIE EISENMAN (2 June 2007)
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Dont smoke use sunscreen
- Abduljabar A. Theyab (2 June 2007)
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Nutritional Support
- Tarik Z. Nursal (2 June 2007)
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Take care & listen.
- David D Jones, 1 Dunluce Ave Belfast BT9 7HR (3 June 2007)
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prevention is better than cure
- Ruchika S. Nagori (3 June 2007)
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Always listen to the patient
- Armando A. Calvo (3 June 2007)
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Improving Medical Care
- Phillip Periman (3 June 2007)
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'I can't hear what you're saying because your actions are SHOUTING so loudly.'
- Anwar A. Chahal (3 June 2007)
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Transparency
- Fernando S Cavalcanti (3 June 2007)
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MDGs!
- Dr. Naseem A. Qureshi (3 June 2007)
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Cut Waiting Times
- Edward P GIBLIN, 12 St Neots Rd,Sandy. Beds. SG19 1LB (3 June 2007)
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Better utilisation of technology and preventive services
- Rajat Bhatt (3 June 2007)
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children's health
- vivek v gharpure (3 June 2007)
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Factors affecting mortality in leptospirosis
- Dr. Jitendra V. Dave, Dr(Mrs)V.M.Bhagat, Dr R.D.Patel, and Dr Mayur Jarag (3 June 2007)
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Primary Prevention Elementary sir!!!
- dr mohan devegowda (4 June 2007)
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Making a difference
- benedict mccaffrey (4 June 2007)
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Improving patient care.
- Carlos A Scarampi (4 June 2007)
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standardisation, categorisation of practice & intensive value based education of healthcare providers
- Dr.Pramod Madhukar Kulkarni (4 June 2007)
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More talk and less pills
- Anuruddha M Abeygunasekera (4 June 2007)
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100 words for BMJ
- Ettore Guidi (4 June 2007)
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Increasing the health of the nation
- David Jenkins (4 June 2007)
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Avoiding unnecessary tests and treatments
- Soledad Marquez-Calderon (4 June 2007)
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Making a difference
- Roger H Jones (4 June 2007)
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Quality and safety in clinical care
- Graham Neale (4 June 2007)
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Empathy not sympathy
- MANJEESTHA DAS (4 June 2007)
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Integrated system improves patient care
- Sung Hyuk Choi (4 June 2007)
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Education on medical error is essential
- Glenn W Mitchell (4 June 2007)
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Accident prevention
- James M Hynson (4 June 2007)
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Effective treatment
- Leslie G Scarth (4 June 2007)
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the new approach to the patent
- Dan Botezatu (4 June 2007)
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Life registry for continuous support
- José I Valenzuela (4 June 2007)
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Organising hospital-infection preventing policies
- Razi Riyadh Hati (5 June 2007)
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first, do no harm
- David J Biau (5 June 2007)
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Making the biggest difference
- Brian R Budenholzer (5 June 2007)
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Don't forget biopsychosocial model!
- Dr. Naseem A. Qureshi (5 June 2007)
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Baby and the bath water
- Kim Botly (6 June 2007)
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Educating decision makers before educating patients
- Augusto Pimazoni, Rua Borges Lagoa 908 - Apt. 123 - Sao Paulo, SP - zip 04038-002 - (6 June 2007)
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Antenatal Care Makes a Difference
- George D. Carson (6 June 2007)
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Continuity of Care
- Stephen C Harper (6 June 2007)
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Bury "Think Dirty"
- Michael D Innis (6 June 2007)
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Establish objectively best treatment for the patient in front of you
- J. Deinum (6 June 2007)
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Interaction of different factors
- Benedetto Mangiavillano (7 June 2007)
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Public Health
- Anthony J Morkane (7 June 2007)
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Honesty is the best health policy
- Graham Kyle (7 June 2007)
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Patient centered care
- Keugoung Basile (7 June 2007)
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The role of doctors in patients' education: What can medical education do?
- Samy A. Azer (7 June 2007)
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Evaluate delegation
- S. Michael Crawford (7 June 2007)
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...........when doctors and patients meet one to one.......
- Dr Bimal K Agrawal (7 June 2007)
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Palliative and end-of-life care for all: according to need not diagnosis
- Scott A Murray (8 June 2007)
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Re: improving the health care in our developing countries
- soulaiman elias soulaiman (8 June 2007)
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Endotheliology in Primary Care Practice
- A. O'tayo Lalude (8 June 2007)
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Do not treat the X-Ray, treat the patient
- Kandiah Senthilnatha (8 June 2007)
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Satisfaction with anaesthesia care – from the patients’ point of view
- Thomas Heidegger (8 June 2007)
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Real Care plus Knowledge
- Lucianoi Tarantino (8 June 2007)
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use the internet during consultations
- dominic j stevens (8 June 2007)
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A humane attitude toward patients
- Takuya Watanabe (8 June 2007)
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leave us alone?
- mark r stacey (8 June 2007)
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Universal Health Care, Free for All
- Richard L Nelson (8 June 2007)
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Offering choice in rehab after MI
- Hasnain M Dalal (9 June 2007)
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Two Ways to Health
- Jan Pitha (9 June 2007)
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Who’s going to play doctor?
- Saskia Holtslag, and Peter E Westerweel, MD; University Medical Center Utrecht, the Netherlands (9 June 2007)
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Detection of smoking-related disease
- Finn Edler von Eyben (9 June 2007)
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The integrated system improve patient care
- Sung Hyuk Choi (9 June 2007)
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Changing the health trajectory of new lives
- Alan A Woodall (10 June 2007)
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Keep it simple in Teaching the Patient
- Patricia J Peterson (12 June 2007)
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Behavior Change
- Larry A. Green (12 June 2007)
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What's your poison?
- Ken Checinski, Ferhal Utku (13 June 2007)
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The origin of the word 'doctor' is to teach
- George Peat (14 June 2007)
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A proper approach.
- Aldo Riani (14 June 2007)
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Hypertension is the most important problem for my patients
- Frank Bender (18 June 2007)
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Empathy and communication are priorities for your patient
- Stefano Bellentani, Stefano Bellentani, M.D., PhD (21 June 2007)
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Clinical Practice Evidence Based and Patient Centered
- Wanderley Marques Bernardo (25 June 2007)
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My patient and his diabetes
- Mohamad Said M. Takrouri (2 July 2007)
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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 willingness among international journals to publish this research in order to reach health care professionals. Perhaps the BMJ, as a partner of doctor and patient, could take leading role and will pay more attention to COPD disease management in the coming years. Competing interests: None declared |
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Theo Schofield, Retired General Practitioner and Lecturer in General Practice, University of Oxford The Medical Centre, Shipston on Stour, CV36 4BQ
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Communication between patients and their doctor, nurse or other health care professional is the essential ingredient of all effective healthcare. Effective communication can ensure that the correct diagnosis is made, that the patient's ideas, concerns and expectations are understood, and that social factors are taken into account in their care. Effective communication also enables the patient to understand their condition and the options for management, to share decisions about their care, and to be able to participate in their own care. An effective relationship with patients creates partnership and trust, and enables the patient to participate fully in their consultation. There is a substantial body of evidence that links effective communication with positive health outcomes, including satisfaction, reduction of concern, concordance with treatment and lifestyle change, uptake of screening and preventative care, reduced anxiety and depression, and improved health indicators. Competing interests: None declared |
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Tom Fahey, Professor of General Practice & Family Medicine Royal College of Surgeons in Ireland Medical School, Dublin 2
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A patient-based electronic health record that will enable 1) evidence -based decision support (for diagnosis and management); 2) decision aids that incorporate patient preferences about individual treatment choices and self care programmes to suppport patient's self managment; 3) an integrated facility to anonymise and compile quality indicator data so that comparative clinical data can be examined within and between practices and support initiatives such as the Quality Outcome Framework (QOF). Competing interests: None declared |
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Elizaveta Naumova, Assistant professor Saratov Medical State University, 3 Clinical hospital, B.Sadovay 137, Saratov, Russia, 410054, Professor Yury Shvarts
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I agree with Dr. Peter M Lapsley's point of view about patients’ participation in their care. On the one hand, information plays the major part in patients’ possibility to take part in treatment process. The patients themselves in most cases want to receive the additional information on treatment. It is necessary to note the importance of the structure of the given information: for the patient the greater value is not in the knowledge about disease in general, but more specifically about they own health and the treatment which has been appointed, especially about the medicines, prescribed to the patient by the doctor [1,2]. On the other hand, when we provide information for patients we have to take into account patients' expectations of the treatment and patients’ fears about treatment. Patients quite often mark fear of side effects from preparations, and this is based in the most cases not on own experience, but on the experience of other patients or on information from summaries (instructions to application) to medicinal preparations [2,3]. At this, in any summary to a medicinal preparation, as well as in the majority of information brochures for patients, side effects of preparations are described much in detail, while positive effects of the preparation are described briefly, and very often only from the medical point of view what makes their perception by the patient extremely entangled. As a result, patients know about the bad consequences which they can expect from their treatment, but not always the positive sides of this process. Present-day evidence based medicine is aimed at life prolongation first of all, but it is noted in some research that such strong biological motivation as self-preservation was not always marked by the patients as the most important. Patients are more afraid of loss of social function and freedom connected, for example, with amputation of limbs, strong vision disorders, urination dysfunction, than death [4, 5]. In other words, the patients expect from their treatment the effect of decrease of risk of complications, improvement of their condition, increase and keeping of their body’s general tone [6]. It can follow from all this, that if the information for the patient contains the data on influence of preparations not only on longevity, but also on the improvement of life’s quality, and also on the improvement of subjective general well-being, in such case, its influence on the patient behavior (such as adherence to long-term treatment) and on health care improvement can be stronger. 1. Thorsen H., Witt K., Hollnagel H., Malterud K. The purpose of the general practice consultation from the patient’s perspective – theoretical aspects. Family Practice 2001;6:638-643. 2. Treherne GJ., Lyons AC., Hale ED, at all. “Compliance” is futile but is “concordance” between rheumatology patients and health professionals attainable? Rheumatology 2006;45(1):1-5. 3. Aikens JE., Nease DE., Nau DP. at all Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication. Annals of Family Medicine 2005;3:23-30. 4. Hendricks LE., Hendricks RT. Greatest fears of type 1 and type 2 patients about having diabetes: implications for diabetes educators. The Diabetes educator 1998;24:168-173. 5. Davison SN., Simpson C. Hope and advance care planning in patients with end stage renal disease: qualitative interview study. BMJ 2006;333:886 6. Hunt LM., Valenzuela MA., Pugh JA. NIDDM patients’ fears and hopes about insulin therapy. The basis of patient reluctance. Diabetes Care 1997;20(3):292-298 Competing interests: None declared |
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Glenn Stewart, Assistant Director of Public Health EN4 0DR
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In an age where we are increasingly worried about climate change, heart health, obesity, physical activity, fuel prices, congestion, GP physical activity referral schemes, access to anything, one of the greatest gains in health might be through making it easier and more agreeable for people to walk and cycle as part of their everyday lives. Rather then despairing of the obesity epidemic we should design a transport system which is not dangerous, unpleasant or frightening so that people will undertake physical activity without thinking about it. I think the above is a crisis that we need to build ourselves out of. Competing interests: None declared |
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Jean P Fisher, GP and tutor to refugee doctors REACHE Northwest, Hope Hospital, Salford M6 8HD
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I work with asylum seekers in general practice and as tutor to refugee doctors. The intervention that would benefit my patients and my students most would be a rapid, and transparently fair, asylum process. Many asylum seekers are left without a final decision for months or years. Others have their asylum claim rejected whilst the government recognises that they cannot safely be returned home. They are stranded on minimal income, unable to move forward with their lives. Antidepressants and counselling are not the answer. Those in the system for more than six months should be given the right to work. Competing interests: I support the Strangers into Citizens campaign www.strangersintocitizens.org.uk/ |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6LA
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Sir The practice of medicine currently exists in the context of a severely and comprehensively dysfunctional society and should not be viewed separately from it. It is a commonplace that the greatest advances in health have been achieved at the population level so it is with our current predicament. Let us reacquire the civilising habits of a well functioning society and medicine will take its place in the newly healed order. Steven Ford Competing interests: None declared |
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Janet Boaler, retired anaesthetist pain management retired address BH13 6BL
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Use consultation, if possible, to advise on other actual or potential health problems such as smoking aversion, weight control, exercise and diet. This should be accopanied by appropriate referral, e,g. GP referral to local leisure centre, smoking aversion clinic or dietician often within practice or PCT area. Follow up appointment sometimes advisable. Better treatment of elderly with chronic osteo arthritis (usually analgesics only) Acupuncture or osteopathy along with an exercise program can be helpful. Recommendation of useful supplements such as glucosamine/chondroitin and Omega3 should be suggested in most cases. In other words do not rely completely on prescription medicine or surgical intervention as the only alternatives for such patients. Competing interests: None declared |
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Elizabeth A McClure, General Practitioner Northgate Village Surgery, Chester CH22DX
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The development of communications and consultation skills by Balint, Pendleton and Neighbour has facilitated deepening of the doctor patient relationship. With the increase in mental health problems in our society , the greatest contribution I make to peoples' lives and future health is to hear, accept and validate their feelings and experiences. This is not very different from the skill of a priest, but equally valuable. The greatest gifts I have had from patients is the relief and gratefulness for this acceptance, this emotional healing. e.a.mcclure@dial.pipex.com Competing interests: None declared |
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Katherine H Checkland, GP and Walport Clinical Lecturer Eyam Surgery, S32 5QH and Manchester University M13 9PL
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Just looking at the titles of these responses I am heartened that we seem not to have forgotten the art of medicine as well as the science. As a GP the single most important thing I can do for my patients is to take them seriously as a whole person. When necessary, this will involve providing up to date new treatments, screening them for disease or doing fancy investigations. At other times it will involve simply listening to them, being with them as they suffer physically or emotionally or helping them to find their way through the whole experience of being ill. Any trained technician can deliver treatment according to guidelines; it takes real skill and a commitment to the difficult discipline of reflective practice (see Schon, The Reflective Practitioner 1991) to really make a difference to peoples' lives. Of course these things can't be measured, ticked off or incentivised, but we know when we have done it well because our patients make it clear in many different ways. We also know when we haven't done it well, and recognising and learning from this is surely what 'lifelong learning' as a doctor must be about. Competing interests: Author is a GP |
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David Flook, consultant surgeon Royal Oldham Hospital, Rochdale Road, Oldham, OL1 2JH
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Gallstones are common and dangerous. Gallstone pancreatitis alone, causes more than 500 deaths/year in the UK.(1). Anually, approximately 50,000 cholecystectomies are performed in England (2)-elective costs £1875. 14% are emergencies (£4-4500), 28% have one or more emergency admissions (£2000), 20% have attended A&E. From a typical DGH experience (3) at these rates, emergency admissions in England cost at least £10 million/year. Gallstones are easily, safely diagnosed by ultrasound scanning and are treatable with low morbidity and mortality by short stay surgery. A screening programme offering treatment before onset of complications could save many lives and millions of pounds. (1)Corfield AP, Cooper MJ, Williamson RCN et al. Acute pancreatitis: a lethal disease of increasing incidence. Gut 1985;26:724-9 (2)NHS institute for innovation and improvement 2006 Focus on cholecystectomy. (3)Shekkeris AS, Sarkar S, Klein M, Anwar RM. Delay in cholecystectomy for symptomatic gallstone disease results in increased morbidity and cost. Br J Surg 2005:92, Suppl.1 p99 Competing interests: None declared |
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Steven A. Burr, Deputy Director of Teaching Nottingham Medical School
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I propose addiction, as many of our problems seem to be driven by it. For example: smoking, alcohol, illegal drugs of abuse, and eating the wrong things. Competing interests: None declared |
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Els Licht, GP, PhD student Department of General Practice, VU Universtity Medical Centre, Amsterdam, The Netherlands
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Previous trials have shown effectiveness of all kind of treatments for different conditions in primary care patients. However, older patients, who we see in our practice more and more, often don't have just one condition, like diabetes or depression. Instead, they present with complex combinations of somatic and psychiatric morbidities, and disabilities. Results of trials are difficult to translate to these patients. As written in the responses by others, GPs want to focus on the whole person. Now it is time for researchers to do this as well: take a step further than spending time and money on one-condition trials in General Practice. Focus on the whole person with his combination of morbidities and disabilities. It's complex, but a challenge as well! Why do researchers seem to focus on one-condition trials? Is research on older patients with multimorbidity hardly carried out because of its complexity? Or is it a lack of interest? I would like to challenge researchers to design studies for older primary care patients with somatic and psychiatric comorbidities, like depression. More knowledge can help to improve health care for our older population. And to achieve this, we need more than knowledge on how to decrease blood pressure or HbA1c as quality of life is becoming more and more important with increasing age. Competing interests: None declared |
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Jonathan R Benger, Consultant in Emergency Medicine United Bristol Healthcare Trust, Bristol, BS2 8HW.
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I must confess to being a bit puzzled by this "filler" from the BMJ. It started by asking how to make the greatest difference in a consultation, and ended by asking what we'd like to see in the journal. I'm not sure these are quite the same thing, and am heartened to read the responses of so many others who thought that doctors make the greatest difference to their patients by listening, examining, understanding, communicating and interacting in a way that has been the cornerstone of medical practice for hundreds of years. Whether the BMJ will now commission a range of relevant articles and detailed analyses - including morbidity and mortality - of the doctor- patient consultation remains to be seen. Competing interests: None declared |
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PRANAV KUMAR, SSHO PORT TALBOT,SA127BX
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The greatest difference I have ever made has been to demystify the disease and treatment options.The transformation of a soul staring in to the unknown;of a passive recepient shackled by fear,ignorance and gratitude,to one who understands his illness and it's impact on their life,the option of remedies and has the information to choose from with confidence.An empowered being who asks questions and feels in control and at the same time feels at ease to tell me how it all touches his life and plans so that I can make a little more difference. Competing interests: None declared |
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Trevor G Stammers, Lecturer in Healthcare Ethics St Mary's University College, Twickenham, TW1 4SX
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I have no doubt that taking an alcohol history saves lives, careers and families. People know if they smoke or not but they often do not know when they are drinking hazardous amounts of alcohol. It is far easier to encourage and help patients to deal with excessive alcohol intake at an early stage rather than trying to help alcohol-dependent patients when their addiction is well-established. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Life is a quest for love. In order to receive love, we must be dependent. In order to give love, we must be independent. The conflict between dependence and independence affects every facet of our lives. Life and love begin with our parents. As helpless babies, we depend on their care. With the right kind of care, we learn to love them and ourselves. With the right kind of parenting, we learn dependence and independence. Of course, there is no perfect parenting. So we all have trouble with dependence and independence. Sometimes we are dependent when we should be independent, and vice versa. Health-care is reminiscent of childhood. The doctor is our parent, and we are helpless babies. We feel secure in his office, and long for his concern, reassurance, and medicine. We are awed by his jargon, worship his intellect, and feel totally dependent. Of course, health-care is not childhood. The doctor is not our parent, and we are not helpless babies - no matter how much we wish this were true. Sometimes, the doctor's words, procedures, and medicine do not solve our health problems. Often, our health problems are the result of dehydration, malnutrition, and addiction. These problems are self-inflicted and require changes in our attitude and lifestyle. It takes independence and courage to make these changes. Competing interests: None declared |
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Wendy-Jane Walton, GP, Macmillan GP Facilitator Marden Medical Practice, Shrewsbury SY2 6DL
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Accompanying patients on their journey towards a good death, ensuring that their symptoms are controlled, their fears addressed, and that they are at peace with the inevitable, may be the greatest service we can ever offer, to patients and relatives alike. However: “Preferred place of death may be a hollow concept and the promise of choice a cruel sham if services are not available because of lack of funding or other resources. Whilst promising patients a planned death is seductive, the reality may be that the complex uncontrollable nature of the dying exposes real choice as being fool’s gold”(1) 1. Munday D, Dale J, Murray S. Choice and place of death: individual preferences, uncertainty, and the availability of care. J R Soc Med. 2007 May 1, 2007;100(5):211-5. Competing interests: None declared |
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Alex Williamson, Publisher BMA House, London WC1H 9JR
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I am a member of the "sandwich generation". I now care for my elderly mother and in the past few years - a father with multiple myeloma and dementia. Many of my friends are in similar situations and many of us are totally appalled at the care they receive from the "professionals". This is a growing problem. The elderly deserve good, coordinated care, especially at the end of their lives. They deserve to die surrounded by their loved ones and preferably in familiar surroundings. The BMJ and the Group as whole might campaign for cordinated care - especially for the elderly at the end of life. Competing interests: Iam a member of the BMJ Group's exec team and the publishing director for the journals |
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James Hickman, GP North Curry Health Centre, North Curry. Taunton, TA3 6NQ
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Listen. Competing interests: None declared |
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Adrian H Sie, Specialist Registrar in Paediatrics Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ
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Motivational interviewing is a particular way of communicating with patients about changing behaviour eg taking a new drug, or changing lifestyle. The doctor engages with the patient to identify any perceived drawbacks, and then consider any alternative choices and their relative merits and disadvantages. Together, they can then develop a strategy for dealing with any such problems, and the patient is then free to make their own choice. Realistic and achievable goals can then be set. By avoiding confrontation, engaging with the patient and increasing their autonomy, trust is established and the potential for a successful outcome maximized. Competing interests: None declared |
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Melissa K Raven, Adjunct lecturer Flinders University South Australia 5042
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It is outrageous to claim that 'most health care occurs when doctors and patients meet one to one'. Most health care occurs when parents/caregivers and children meet one to one, or more than one to one, along with other family interactions. Okay, so you meant most *professional* health care. Then nurses are at the top of the list, with many other health professions contributing. All right, so you really meant most *medical* care. Fine, but why didn't you say so? Medicine has an ignoble history of appropriating/obscuring other groups' achievements, but I am surprised to see the BMJ (editor?) continuing this tradition so blatantly in 2007. Competing interests: None declared |
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Simon Fountain-Polley, SpR Paediatrics Birmingham Children's Hospital B4 6NH
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Although we cannot turn back the clock into any previous "golden age", one way to improve health might be a return to traditional family values. Tighter family units living in close vicinity helped provide support and care for individual members when unwell. In paediatrics many children who we see require a wise experienced grandparent to recognise the normal, and guide new parents through the many frightening but manageable common childhood ailments; as opposed to seeking advice in emergency departments. Modern mothers struggle to breastfeed partly due to lack of on-hand encouragement and suppoort. In return younger family members could care for their senior relatives in their dotage, thus relieving crowded hospitals and nursing homes. Extended families may provide an improvement in the health of the nation that no political or medical solution could ever hope to. Competing interests: None declared |
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Philip R Williams, PRHO QMC, Nottingham, NG7 2UH
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From the perspective of a house officer, the one intervention which I have witnessed making the biggest difference to patients, whatever branch of medicine applies to them, is the Liverpool Care of the Dying Pathway. Something almost magical occurs once this document is invoked: all needles disappear, all the correct medications are prescribed, needless interventions and investigations cease, and the family, nursing staff and medical staff all unite towards the shared goal of comfort. What could be more pleasant for a patient in their last days? Competing interests: None declared |
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Dindukurthi Sudhakar, Primary Care Pediatrician Bangalore 560019, India
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As a PCP, I would like to stress on the following requirements. There need to be a maximum amount of trust towards the doctor. The parents should approach with the intention of knowing what is best for their child rather than deciding beforehand, by themselves and expecting the same from the doctor. Parents should give attention to all round development of their wards rather than just the presenting illness. Have an open mind to discuss and deliberate about the issues involved. Rapid diagnostic kits to be made more efficient and popular to minimise the haphazard use of antibiotics. sdkar57@yahoo.co.in Competing interests: None declared |
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Alison J Melvin, Consultant Physician Bedford Hospital, Bedford, MK42 9DJ
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If every doctor had been a patient or a parent of a patient for any length of time there would be fewer calls for improved communication. Treat every patient as you would wish to be treated. Talk to them about their medical problems as you would talk to your (non-medical) friend about their problems if they asked you. Ensure that you understand what their priorities are at each consultation and provide them with information to take away and read. Treat them with courtesy and dignity in hospital. Do not interrupt their meals (or worse!). Introduce yourself and your team, talk to the patient, not at them and possibly most important of all, show the patient that their welfare is important to you by washing your hands after examining another patient. In this way patients are less likely to be at risk of an adverse event through mis- communication or hospital acquired infection and are more likely to adhere to treatment. Competing interests: None declared |
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Colin J Greaves, Senior Research Fellow Peninsula Medical School EX1 2LU
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"Understanding health behaviour" is a key issue for medicine. Apart from critical rescue situations (e.g. surgery, A&E care), self care, conducted by patients on themselves is the single most important factor influencing health outcomes in chronic conditions (progression of diabetes, heart disease, course of asthma, COPD, depression). It is also a fundamental factor in the development of many of our most prevalent and burdensome illnesses (e.g cardiovascular disease, cancer, COPD). Without medication adherence (know to be around 30-50% in a number of chronic conditions), how can medications work? Without clear strategies for managing health behaviours (smoking, diet, physical activity, exposure to pollutants), how can we expect patients to maintain good health? Without clear strategies for managing stress and for communicating effectively with health professionals, how can we expect patients to cope with illness? Understanding health behaviour has the potential to inform not only health promotion activities, but also support for self care of chronic illnesses and efforts to optimise the effectiveness of consultations /the therapeutic relationship. This is of course a challenging area and one where the science is not perfect, but there are now good examples of effective health behaviour interventions. A focus on the state-of-the-art of behavioural medicine and what the future might look like would be a great theme for BMJ to explore. Competing interests: I conduct research into self-care of chronic conditions and lifestyle change. |
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Antony S Willman, Army GP Trainer Larkhill, Wiltshire, SN4 8QY
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One of the key elements in my consultations as an Army doctor is to put the patients ailment into a social context by relating it to the work they do. A young soldier can have any one of a number of roles from deploying onto the front line in Afghanistan to manning a clothing store in Yorkshire. They both involve concerns & fears - we can address those - but a sense of achievement by completing the task has huge holistic benefit. By performing an occupational health assessment and allowing the soldier to remain in useful employment, it not only increases worth but allows the soldier to take ownership of the problem, still feel part of the team (especially if the soldier deploys on an operational tour despite having a medical problem) and keeps them psychologically well. They aren't just signed off sick. I am lucky, I have the luxury of time in the consultation to do that but I would bet on its benefit if analysed from a cost effectiveness point of view. Competing interests: None declared |
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Dr. Naseem A. Qureshi, Consultant psychiatrist & Head of Research Unit, Ministry of Health, Area code:11176, Riyadh, Saudi Arabia
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To The Editor, BMJ. Sir, Poverty and diseases are reciprocally connected to a very greater extent and this simple common sense fact had been ignored since long time but now thanks to the planners and developers of "World Trade Organization and its core concept globalization", that partially led to addressing this issue; poverty causes a variety of diseases and diseases result in poverty through well known trajectories. A variety of sophisticated and well-planned interventions, some are already placed in several countries, for eradicating poverty will certainly transform the world and the people who could have a very good quality of life. At global level, one suggestable intervention is to stop both eying and waging war on the economies of low-income and middle-income countries having rich resources suh as diamonds and gold, black gold, poppy fertile land, huge gas reserves, animal reserves and uranium, by rich nations. All arising problems could be solved by diplomatic means without running out of patience. Trillions of US dollars used in wars can be used to help poor people not only living in poor countries but also of rich nations. Finally, a thought for all of us; "scientists,health providers and consumers should not be the stooges of politicians but other way round." Declaration of interest: none Address: Dr. Naseem Akhtar Qureshi MD, PhD Consultant Psychiatrist, General Administration for Mental Health & Social services, Ministry of Health, Riyadh, Area code;11176, Saudi Arabia. Competing interests: None declared |
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Pedro Solberg, Pediatrics Rio de Janeiro, RJ 22470-240, Brazil
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Take time to listen to your patient. In critical moments, hold his hand. They never forget this simple gesture. As a pediatrician present at deliveries, normal or c-sections of over 3000 babies I have discovered that the most important thing I can do during the process is hold the mother´s hand. They are grateful forever and talk about it for many years. Competing interests: None declared |
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Vaidyanathan Gowri, assistant professor SQU, code 123, OMAN muscat
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The intervention which will minimise morbidity will be "NOT TO INTERVENE". For example an ultrasound scan done in the third trimester without a valid indication, screening for chlamydia, a "routine" renal function test in an otherwise healthy adult may all result in agony and precipitate more interventions. There are more examples that can be given in adult medicine for screening and therapeutic modalities. Counselling and least investigations will go a long way in making a difference Competing interests: None declared |
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Giuseppe Lippi, Associate Professor of Clinical Biochemistry Sez. Chimica e Microscopia Clinica, Dip. Scienze Morfologico-Biomediche, Verona University
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Major emphasis is being placed on medical errors, which should be regarded as a major challenge for improving healthcare quality. There is a common perception that most medical errors occur from misuse of drugs or mishandled surgeries. However, medical errors can also take place within the laboratory diagnostics, such as misinterpretation of prescriptions, preanalytical and analytical errors that might be associated with incorrect choice of therapy, failure to use an indicated test, misinterpretation of results. All these problems have a strong influence on patient outcome and healthcare expenditures. Interventions aimed to reduce uncertainties within the laboratory diagnostics offer a great potential benefit for improving healthcare quality. Competing interests: None declared |
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Joaquin Averbach, public hospital staff HIGA Oscar Alende. 7600 Mar del Plata. Buenos Aires. Argentina
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We are still seen as responsible for community health, and though we cant take under our responsibility matters as food, transit or work regulations, I wonder who will, and if we are not in a good position to state a point of view. While we are provided with new, more powerful and effective drugs to lower cholesterol or to control insomnia, society gets more and more sedentary, obese, individualist, violent. It has often been said that medicine plays a social control role. Do we agree? Is that (part of) what we do within the walls of our office provided with the authority of our profession? During the last decades we have been acting without much reflection, often in response to technologic innovations. I believe that what we need most is to develop a reflective attitude about our practice. Competing interests: None declared |
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Brian P McNicholl, consultant Emergency Medicine Emergency Dept , Belfast Trust, BT 12 6BA
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A thorough history and examination are the foundations of medical care. The diagnosis, treatment , prognosis and aftercare complete the building. With a little support it can become a pleasant home. A simple formula, cheap, and usually works. Yet many patients, despite the wonders of modern technology, do not get the full house. This house price is affordable. Build good buildings. Spurn those on quicksand, building castles. Competing interests: None declared |
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Moahmed Salim Merchant, senior resident Saudi Arabia 10101
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Making a difference Routine checks can save a patients life and end organ damage. Mortality and morbidity in patients with hypertension can be modified by simple follow up. Factors such as smoking, hyperlipidemaia and diabetes can be easily controlled in most patients. However this needs the education of both the doctor and the patient. Knowledge trust and better patient doctor relationship can save many lives and end organ damage. If you go to any haemodialysis unit and see the files one may find either the treating doctor or the patient himself was responsible for his end stage renal disease. Competing interests: None declared |
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Douwe A A Verkuyl, gynaecologist Hoogeveen, The Netherlands
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Everybody would like to have a reasonable living standard. Living as Americans the planet would sustainably support 1.2, as West Europeans 2.4 as Indians 7.4 billion (200 million Indians are malnourished). Attention to reproductive health with every relevant patient contact will help. In the USA (where food is increasingly transformed into fuel) 49% of all pregnancies are unintended. A contraception method stopped perhaps because of hypertension, diabetes or psychosis and no alternative provided. Nobody knows how many millions unintended not aborted pregnancies there are. But they contribute to the annual world population increase of 78 million and make a reasonable living standard for everybody even more remote. Competing interests: None declared |
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Roberto G Romanelli, Assistant Professor Dept. Internal Medicine , University of Florence, 50134 Italy
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The best we can do for our patients is a close observation of all the symptoms and signs of disease through an accurate examination of their conditions with the aim of the latest updated technical tools available in our hands in this particular place of work. Moreover, a correct patient- physician relationship through a constant attention to the first and second lines of requests of the patient strictly related to their actual physical conditions and their affective involvements and psychological compromissions related to the illness will greatly help the clinical outcome of our subjects. This will be the aim of our daily activity. Competing interests: None declared |
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Gerda Pohl, salaried GP The Market Surgery, Wath upon Dearne, S63 7RA
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dear BMJ team, responding to your survey question of which health intervention can make the biggest difference to patients, I think high quality contraception and sexual health services should come in close to the top. regards, Gerda Pohl, MRCGP, MRCOG Competing interests: None declared |
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Peter J Mansfield, Aviation Medical Examiner 21 Brewers Wharf, NEWARK, Notts NG24 1ET
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Equipping people to manage their own health confidently and competently is not difficult, and can in my experience reduce demand for medical services by 50% with no loss of benefit. But this is not achieved by preventive medicine. Health requires a quite different body of knowledge, of which doctors are taught nothing, and of which medical knowledge is only a special case. If you doubt this, try defining health to yourself, and ask when you last employed it as a clinical tool, or devised a treatment plan in terms of health. See what I mean? Competing interests: Proprietor of Good Healthkeeping. |
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Barry J. Goldlist, Professor and Head, Geriatric Medicine University of Toronto, 1003-550 University Avenue, Toronto, Canada M5G 2A2
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One of the major challenges facing western medicine is the burgeoning number of elderly with functional impairment. While strong evidence has developed on many areas of management, these are difficult to implement even in consultant geriatric services with large multidisciplinary teams. Primary care providers often have to tackle these problems by themselves, a truly daunting challenge. I believe that the only way to substantially improve the management of these patients in the community is by developing true teams for management of complex cases. This requires much more than just having patients seen by multiple health care professionals, as true team work requires the building of trust and effective communication. This would allow the formulation of comprehensive management plans, not the blizzard of often contradictory recommendations that the elderly often get.
Competing interests: None declared |
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R Brian Haynes, Professor of Clinical Epidemiology and Medicine McMaster University, 1200 Main St W, Hamilton, ON, L8N 3Z5, Canada
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If you want to make a difference in improving patient care, you could do no better than to help patients to follow their self-administered treatments. Less than half of patients do so and the result is very substantial under-achievement of benefits from all efficacious self- administered trreatments, whether they be in pill form, injectables, diets, exercise or stopping smoking. Indeed, the act of nonadherence to treatments results in a doubling of mortality, even when the treatment is a placebo (as shown in randomized trials). Of course, if there were good and easy ways to help patients follow treatments, we might do a better job of this. While there are some ways to help, these are typically labour intensive and thus expensive, and most practitioners don't use them or even know of them. Shedding light on these may help some, but we also need better ways to assist patients. Thus there is both a knowledge translation agenda and a research agenda if we are to make progress. Competing interests: None declared |
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Christopher J Burns-Cox, Consultant Physician Southend Farm,Wotton-under-Edge GL12 7PB
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Doctors should be more outward looking. They can have the greatest influence on health and achieve most by working with lay local and national societies. Where are the doctor school governors, prison visitors, parish and town councillors,campaigners for human rights, campaigners against war and MPs? There are some but very few. Doctors have abrogated their responsibility for wider aspects of health. Competing interests: None declared |
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Satyendra K Tyagi, Consultant Meerut, India 250003
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The humiliation of being a patient rather than a human being starts early in the hospital. As per the protocol one has to be bathed prior to surgery. Any reasoning that one could bathe without help is not headed to consequently one is methodically and impersonally stripped lying naked bereft of all dignity. The embarrassment and the humiliation is not the concern. Why do many or most hospitals forget that even a semi-conscious or perhaps even a totally unconscious patient has a subconscious concern about his dignity? Whatever the reason, it is time someone addressed the issue of patient’s dignity or the loss of it. drtyagi@gmail.com Competing interests: None declared |
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Clive E Bowman, Medical Director BUPA Care Services BUPA Care Services, Bridge House, Outwood Lane, Horsforth, Leeds LS18 4UP
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Good palliative care has extended from incurable cancer to malignant but not cancerous diseases but doctors have limited evidence or training on which to call to diagnose and communicate the transition from living with to dying from in conditions such as Alzheimer’s disease in older people. Part of the legacy of the Shipman aberration, perhaps aided and abetted by discontinuities of modern medicine is an increasingly defensive approach with well intentioned but misguided hospital referrals when a diagnosis of dying and commencement of palliation is needed. The demography of ageing and the propensity of older people to die are incontrovertible as is the unprepared ness of medicine to diagnose and communicate dying. I now witness occasions when the death of residents in care homes are treated as criminal matters with investigation eventually resulting in acknowledgment of a timely death managed with dignity. Research, evidence and training are required accompanied by public awareness. Competing interests: medical director care homes |
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John A Evers, Consultant Physician with Special Responsibility for the Elderly St Austell, Cornwall PL26 6AA
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The NHS plan made a notable omission: it never said what the NHS was for, probably because it isn't generally agreed what it is for, or indeed what doctors (and therefore medical literature) is for. The dramatic side of medicine (cancer, intensive care) is what is publicised in the media; but what the great majority of people need when they are ill, in pain or losing their ability to function independently is a wise and understanding listener who can devote time to providing reassurance, practical advice and support, sometimes enhanced by special procedures or prescriptions. Let us discuss what services, skills and staff are needed to undertake this mission. Competing interests: None declared |
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William G Kernohan, Professor of Health Research University of Ulster, Newtownabbey BT37 0QB
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There is no time to spend in deep conversation. There are 100 more patients who need my help. The only way forward to make a difference is to change the scene. The 100 will be my team. I will manage them as a resource as well as a sink of time, drugs and expertise. After all, each one is an expert on themselves and, with proper management to ensure safety, they can help other people in the same boat as they are. I must find out what each can do, for themselves, for others in the same place and for me. I will enter these details in my PAS and build a new resource for health and social care in my patch. Using ideas of social capital: those who help most will bank some capital for their own future care. Dont tell the treasury! Competing interests: None declared |
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helene a brandon, Consultant obstetrician and gynaecologist Queen Elizabeth Hospital, Gateshead, NE9 6SX
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The greatest improvement I can imagine would be if someone could persuade, educate and motivate young diabetic women to engage with preconception services and improve their diabetic control prior to conceiving. This would make a huge difference to the success of their pregnancies. Competing interests: None declared |
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William H Bestermann Jr, Medical Director-Vascular Medicine Center Holston Medical Group, Kingsport TN 37660
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The 2001 Institute of Medicine report "Crossing the Quality Chasm"
documented serious deficiencies in the management of chronic conditions.
They identified 15 chronic conditions worthy of focused effort. A
cardiovascular center of excellence (COE) system would address fully half
of the 15. In stable angina patients, bypass surgery and angioplasty add
nothing to optimal medical therapy in preventing myocardial infartion. The
COE would provide integrated management of hypertension, hyperlipidemia,
and type 2 diabetes using
Competing interests: I have done speaking/clinical trials for Merck, Pfizer, Novartis, BI, Sanofi-Aventis |
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Pamela J. Lockwood, Medical Director Cincinnati Ohio 45236
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All of the wonderful knowledge and technology physicians currently have available to them will not improve the health of individuals or populations unless we learn to listen, motivate and support patients in identifying concerns and choosing paths to better health. I believe physicians and all health care providers need to understand change readiness and motivational interviewing and use it in every interaction with patients to capitalize on opportunities to assist with behavior change and acceptance of self management. Competing interests: None declared |
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Richard J Purvis, Consultant Paediatrician Childrens Centre, Damers Road, Dorchester DT1 2LB
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The increasing early recognition (and potential management) of these genetically-determined ,life-long disorders can alleviate the distress experienced by children and their families,as they try to understand their individual predicaments, while being considered awkward, naughty and challenging in their behaviour. Their problems until now have often been increased by their contact with a multiplicity of professionals, who have seen them to deal with their individual symptoms e.g. headaches, constipation,clumsiness,faddy appetites,poor sleeping,aggressive behaviour,seizures.This has often delayed the recognition of their intrinsic diagnosis. The core symptoms of these neurodevelopmental disorders are now well recognised. The commonest are ADHD(Attention Deficit Hyperactivity Disorder) and ASD(Autism Spectrum Disorder,which includes Asperger's Syndrome) They require accurate diagnosis by a multidisciplinary team ,continued support and education for the family,and appropriate handling and understanding in school. These have been shown to mitigate the problems which arise in the transition to adult life, which have often in the past - and ? present - resulted in their behaviour being dealt with in the Criminal Courts and Corrective Institutions,instead of being able to lead a healthy normal life, directing their energies into acceptable pursuits Competing interests: None declared |
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Sani Abdel- Aziz Hlais, Clinical instructor Family Medicine department, Saint- Joseph University, Beirut, Lebanon.
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I think somatisation is one of the major concerns in primary care. GPs and Family Physicians are the best positioned to deal with somatising patients. Competing interests: None declared |
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James E. Schlosser, Associate Chief of Staff for Ambulatory Care 01730
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The most powerful force for health improvement in the world is patients' own self-care capability. Health systems can leverage this force through systematic changes to teach self-care skills and knowledge and build systems to support and amplify patient self-care. Sharing knowledge resources, facilitating communication between pattients, promoting patient-held medical records and supporting patients in care planning can all contribute to better health and well-being. Promoting mindfulness-based interventions can lead to improved patient capability to manage stress and unhealthy behaviors which underly many modern chronic diseases (obesity, chronic lung disease, substance abuse, heart disease, etc.).
Competing interests: None declared |
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Stephan D Thome, Hematologist/Oncologist Omaha, NE 68114
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Good medical treatment starts with a good diagnostic evaluation. Medical practitioners need to pay continued attention to basic skills in history taking, physical examination and proper use of diagnostic tools. Once the medical diagnoses are firmly established, proper patient education and communication with the other members of the health care team are essential for therapeutic success. Evidence-based medicine with easily accessible guidelines can help streamline this part of health care delivery. Population health in the developed world can best be improved by programs that encourage tobacco cessation, healthy eating habits, healthy exercise habits. Financial barriers (lack of insurance coverage, punitive copayments) are another issue that warrants improvement. Competing interests: None declared |
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B Shah, GP London W1G
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I agree. Competing interests: None declared |
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Paul R O Nyatigi, jobseeker NG118DW
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Relying on paternalistic, individualized and less empowering medical paradigm may not be the best path to negotiate when dealing with population health. The proponents of this paradigm ostensibly ignore the wider determinants of health and do not recognise the benefits of participatory approach to healthcare delivery. We need to embrace a mixed bag of paradigms bordering the more empowering and participatory paradigm on one extreme and paternalistic, individualized and the less empowering medical paradigm on the other pole. This hybrid approach is acceptable alternative to addressing the existing health inequalities with the aim of improving the health of disadvantaged groups. Competing interests: None declared |
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ANDREA PELUCCHI, SENIOR ASSISTANT - SERV. DI FISIOPAT. RESPIRATORIA - P.O. DI SESTO SAN GIOVANNI 20099 SESTO SAN GIOVANNI - ITALY
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Listen to the patients is mandatory in our profession, as well as learning to put the correct questions to understand what's happening. It is fundamental, independently we work on lung diseases, cardiovascular diseases, diabetes or dermatological diseases. I work in a lung department and the smoking addiction is my biggest problem: COPD prevalence and COPD-related mortality and morbidity have increased enormously during the last decades, and there is a further increase in COPD prevalence. As written in the ATS-ERS definition (2004) "COPD is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking." In my opinion, health care professionals and researchers should focus on how to improve health care or disease management for patients with COPD, mainly on helping them to change their lifestyle (e.g. stop smoking!) We should be the first, as doctors, to stop smoking!! Competing interests: None declared |
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Dr Jayaraman Nambiar, Associate professor KMC Manipal 576104
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One of the ways of avoiding mistakes or mishappenings is to check check and check. Check your colleagues. Check the history and examination even if its done by the best in your institution. Check scan findings, check everything by yourself. Dont trust anyone other than yourself! Check check and check ! Competing interests: None declared |
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ADOLFO PRECIADO SOLÍS, Practicing physician ANGULO 432 GUADALAJARA, MÉXICO 44200
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1.It is urgent to start real prevention of type 2 diabetes; not even early diagnosis is enough. 2.We must recover people´s trust in their doctors with a more human and compasssionate care. 3. We must decrease commercial meddling in medical care. Competing interests: None declared |
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Manuel Praena, Primary Care Pediatrician La Candelaria. Health Centre. 41006- Seville. Spain
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A way to improve the security of patients is to monitor and to register the adverse events that our medical activity causes. To analyze their causes and to avoid their reoccurrence. Adverse events range from a hyper-dosage of a drug with the risk associated for the patient, to deficient identification of a biological sample before its shipment to the laboratory where it will be analyzed. All the Health Care centres would have to make an audit of adverse events that allows to design a strategy of improvement for the security of patients. Competing interests: None declared |
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Prof. Enrique J. Sánchez-Delgado, M.D., Director of Medical Education Hospital Metropolitano Vivian Pellas, Managua, Nicaragua
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Good words make a difference. They educate, advise, motivate. You never use the same brain twice. After the great improvements in lifespan the last century, the real threats for our century are obesity, diabetes, sedentarism, smoking, malignancies, dementia, depression, lack of direct social contact and overflow of information. Prevention is still the best medicine. We doctors can best help our patients advicing, educating and motivating them for a healthy lifestyle. BMJ could have a section dedicated to help and train doctors to do our best job in these aspects. Competing interests: None declared |
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William G Notcutt, Consultant anaesthetist James Paget hospital, Great Yarmouth NR31 6LA
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Pain is the commonest symptom that patients describe. For many, this is a long standing companion particularly when definitive treatment is delayed or ineffective. Most doctors in the UK have rudimentary education in the management of pain and its associated problems. If this were a mandatory subject at all levels of almost all medical training, then quality of care and of life would improve, mortality might fall (suicide, immobility), and bio-psycho-social morbidity would lessen. The tools to do this are available and simple to use. The unwillingness to address this problem is similar to earlier attitudes to Palliative Care. Competing interests: None declared |
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Aureo Muzzi, pulmologist Cattinara Hospital s Fiume 447 34100 Trieste Italy
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A doctor helps the patient if: he often studies from EBM reviews in order to use the time better, he seeks motivation for his job, he does what it takes to serve the health and the quality of the life of the patient, he doesn’t use defensive medicine, he favours the economy of the system because otherwise there won’t be enough money for all, he is independent from the system trades, he informs citizens of the importance of life style, he treats the chronicity in order to favour the quality of life and not immortality. Competing interests: None declared |
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Matthew Garber, Pediatric Hospitalist Greenville Memorial Hospital Greenville, SC 29605
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One of the biggest health issues is variation of care and subsequent variance in outcomes and cost. As pay for performance and electronic medical records evolve, standardization of care should be actively incorporated. Guidelines, hopefully derived from evidence and based on outcomes, need to be developed and disseminated, and doctors need to be incentivized to adhere to them. A small variance from the guidelines could be tolerated to give physicians room for clinical judgement, but large or frequent deviations would be investigated. The electronic medical record could aid physicians in adhering to the guidelines, and be updated automatically. Thank You. Competing interests: None declared |
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Andrew N Crowther, Retired GP Tewkesbury Glos GL20 6HY
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When I retired from General Practice, I was surprised at the number of patients who said to me "I remember when you said to me...." and that my comment had helped them in some way or other. For the life of me I cannot remember what I had said, and whether it had been well thought out or just an 'off the cuff' comment. It is often the chance remark that makes all the difference during a consultation, both for the clinician and the patient. The art of medicine is in supplying and understanding these passing remarks, but I wish I knew how I made these important comments at the right time. Competing interests: None declared |
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Inge Axelsson, MD, PhD, paediatrician Ostersund Hospital, SE-83183 Ostersund, Sweden
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Vaccination is still the great thing in medicine, both in low and high income countries, and in children and in old people. Millions of children survive every year thanks to vaccine. Competing interests: None declared |
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Ashis Banerjee, Consultant in emergency medicine Barnet and Chase Farm Hospitals NHS Trust, North London
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An effective interaction should be based on a genuine sense of care and empathy, two words which are diinishing in importance in the vocabulary of medicine in the industrialised world. This should be fuelled with relevant knowledge that is falling victim of radical experiments in medical education. Also, look away from the medical establishment for genuine innnovation- there must be a forum for the ordinary practitioner in front-line practice (not a professor, director, editorial board member, teaching hospital consultant, royal college official) to ensure that their observations can be given a hearing. Remember that major paradigm shifts have frequently come from relatively humble settings. Competing interests: None declared |
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Mukesh Kapoor, Resident Physician Advocate Lutheran General Hospital, 1775 Dempster Street, Park Ridge, IL 60068 USA
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The World Health Organization (WHO) estimates that globally in 2005, at least 400 million adults were obese and at least 20 million children under the age of 5 years were overweight [1]. Overweight in children, and obesity in adults has been linked to numerous adverse health outcomes [2, 3]. A previous study showed that as high as 77% of overweight children, remained obese as adults [4]. Encouraging healthy diet and lifestyle at an early age and implementing other preventative strategies in children and adolescents is of exquisite importance in preventing this global epidemic of childhood overweight and adult obesity. 1. World Health Organization. Obesity and Overweight. Fact sheet 311. Sep 2006. 2. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. Apr 19 2005;111(15):1999-2012. 3. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obes Res. Sep 1998;6 Suppl 2:51S-209S. 4. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics. Sep 2001;108(3):712- 718. Competing interests: None declared |
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Himanshu Kataria, I belong to 'lost' tribe of SHO!! Newham, London
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Unfortunately, owing to complex referral system and more trainee than trained doctors alongwith host of other problems mean that in present times, I believe, patients really get too little interaction with doctor. The host of problems are reducing working hours, increasing paper work (especially for trainees), complex communications and IT Systems, deteriorating infrastructure in general, etc. Obviously proper history taking and examination of every patient is the key thing which will improve patient care - which was true at the birth of medicine and is true even today - problem is present systems mean that GPs have 10 mins to see one patient and Consultant clinics have patient every 15 mins. Inpatients sometimes see the supervising consultants twice/once a week in some hospitals and A&E doctors have 4 hour targets to meet!! Rather than aiming to decrease clinical duties of doctors in almost every field (by way of creating new class of professionals called Practitioners) what we need is systems to decrease wastage of doctors' times in calling/chasing results/waiting for call backs/finding equipment which works/looking for hospital notes, etc. etc. We need better infrastructure and support staff to provide best customer service to patients and increase doctor-patient interaction. Competing interests: None declared |
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Fotios Drakopanagiotakis, Fellow in Pulmonary Medicine, Department of Respiratory Medicine Louis Pradel Hospital, Claude Bernard University, Lyon 69500 Bron
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The important issue is to build a relationship based on trust between the patient and the physician. And it is well known that every succesful relationship takes time and needs continuous care to develop. The same applies to physicians. If the burden of everyday work does not allow us to respond to our patients' emotional needs, then we do something wrong. The patients with pulmonary diseases are patients who usually suffer from chronic debilitating illnesses. And sometimes their breathlessness goes away without the nebulizer...Just by talking and sharing their anxiety. Competing interests: None declared |
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Prakash Manikoth, Consultant Neonatologist NICU, Royal Hospital, Muscat, Oman
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Breastfeeding makes a positive influence on the life of the infant, the mother, her family, the society and the country. Formula feeding is a recipe for disaster and needs to be discouraged like tobacco smoking. There is a large body of evidence in the medical literature which shows improved health and developmental outcomes of human milk fed babies and their mothers over formula fed babies. Competing interests: None declared |
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Patrick D. McGorry, Professor of Youth Mental Health ORYGEN Research Centre, University of Melbourne
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Currently mental health services are structured the same way as general health services, that is with a fundamental division into paediatric and adult systems of care with a pyschogeriatric service system added on. This results in a system of care which is weakest where it needs to be strongest. "Mental illnesses are the chronic diseases of the young" (Insel and Fenton 2005). The peak incidence of the major psychiatric disorders of adult life occurs between puberty and the mid twenties. While this is the most mentally unhealthy phase of life, it is now the healthiest in a physical sense. Adolescence and early adulthood is also a discrete developmental phase which is extended and increasingly complex, and has its own subculture. This means that a substantial restructure and enhancement of the specialist mental health system and new primary care models are required which can respond more effectively to this major public health issue. Competing interests: None declared |
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Elizabeth Cottrell, Foundation Year 1 University Hospital of North Staffordshire, Stoke on Trent, Staffordshire, ST4 7LN
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As doctors we all reel off examples of our team-working skills but how true to reality are they? Patient care would be infinitely improved if we all put aside "work politics" and help each other to help the PATIENTS. Patients get frustrated when they have long waits, rejections from "other teams" and different "stories" every time they see a doctor. You scratch my back I'll scratch yours.. However you would like to think of it lets be crazy, throw away our egotistical attitudes that everyone else is on another (worse) team, put on a united front and start working together. Competing interests: None declared |
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James D Newton, Specialist Registrar Northampton NN1 5BD
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Many patients require central venous access - estimated as 200,000 per year - but due to poor procedural technique or inadequate after care many develop iatrogenic infections. A central line is the commonest source of bacteraemia (1) and a frequent source of Methicillin resistant Staphylococcus Aureus (MRSA) infection (2). Focus on this common intervention and ensure all health care staff involved with insertion and use of a central line receive adequate training and have access to appropriate equipment to ensure sterility. Combine this with the use of ultrasound as recommended by NICE (3), and we can significantly reduce complication rates including MRSA bacteraemia. An alternative strategy is the introduction of 'proceduralists' such as in the United States (4) but this is unlikely to be practical in the current National Health Service. --------------------- References: 1) Coello R, Charlett A, Ward V et al. Device-related sources of bacteraemia in English hospitals - opportunities for the prevention of hospital-acquired bacteraemia. J Hosp Infect 2003;53:46-57. 2) Carnicer-Pont D, Bailey KA, Mason WB et al. Risk factors for hospital-acquired methicillin resistant Staphylococcus Aureus bacteraemia: a case-control study. Epidemiol Infect 2006;134:1167-1173. 3) Technology appraisal Guidance no 49. Guidance on the use of ultrasound locating devices for placing central venous catheters. National Institute for Clinical Excellence September 2002. 4) Ault MJ, Rosen BT. Proceduralists - Leading patient safety initiatives. N Engl J Med 2007;356:1789-1790. Competing interests: None declared |
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Luca Mascitelli, Chief of Sanitary Service Comando Brigata alpina Julia, Udine 33100 Italy
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Obesity has become an epidemic condition in developed countries: an 18.5% rate of mortality in the USA is attributed to poor diet and physical inactivity(1). In the 21st century, increasing rates of obesity may lead to a decline in overall life expectancy(2). However, under the influence of pharmaceutical industries, physicians are pressured to medicalising lifestyle issues. Indeed, they are trying to ensure lifelong drugs to healthy people, in order to find an ill for every pill. Transforming individuals with unhealthy lifestyles into patients distracts attention from relatively simple lifestyle changes that can achieve greater reductions in morbidity and mortality. Luca Mascitelli, MD
1. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ; Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360: 1347–60. 2. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352:1138-1145 Competing interests: None declared |
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Aung Maug, Medical NGO service Dhaka, Bangladesh 1213
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Doctors should not be in their chambers only for diagnosing and prescribing drugs to treat diseases! The impact of the attitude of a doctor is mostly reflected on how a community behaves with a particular disease/patient. If a doctor's behavior puts distance between doctor and patient the accompanying people will perceive it as a serious disease and will treat the patient in that way. The knowledge the doctors have on the epidemiology of a disease or its prevention & treatment, is lacking for patients & their companions. So the responsibility of doctors is to make the patient and his/her companions feel comfort with a feeling that he/she is in the right place to have help/suggestion, to let the patient have clear idea on causes of the disease, prevention, treatment, importance on lifestyle/risky behavior to avoid/prevent the occurrence of the disease and the importance of regular treatment. Doctors should be the first focus of any intervention to changed their practice (knowledge - attitude - practice) as their practice in most of cases works as a barrier in public health interventions (especially in developing countries). Competing interests: None declared |
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carolyn V Brown, private physicianj Douglas Alaska 99824
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In every medical and health care encounter, there is the possibility to think about four important concepts: 1. Primary prevention – avoiding the issue from the “get-go” 2. Secondary prevention - helping to manage the issue as early as possible so as to avoid further damage. 3. Tertiary prevention – dealing with the end stages of the issue as best as possible. 4. Quaternary prevention – learning what we can from autopsy, laboratory, and end of issue findings. What more could medicine hope for? Why don’t we teach this and do this on in a consistent way? These are my suggestions. Competing interests: None declared |
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Robert O. Cannon, MD, MPH, Physician Palo Alto, CA 94303
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It is not the knowledge, experience, and/or technology brought to bear that ensures adequate care - it is the time spent with the patient, family and community that is the key. Unless we spend more time with our patients we will not discover the hurt and its source(s) and our interventions will be too often inadequate or even hurtful. The complexity of the mind-body interaction in maladies cannot be understood in an individual without the investment of time - not just skill. Care will not be adequate, and our profession effective, until we ensure we not only bring expertise to our interaction with our patients but also what so many need - investment in knowing them as a unique individual - and this takes time. Empathy comes from understanding, and care comes from our ability to empathize and engage in a partnership. Until we have the time we won't have the ability. Competing interests: None declared |
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Stan Baltsezak, Co-ordinating doctor, International SOS Singapore
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We have a simple, cost effective, evidence based intervention that influences both morbidity and mortality, enhances quality of life, improves both physical and mental health - Exercise (of moderate intensity). Dr William Osler, at the end of 19th century, got it right, defining the quadrangle of health: Rest, food, fresh air and exercise. Healthy food in moderate quantity, sufficient rest and exercise, pollution free environment will still (at the beginning of 21st century) make the greatest difference to personal health. Competing interests: None declared |
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David Brookman, Remote Rural GP Brewarrina, NSW, Australia
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In these days of economic rationalism we now accept 5% unemployment as being 'full', and in Australia our government has even fiddled the statistics to make one hour of work per week workforce participation. We are currently going through the pre election shift of people from unemployment to pension or sickeness benefits to make the figures look even better. The real rate is quite high. Unemployment equals poverty, loss of social role, increased liklihood of crime, increased drug abuse, increased all cause mortality, and a sense of hopelessness in adolescents. Hopefully the economic philosophy will swing away from the current 'dry' social darwinisim back toward a humanitarian Keynesian view Competing interests: None declared |
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Mohy K El Masry, Professor Clinical Toxicology and Consultant Internal Medicine Ain Shams University Hospitals - Cairo
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Patients suffering chronic diseases like diabetes, bronchial asthma, hypertension, ischemic heart disease, generalized anxiety disorder, and addiction would benefit much by access to medical information and continuous learning about their diseases. This is evidenced by the higher tolerance of well informed people to disease compared to those with limited information. While sharing in the management of his disease, the patient will help the practitioner in avoiding complications and tolerating certain disease manifestations. Morbidity, a relative term, is then reduced to a considerable extent. The problem will lie in those incapable to exploit the medical information concerning their disease. Competing interests: None declared |
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Susan E Jordan, senior lecturer University of Wales, Swansea, Swansea SA2 8PP
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While helping patients cope with the burden of illness, healthcare professionals may, sometimes, overlook the burden of treatment, including adverse drug reactions. These account for around 4% of hospital admissions, and over 70% are avoidable[1]. By undertaking regular, structured patient monitoring for adverse events, coupled with appropriate follow through, multidisciplinary teams could reduce the incidence and severity of adverse drug reactions. However, such tasks lie on the inter- professional boundaries between doctors, pharmacists and nurses, and risk being marginalised. As with other ‘boundary work’, responsibilities are not clearly allocated and may be delegated to patients or remain neglected and ‘orphaned’[2]. 1. Pirmohamed M., James S., Meakin S. et al. (2004) Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients. BMJ. 329, 15-9 2. Jordan S. 2007 Adverse Drug Reactions: Reducing the Burden of Treatment. Nursing Standard 21(34) 35-41 Competing interests: None declared |
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Mark E Batt, Professor Sport & Exercise Medicine Centre for Sports Medicine, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH
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Physical activity is widely recognized as the ‘best buy’ in public health – thus to minimise morbidity, reduce mortality and improve quality of life of our patients we have to be actively engaged in promoting physical activity as part of healthy living. Physically active people have a 20-30% reduced risk of premature death and up to a 50% reduced risk of chronic disease such as coronary heart disease, stroke, diabetes and cancer. Yet, 60% of men and 70% of women are not active enough to benefit their health.(1) Thus we have a responsibility as health care professionals to understand, promote and enable physical activity as part of everyday life and health living. This should become a standard component of a medical history and a prescription for healthy living an expected output of every patient encounter. (1) Summary of intelligence on physical activity.DH 2004 Competing interests: None declared |
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John Kennelly, General practitioner Pasifika Health Care, Lincoln Rd, Henderson, Auckland, New Zealand 1008
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Implementation of evidence-based medicine.
Variation in health care is a natural consequence of uncertainty in biological systems. The combination of information technology and evidence-based medicine has the opportunity to create a system whereby we agree on three fundamental patient-centred questions: diagnosis, treatment and prognosis. If there is disagreement with the evidence, there may be a need for change, so we gather data, learn about the disease, inform our practice to improve patient care and in doing so, spread the risk of medical error or mistake. The community, not doctors should be insurers against the risk of insufficient or uncertain science. Competing interests: None declared |
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Rob Z Torok, A&E Consultant West Dorset General Hospital, DT29TB
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Firstly: Enhancing the integration of our services with focus on our prime purpose of caring for our patients. This to be clearly prioritised above our various sub-agendas and group/speciality loyalties which need to be aknowledged and serviced but only secondarily. Acceptance that systems can only run efficiently with in-built reserve capacity - design them around this for the benefit of our patients and staff, resisting the pressure to over-burden them at the expense of all. Second: Educating patients and promoting a culture of realistic expectations, an acceptance of the at times random fragility of life and an understanding of their responsibilities for appropriate use of services - that their behaviour has a direct impact on those. Third: An exploration between health and happiness/contentment to enable both Healthcare workers and patients to have an open dialogue about options, accepting that at times quality of life may mean other factors are appropriately given higher priority than health. Competing interests: None declared |
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Brian Stello, physician, researcher Lehigh Valley Hospital, Allentown, PA, USA 18105
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New medications, lifestyle recommendations, screening and monitoring studies are all of limited usefulness without one significant underlying skill: the ability to understand a patient and effectively promote behavioral change. Resources abound with guidelines, medical recommendations, and evidence, and they grow more sophisticated by the year. They are all for naught unless a physician is capable of understanding a patient and capable of helping that patient advance to a stage where they can make a meaningful and sustainable change in lifestyle toward healthier behaviors. This is not to minimize the importance of sound clinical decision- making, treatment, and advice. I merely intend to state that without the foundation of effective motivational communication between doctor and patient, the clinical is limited. The paradox is that such communication is often not done between doctor and patient. Competing interests: None declared |
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Rupert Gude, Retired General Practitioner Tavistock, Devon, PL19 9EL
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All patients should have an upto date summary of their illnesses and drug treatment with synopses of the more important illnesses and investigations. This would 1, Ensure that what the doctor thought they had had concurs with the patients view. It would also enable the patient to add other conditions not listed and add relevant family history as it occurs. 2. The patient would have greater understanding about admissions to hospital when they were intensively investigated or severely ill with poor communication of results 3. It would be of great help to the junior doctors in OPD or on the emergency ward so they do not have to wade through inches of notes all falling out or scroll through metres of screen trying to find relevant information. 4. Links could be attached to diagnoses so the patient could obtain further information and they would have a greater understanding of their illnesses. 5. It would be of great use when the patient needs medical help away from home. Road to Health Baby books for under 5s were pioneered in West Africa in the 1970s and are now universally held by mothers. Why not extend this concept to the rest of the population? Competing interests: None declared |
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Rebecca Scott, GP retainer Bromley by Bow Health Centre, London E3 3BT
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How can I make the greatest difference for my patients? Release them from the idea that the doctor can cure all their problems. Even where patient's have truly medical problems, it seems the greatest benefit can often be obtained from improving their quality of life in other areas - seeking employment, becoming more confident beyond their front door, able to operate independently in their community and beyond, being creative, helping others, making sense of their lives spiritually. As doctors we are well placed to help patients in this way, giving them confidence to look beyond us for a way forward. Competing interests: None declared |
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Syed Abdul Mujeeb, Assoc. Prof/doctor AIDS Surveillance Center, Jinnah Postgraduate Medical Center, Karachi, 75510, Pakistan
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The use of current techniques and approaches for living a successful life described in self improvement books can produce promising results in patients and high risk population. In a small experience with HIV/AIDS patients and high risk population, I found these techniques quite useful in lowering their anxiety, reducing their pain, alleviating their fears, improving their compliance to the treatment and empowering them to have better control over their life. I strongly suggest to explore these techniques and approaches as new interventions in health care system to improve health and quality of life of our patient and high risk population. Competing interests: None declared |
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Sawsan Talib Jamal, Family physician head of Jaber AL ali health centre , ministry of health , Kuwait 13960
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I think we should work on health education because most of our patients are coming for many trivial symptoms and we are over whelmed with large numbers of patients , that some patients with real problems are lost in between. Competing interests: child health |
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R Mohindra, doctor unemployed
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Medicine is about improving healthcare outcomes. Really? I don't think so. It is about improving the welfare of the patient. Proof: a competent patient can refuse life-saving treatment. Welfare is intimately entwined with physical health but they are not the same thing. The realisation that medicine is about people not biological entities is one of the most important things we are re-learning after the rapid medical advances of the last century. At the bedside the requirement for consent has been one of key drivers for securing this key goal of medicine. With the recent legal changes the future remains bright. Competing interests: None declared |
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Robert D Southward, Consultant, A&E Hartlepool, TS24 9AH
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Injury Treatment. Professor Batt (1) argues that the population should be encouraged to exercise. What happens when these people then suffer an injury either acute or an overuse type injury. The General Practitioner may refer to physiotherapy (usually long waiting list) or orthopaedics (longer) or in the case of acute injuries to the accident and emergency department (AED)(4 hours). It is no wonder that some non-acute injuries therefore reach AEDs. The standard care is to exclude a fracture and provide advice on the PRICE regimen. This surely is not the best that a modern health service can manage for soft tissue injuries. These patients with good advice and rehabilitation management will return to work sooner, have less long term problems and recurrences and therefore benefit from continued exercise and be able to contribute to the nations economy further. Rapid response Physical activity and exercise: A service for national health. Professor M A Batt - posted 01/06/07 Competing interests: None declared |
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katpadi varadarajan arulalan, primary care paediatrician Vellore, South India
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There are several problems which require our attention simultaneously. Eg.Mentally retarded child with spasticity needing medical,physical,occupational therapies. Child should be transported every day to the training center. To meet all ends both parents have to go for job.Unless the health care cost are reduced how we can help these children, let alone provide care after their parents death ? We can give our consultations free, but what about the therapists, equipments, transport vehicles? Atleast in India, Government alone cannot do every thing.Business organisations are willing to do so if we properly project our work. For example our well wisher from the profit of his aromatic company is spending thousands of rupees for the dream projects of our clinic ( low cost vaccines, family welfare measures,free medical treatment for mentally retarded children etc) which would not be possible with out outside financial help.So co-ordination with business houses can make dramatic changes. arulalan export_katpadigandhinagar@rediffmail.com Competing interests: None declared |
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Woody Caan, Professor of public health Anglia Ruskin University, Cambridge CB1 1PT, UK.
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Healthcare for people with little or no spoken language was a disaster until the eras of the BDA-standardised British Sign Language (1890 onwards) and then of Makaton (1985 onwards) for people with learning or co-ordination disorders. Think of obstetric care for a primaparous woman in labour, who is without oral communication, without signs or symbols... Until the modern era, all acute medical and surgical interventions on people without spoken language were in effect a nightmarish assault, and chronic disease management was an incomprehensible tyranny. Standardised signs turned on the light... Competing interests: RNID member |
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Alessandro Calderan, GP San Donà di Piave CAP 30027 - Venice - Italy
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items for future BMJ, obviously evidence based: 1) screenings for cancer 2) invented diseases 3) when to stop cures As someone else said: “Not all of life's problems are diseases, and to try to make them such will make us mad and disempower everybody”. BMJ 2005;330:1157 (14 May), doi:10.1136/bmj.330.7500.1157 Competing interests: None declared |
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Dr Rajender Singh Chauhan, Senior Specialist and HOD Ophthalmology,Regional & referal hospital,Sohar,Sultanate of Oman Sohar PB 49,PC 311
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A doctor must master his subject leading on to professional competency. You have to be a good clinician first, Invite the patient in his disease management by proper communication. Be profesional. show your concern, assure the patient, develop rapport. Respect patient dignity, maintain confedentiality and freedom to choose the second openion are key to success. You must always be available to your patient, proper advise. Remember Patient is always right, so if you do not make a diagnosis then you are inefficient and let the patient take another openion or take a colleague's opinion irrespective of their seniority. Best wishes. Competing interests: None declared |
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Maura Murphy, locum GP 129 Sefton Rd, Litherland, Liverpool L21 9HG
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It is important to establish what our patients eat and what exercise they do. Lifestyle is probably key to underlying problems with weight and fitness and thus health. Advertising good food intake in the practice, in supermarkets and via a dietitian could make a big difference to health. During the war with rationing people were less obese and fitter it seeems.
Exercise classes available at or near health centres which are not too expensive probably would also make a difference to the couch potato types that may eat too much, drink too much and not exercise.
Putting the prices of alcohol up would also help health probably too (but would be very unpopular I think!)
Competing interests: None declared |
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Cristan Q Cabanilla, Pediatric Pulmonologist Philippine Children's Medical Center Quzon City 1108 Philippines
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1. For childhood pulmonary tuberculosis, a. Better vaccine b. Recognition of latent infection c. Accurate prediction of the presence [and absence] of disease 2. For pediatric community-acquired pneumonia, a. Accurate and early prediction of the presence [and absence]of bacterial etiology b. Availability of vaccine to marginalized members of the community Competing interests: None declared |
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Mithun Barik, Electronic Medical Records Consultant 824, Corporate Centre, Nirmal Lifestyle Complex, LBS Road, Mulund, Mumbai - 400 080, India
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A patient based electronic health record will not only enhance patient participation and decision making but also will increase doctor- patient communication by reducing time-consuming paper work. It will also keep the doctor updated about the patient's health status in real time and thus would enable quick action. An integrated electronic health record will speed up referral consultations and alerts will decrease prescription errors. Ultimately it will help to restore the human face of medical consultation as doctor's eyes will now focus more on patients rather than in patient files trying to find out past history or investigation results. Competing interests: None declared |
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Kate E. Koplan, Senior Resident in Internal Medicine Brigham and Women's Hospital, Boston, MA 02446
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Information technology is not just the wave of the future, it should be the wave of "right now." While our esteemed colleagues on the East of the Atlantic may already be using complex computer-based systems to help manage patient health records and physician healthcare activities, their US counterparts are lagging behind. There are many individual institution -based initiatives in the works, and these have been shown to improve patient record-keeping and to aid clinician decision-making. However, the committment to IT development should be a larger one, one that is national in scope. IT improvements to help the US healthcare system will lead to improved patient care and physician satisfaction, not to mention outcomes- based research opportunities. Competing interests: None declared |
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Chandra Sekhar Devulapalli, Consultant Paediatrician Ringerike Hospital, NO-3504 Honefoss, Norway
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I have following two main suggestions for improved care for the patient: 1) I would love to see all doctors taking their patients seriously and communicating with them properly at all times. Most of the problems that eventually arise from doctor-patient relationship are often due to inadequate and improper communication with their patients. Health care providers should be able to implement policies that will encourage patient -doctor communication in stead of concentrating only on making money. In my opinion, communications skills with the patient should be a part of curriculum for medical students. 2) It is necessary to provide a satisfactory accommodation and all other materialistic comforts also to the patients as for the others. However, one thing is certain that no matter what, materialistic comforts can not replace proper care that can be provided by either patient’s family members or close friends. Competing interests: None declared |
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ARIE EISENMAN, head of medical emergency department The Western Galilee Hospital, PO: 21, 22100 NAHARIYA, ISRAEL
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Two major medical achievements, I believe, make the greatest difference, reduce mortality and improve quality of life, provided it is properly implemented and deployed by medical authorities and practitioners all over the world. Both relate to life saving in the event of cardiac arrest. The first is the invention of an automatic external defibrillator (AED) which, provided it is available in any common place, can allow laymen without previous medical education to restart a fibrillating heart. The 2nd is the recent 2005 resuscitation guideline that allows everyone, wherever he is, with minimal training and without any equipment to save other's life. Competing interests: None declared |
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Abduljabar A. Theyab, resident doctor Egypt/Cairo
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If I have to choose on the area where I can benefit my patient best it would have to be getting him/her to quit smoking if a smoker and use sun screen for both. There has not yet been a better intervention for smokers to promote there health then quitting this habit, furthermore skin cancers keep being top of the list in there incidence at all time. However these two pieces of advice to my patients would probably differ if my advice was given to a particular demographic and geographic faction of the world like subsaharan africa or Bangladesh because then vaccination and HIV prevention would come first. Competing interests: None declared |
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Tarik Z. Nursal, Assoc. Prof. General Surgery Baskent University Adana Teaching and Research Center
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I believe the most important difference the society can make is to put pressure on governments to spare a tiny fraction of their incomes to support starving children in poor countries. This could only be done through supporting independent economies of those countries. This strategy could be extended to all countries to screen all patients for malnutrition as nutritional depletion is the most prevalent problem in hospitalized patients. This could be solved by increased awareness and timely intervention.
Competing interests: None declared |
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David D Jones, GP The Kelly Practice, 1 Dunluce Ave Belfast BT9 7HR
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Prevention still remains better than cure and early intervention must remain the best form of cure when prevention has failed.Early intervention depends on patient awareness of their own bodies and the availability of someone they trust to advise them.Trust is the key word and that is only developed by availability and approachability which means time.Time in our hectic self obsessed world is in increasingly short supply but is what most patients value in the consultation and without a consultation there is no diagnosis treatment plan or measureable outcome. Competing interests: None declared |
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Ruchika S. Nagori, resident doctor, ophthalmology ahmedabad,india 380016
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Majority of diseases in medical sciences follow the iceberg phenomenon. The part above the water is much less than the one below it. so an early detection is a key to the successful management. A careful history and meticulous examination at the first visit of the patient, though tedious, is real useful. Being an ophthalmologist, i suggest a mandatory fundus examination in every patient even if he has no complains. This helps to rule out conditions like diabetic retinopathy, hypertensive retinopathy, retinitis pigmentosa,optic atrophy,etc. which manifests late but are present in latent form for long. Intraocular pressure should be measured to save patients from glaucoma blindness and much more. Competing interests: None declared |
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Armando A. Calvo, Principal Proffesor Universidad Peruana Cayetano Heredia - Lima-Peru
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Today we have the ability of knowing the patient by images, numbers and questionnaires, but who knows really the patient?; the sick man. I think, we can improve all medicine areas, diagnosis and therapeutics, if we learn to listen to the patient. The first step to make a work up is to know the problem and this is only possible if we listen carefully. If we want to introduce the patient in the "self care", it is necessary to listen first. To choice a therapy, first listen, what is the patient opinion, his preferences, his habits and his will. Competing interests: None declared |
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Phillip Periman, hematologist & medical oncologist 1000 Coulter Dr., Amarillo, TX 79106, USA
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My list for improving medical care based on my experience in the USA include the following: 1. Increase the rate of autopsies including on hospice patients.Without autopsies we do not have confirmation of our assumptions. 2. Reimburse physicians other than those in the lab to do simple lab tests such as urine analysis, occult blood, gram stains, and blood smear evaluations. 3. Ban hand writing by doctors. All notes and orders should be printed and therefore legible. 4. Pay primary care physicians an hourly rate to encourage spending more time with each patient. 5. Shift general health care to non- physician providers and to the patient. Phillip Periman,M.D., F.A.C.P. periman@suddenlink.net Competing interests: None declared |
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Anwar A. Chahal, Clinical Tutor GKT, Cardiology Fellow King's College, London
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I have paraphrased Ralph Waldo Emerson - his words hold much gravitas and truth. I am tired of hearing eloquent words from our world leaders about making a difference to other human beings whilst sitting on the board of directors for weapons manufacturing companies. The two positions have never sat right with me. More so, it amazes me how this doesn’t cause the rest of us to become outraged. If we really want to see change common sense has to come back. We must adopt wisdom and patience in our decision making. Hysteria, media sensationalisation and knee-jerk responses have got to go. In the UK, we need to revive community spirit allowing families to spend time with each other and their neighbours. Educate the coming generations beyond pieces of paper with good values, ethics and life skills. Time is the most precious commodity we have and we have to spend it wisely. Doctors must be allowed to spend time with patients. Only then will we deal with our biggest health problems: obesity, depression and addictions. Worldwide health can be improved by feeding people and improving sanitation. The two most profitable businesses worldwide remain armament sales and narcotics. Isn’t it disturbing to know if we’re not killing each other, we’re intoxicating ourselves? Eliminate interest, cruel economic systems and throw out sophisticated economists arguments, for allowing hideous atrocities such as mountains of food to be thrown into the ocean each year, as millions of our fellow human beings starve to death. It defies all sense. We must truly accept others as equals and acknowledge every human beings inherent right to dignity and respect. I wish more people believed in Karma and Newton's 3rd law of motion. I have no doubt what goes around will definitely come around, it’s just a matter of time. Competing interests: None declared |
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Fernando S Cavalcanti, Adjunct Professor Universidade Federal Pernambuco
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The doctors should know that the disease belong to the patient, and give as much informations and attention to his complaints. Even in undeveloping countries the patients should know what for the blood test and why so much limitations to live. Why some drugs in the market are not available by the health service as special medicine and some are. We must be gentle with the patient and his family. Competing interests: Member Advisory Board Bristo-Myers Squibb-Brazil |
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Dr. Naseem A. Qureshi, Consultant psychiatrist & Head of Research Unit, Ministry of Health, Area code:11176, Riyadh, Saudi Arabia
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To the Editor, Dear Madam, The following are the Millennium Developmental Goals to be achieved by 2015; Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 7: Ensure environmental sustainability Goal 8: Develop a Global Partnership for Development These goals need to be addressed seriously by all countries- developing and developed- and strategies and plans to do so should be devised and executed. Some progress has already been made with regard to MDGs but developed nations are far behind in committing to their promises. By all means, achievement of these goals will make global, realistic differences in promotion of health, healthcare and eradication of diseases alike. Declaration of interest: none Correspondence: Dr.Naseem Akhtar Qureshi MD, PhD Consultant Psychiatrist and Public Health Specialist, Ministry of Health, Riyadh, Saudi Arabia Competing interests: None declared |
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Edward P GIBLIN, Salaried GP St Neots Road Medical Centre, 12 St Neots Rd,Sandy. Beds. SG19 1LB
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Long waiting times - for Consultants, operations, radiology, investigations, & especially Mental Health treatment - endanger lives. This situation can be remedied simply by increasing hours of availability in Hospitals & Clinics: ultrasounds open from 0800 to 2200 7 days a week for example, OT open for longer. Goodbye waiting lists! Competing interests: None declared |
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Rajat Bhatt, MD 79416
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We will need more effective implementation of technology. Home monitoring devices for weight monitoring (CHF patients),coumadin monitoring,diabetes which transmit data directly to the physicans office so we can preemptively treat abnormailites before it is too late . We should also provide more preventive services . We do not emphasise the importance of weight and diet enough,partly because some groups have a vested interest in patients being overweight and being sick with diabetes and heart conditions in hospital and partly because the reimbursement for weight loss counselling is too low to take the time out of the 15 minutes we have with the patient. Will need better utilisation of existing resources.Too often drug companies come out with spurious results which may be statistically but not clinically significant and there are a lot of 'me too' drugs when cheaper existing generic drugs could have been used. Patients simply cannot afford these costly medications and then we tend to blame them for non compliance. We need to provide for more home hospice services. Patients in their last year of life spend most of the time in the hospital when they could better have been taken care of at home. Competing interests: None declared |
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vivek v gharpure, consultant pediatric surgeon children's surgical hospital, aurangabad, ms india 431001
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advances in understanding of neonatal physiology, pathology and their response to surgery and anesthesia has led to progress and improved outcomes in neonates suffering from correctable surgical illnesses. these conditions previously uniformly fatal are now amenable to surgery. a short spell in the hospital and the baby can go home and lead a normal and productive life for many years. it is so much better to give a newborn a chance to lead a normal life. the family is enriched, so is the society. Competing interests: None declared |
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Dr. Jitendra V. Dave, 4th year resident, Pathology department Pathology department,Government medical college & New civil hospital,Surat,Gujarat,INDIA-395001, Dr(Mrs)V.M.Bhagat, Dr R.D.Patel, and Dr Mayur Jarag
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The patients of leptospirosis coming to our hospitals are mainly referred from the health centers of villages. Most of these patients are poor and illiterate so ignoring their illness during early period of the disease. Thus the patients presenting us are having bad hematological and biochemical profile on admission due to their delay in consulting the health services. So, the treatment of these patients is challenging task for the physicians. But taking some factors related with the laboratory profile of these patients, into consideration, while treating these patients; it might become little bit easier job and also help in decreasing the mortality of leptospirosis. The factors related with bad prognosis of these patients of leptospirosis are oliguric ARF (Acute renal failure), AST (Aspartate transaminase)/ALT(Alanine transaminase) Ratio>3, hyperkalemia, leucocytosis and thrombocytopenia should be taken care as soon as they appear to decrease the mortality in leptospirosis. These factors might not be solely responsible for the mortality but they acting together simultaneously to cause grave outcome. Further studies should be carried out with large number of patients for better evaluation of these factors responsible for great mortality. And there should be some scoring system based on these prognostic factors, for better assessment of the condition of the patients on admission and during treatment and also for better management of leptospirosis. Competing interests: None declared |
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dr mohan devegowda, GP urban
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Since I come from the second most populous country and the majority are young people and also getting globalised in every sense, my priority is primary prevention. We doctors here are not all that aggressive in educating to prevent diabetes, cardiovacular diseases and common tropical infectious diseases. As a General Practitioner and first point of contact in health care I will spend more time and be patient and try to educate as much as possible. Before achieving the difficult task one should be a good clinician particularly updating ones knowledge. Competing interests: None declared |
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benedict mccaffrey, OOH GP Worcestershire
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I believe that a fundamental reinvigoration of our professional values is the single thing that would make the greatest difference to our patients. We need to regain the confidence to turn away from multiple guidelines and protocols especialy where these fail to deliver personal patient care. We need to make the care of our patients our first concern. Reclaiming the ethos of this statement would go a long way. It seems to me that many of us have lost our confidence when it comes to our ability to deliver medicine that cares for the individual before and above all other concerns. Competing interests: None declared |
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Carlos A Scarampi, cardiologist Hospital Español. Buenos Aires. C1209AAB. Argentina
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One of the best ways to improve patient care is to give patient time. Time to explain what he/she feels, her/his feelings about the situation, her/his doubts. Of course, to make sure he/she understood physician’s instructions. This is the basics of medical-patient relationship. If we assist a patient in a few minutes, because we are just worried in what we are going to earn, we are going to make mistakes. Even, if we just do it because it is just a routine, and we only want to do it the fastest possible to have free time, we are not going to fulfill patient’s needs. A patient is not only a disease, he/she is a human being suffering from a disease. Then, he/she is suffering even psychologically. If we do not give her/him time, we are not going to satisfy all his needs. Even, since he/she is psychologically affected, the answers we are going to obtain in a rush interview are not going to be the right ones. Mainly, it is a matter of time. We must devote time to patients. Competing interests: None declared |
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Dr.Pramod Madhukar Kulkarni, consultantpediatric generalist BHOR412206(INDIA)
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1)Categorisation of practice:-
2)Standardisation of practice:-
3)Intensive Education of healthcare providers:-
Mandatory Annual updates & training of basic practice skills with clear guidelines for-protocolized disease diagnosis & management,early recognition of next level conditions & prompt referral; patient/relative communication, based on practice values-evidence base, rationality, cost effectiveness & transperency, professional ethics. Mandatory certification of the same for future practice Though apparently difficult to execute, this seems to be indispensible for ultimate better patient outcome. Competing interests: None declared |
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Anuruddha M Abeygunasekera, Urological Surgeon Karapitiya Teaching Hospital, Galle, Sri Lanka
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Cardiovascular diseases, cancers, diabetes, HIV infection and trauma are among the leading causes of morbidity and mortality around the world. We, the medical personnel, especially in the developing world, prepare to face these killer diseases by requesting sophisticated investigations, prescribing expensive drugs and building state of the art hospitals. If we look at the core issues in a wider perspective, most of these killer diseases are related to obesity, smoking, alcohol consumption, improper dietary habits, lack of exercise and other unhealthy lifestyle measures. When patients consult a doctor or enter a hospital, they are worried about their health and come prepared for change. Hence the medical personnel have a unique opportunity to indce changes in their patients' lifestyle for better. A little extra time spent on educating patients regarding a healthy lifestyle and persuading them to give up bad habits would go a long way in minimising the sequalae of these diseaes than the tests, pills and operations that we tend to offer lavishly after being fooled by the industries with vested interests. More efort should be made to train undergraduate and postgraduate doctors on how to convince patients to change their habits and how not to be misguided by the parties with vested interests in promoting expensive investigtions, medicine and procedures with marginal efficiency. Competing interests: None declared |
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Ettore Guidi, Coordinator Clinical Research Ospedale Niguarda Ca'Granda, Milano, Italy, 20162
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One of the most useful things to improve patient care is to increase patients’ knowledge about what the available medical services can and cannot give and at what cost. General practitioners and hospital specialists will never succeed in the equivocal role of gatekeepers if the patients themselves are not critical about the pro and cons of any medical consultation or procedure. The waste of resources for useless tests is rising both in nationally oriented and in free market oriented systems because too many anxious patients are badly advised by dubious or deceptive advertisements. Competing interests: None declared |
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David Jenkins, Consultant Physician Worcestershire Royal Hospital
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We are told that we are experiencing the first effects of an epidemic of obesity. The consequences of our increased fatness for our health and economy are so huge as to be difficult to comprehend. The subsequent rises in diabetes and premature cardiovascular disease among the economically active members of society could have devastating effects on the health and wealth of the nation. Exercise is clearly recognised as fundamental in combatting the rise in obesity. It appears to reduce diabetes and cardiovascular disease. Joined up thinking is required to promote exercise in our schools, clincs and hospitals. We need to develop strategies that reduce our reliance on cars and increase incentives to walk. Spin-off benefits would include safer roads and reduced CO2 emissions. Exercise promotion should be our chief strategy for improving health in the UK. Competing interests: None declared |
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Soledad Marquez-Calderon, Responsibility for Research and Training Andalusian Agency for Health Technology Assessment. 41020 Sevilla; Spain
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In developed countries a great improvement would come from avoiding unnecessary health care. An ethical analysis about how medical practice is being changed in last years should come from medical societies. It would be the only way to stop the continuous creation of new diseases (with guidelines for diagnosis and treating them), and limit the power of industry and "experts". All this make healthy people became ill. Competing interests: None declared |
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Roger H Jones, Wolfson Professor of General Practice King's College London, 5 Lambeth Walk, London, SE11 6SP
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The recent call for suggestions on particular aspects of diseases or conditions where significant health improvements might be made has produced an interesting set of responses. A few specific conditions have been identified, but many respondents have suggested more ‘generic’ aspects of clinical management as areas of great need. It is difficult not to recognise that we still have a long way to go in areas such as the safe and effective use of information communications technology in primary care and at the interface between general practice and the hospital, the best ways of accessing clinical/management information during and after consultations, the most effective ways of determining and communicating the risks and potential harms of treatments and investigations to patients and the ‘minimum clinical datasets’ that we need to collect to make early and accurate diagnoses of important conditions. There are, of course, many others. In terms of specific conditions I would certainly echo Tony Kendrick’s plea for smarter diagnosis and more appropriate treatments (talk therapies versus drugs) for depression, and highlight the need for better decision guides in areas such as the most appropriate choice of treatment (or no treatment) in menopausal women, the role of the family history/genogram in targeting energetic preventive strategies for metabolic, vascular and malignant disease (perhaps including the indications for and techniques of brief interventions and short-form CBT) and an evidence-based approach for the accurate ascertainment of co- infection, complications and contacts in patients presenting with symptoms suggestive of sexually transmitted diseases. Competing interests: None declared |
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Graham Neale, Visiting professor Clinical Safety Research Unit, Dept of Surgery, Imperial College, St Mary's Hospital London W2 1NY
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Training in quality and safety in clinical care should be a durable thread running through the work and educational programmes of all healthcare professionals - from their first day in training until the day they retire from active practice. Each trust should develop a Quality and Safety Unit headed by clinically active senior member(s) of staff to encourage all professional teams to continuously review the quality of the service that they provide and to discuss mishaps. Professional educationists should seek to incorporate quality and safety as a theme that extends throughout all teaching programmes -'stand alone' modules are largely ineffective. Initiatives such as these could make a big difference to the quality of healthcare practice. Neale G, Vincent C, Darzi A The problem of engaging hospital doctors in promoting safety and quality in clinical care. JRSH 2007;127(2: 87-94 Competing interests: None declared |
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MANJEESTHA DAS, SENIOR HOUSE OFFICER,PSYCHIATRY DR.GRAYS HOSPITAL.ELGIN.IV301SN
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In my experience as a junior doctor I feel empathy is a key word in good doctor-patient relationship, which in turn builds up trust between the doctor and patient. As a result the patient will feel safe enough to confide upon the doctor and speak about his problems in an unbiased way. Thus a good history from a patient will obvioulsy will help the doctor to find a better solution of the problem, which might always not be prescribing medicine, may just be a piece of advice or a referral to the right professional. Competing interests: None declared |
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Sung Hyuk Choi, Associate Professor of Emergency Medicine Korea University Guro Hospital, Seoul, South Korea
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I considered that making a quick diagnosis and treatment for patients is important to enhance patient care and prognosis. So it is necessary for hospitals to conduct research into the distribution of patients so that they are prepared for possible outbreaks of particular conditions. Besides, telemedicine must be accelerated to promote pre-hospital treatment and interconnection between hospitals. In order to provide appropriate treatment in hospitals, cooperation among medical staff is considered essential. In conclusion, an integrated system, where the diagnosis and treatment are done from outbreak of disease, must be established to improve patient care. Competing interests: None declared |
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Glenn W Mitchell, Vice President for Clinical Safety Mercy Health System, St Louis, MO 63017
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The transition from blame based practice to systems thinking continues to be difficult. The individual practitioner’s understanding of human error, engineering controls, and human factors problems is often rudimentary. Medical education, both initial and continuing, focuses on unattainable perfection and isolated physician performance. Malpractice databanks and public opinion are based on personal error in the context of perfectionist expectations. Knowledge of actual human and system performance should inform both our practice and the public’s expectation of our results. The sooner we disseminate new concepts, the better the ultimate health of both our patients and our profession. Competing interests: None declared |
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James M Hynson, Staff Anesthesiologist Kaiser Permanente Vallejo Medical Center, Vallejo CA, 93589
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Physicians rarely talk about accident prevention, yet accidents, particularly automobile accidents are one of the most common causes of serious injuries and death. Has a physician ever recommended driving less aggressively or more carefully to a patient? Probably not. This just isn't an area that is discussed - unlike quitting smoking, weight reduction or limiting cardiovascular risks. Perhaps a national or international campaign to encourage responsible driving would have an impact on health. Competing interests: None declared |
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Leslie G Scarth, Child Psychiatrist(retired) Ex Royal Hospital for Sick Children,Edinburgh
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Clearly, efforts to reduce smoking have had a major impact on morbidity & mortality. However, the effectivenes of all therapies, both pharmacological and Psychological, is relatively poor. A major investment in more effective treatments is urgent. It is likely that drug treatment is more likely to be acceptable for would-be "quiters" but combined with a simplication of psychological treatments(which could then be delivered by less trained workers)seems feasible if sufficient funding can be obtained for this process. Competing interests: None declared |
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Dan Botezatu, gastroenterology doctor urgency clinc departamental hospital galati romania800073
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The ability to interview patients of all ages, moods, and backgrounds, your experience with history taking, identifying the problem symptoms and abnormal findings, linking findings to an underlying process make the patient feel better. Paradoxically, the very skills that allow you to assess all the patients also shape the image of the unique human being entrusted to your care. Competing interests: None declared |
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José I Valenzuela, Chief Special Projects-eHealth. División de Educación. Fundación Santa Fe de Bogotá. Zip: N.A.
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People’s lives should not be treated, in the clinical setting, as mere “eventualities”. Patients are not “a pneumonia” or “a stroke”. Persons´ lives go on in between hospital admissions, and it is rutinary life what determines one’s state of health. People should be able to register their day to day activities and share their lives with others whenever they wish. Creating simple and effective ways to enable autoregistration, as in a diary, can not only help patients express their feelings and exteriorise them before they derive in illness, but could also improve clinical encounters and facilitate medical and peer support. Beyond a Health Record, a Life Record is needed. Taking advantage of IT, health informatics should enable this possibility. Competing interests: None declared |
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Razi Riyadh Hati, general surgery lecturer, general surgery department Faculty of Medicine, University of Aden
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In order to organize hospital-infection preventing policies, it is advised to follow the path of any patient in the hospital and her/his contact. 1- Cleaning of the bed after each sitting on it even if it is last for minutes as in ER-Department. 2- Putting of an adhesive sterile/clean disposable very thin cost-effective plastic paper on the stethoscope's membrane after each examination. 3- Emphasizing the doctors to wash her/his hands after each examination (doctor prevention), and most importantly before each examination (patent prevention). 4- Serial bacteriological examination of the ultrasound gel and ECG leads. 5- The air-system must be completely separated between the different departments with putting of plasma biological filter. 6- Re-evaluating of the antibiotic protocols to be more specific and rationalized. Competing interests: None declared |
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David J Biau, specialist registrar Paris 75014 France
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In the US, deaths due to preventable adverse events are estimated to exceed the deaths attributable to motor vehicle accident, breast cancer or AIDS, when at the same time, an average passenger would have to fly around the clock for more than 438 years before being involved in a fatal crash. If we would just stop all brilliant researches, concentrate on what we already know, and make sure we do it right, well I guess that would be a huge step in improving patient care… Competing interests: None declared |
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Brian R Budenholzer, Family Physician Spokane, WA 99223
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Making the correct diagnosis of the patient's symptomatic disease and implementing effective treatment. Competing interests: None declared |
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Dr. Naseem A. Qureshi, Consultant psychiatrist & Head of Research Unit, Ministry of Health, Area code:11176, Riyadh, Saudi Arabia
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All health providers and also health consumers should understand the great clinical benefits of biopsychosocial model. Almost all diseases that afflict humans are explained differentially by biological, psychological and social factors which affect reciprocally several aspects of a disease. At consultation, health providers should give a thought to these dimensions in particular psychosocial and health consumers should also offer all information related to it. Health providers should understand the patient as a whole and this simple intervention will certainly make tremendous biological, psychological, social and economic differences in healthcare. Declaration of interest: none Competing interests: None declared |
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Kim Botly, longterm gp locum Gower Place Practice, London WC1E 6BN
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In our constant desire to improve the NHS we are in danger of losing the qualities that make it special. In primary care we have the luxury of knowing a patient's full medical history right from birth. Yes, in other countries the consultation times are longer but they need to be because the family doctor does not have this information. In some places where patients doctor hop the doctor may never have met the patient before. More of a triage/A&E service than primary care as we know it in the UK. In such places there is less sense of someone being 'your' patient, of being responsible for what happens to them once they leave the room. Yes, we have problems with communication with other parts of the service, letters don't arrive, results go astray. But on the whole it works very well (and did so before we were computerised). We should identify what is right with the NHS and fight to keep those qualities or they will disappear. Competing interests: None declared |
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Augusto Pimazoni, President, MED MARK Medical Marketing Consultants - Brazil MED MARK Medical Marketing Consultant, Rua Borges Lagoa 908 - Apt. 123 - Sao Paulo, SP - zip 04038-002 -
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Diabetes education is key to the effective control and prevention of complications. As any other medical strategy aimed at preventing diseases or complications, diabetes education costs money and the ROI will only be visible after a few years. There are three major external obstacles to the success of diabetes education: physicians, health plan administrators and government health officials. Most physicians suffer from a syndrome called "Pedestal Effect" that make them feel like the kings of the universe and for whom to deal with an educated patient is a threat to their divinity because the well informed patient "tries to interfere" in medical decisions. Most health plan administrators, mainly in developing countries, are unable to think preventive medicine as a means to reduce costs of complications because they are only driven by immediate profits. Government health officials usually suffer from two major deficiencies: profound ignorance in terms of investing in prevention and the regrettable position of many government heath care institutions that do not consider health investments as a top priority. Although the target of all the needed educational strategies the patient is nothing else that a victim of ignorance of decision makers. Augusto Pimazoni, MD
Competing interests: Medical Marketing Consultant for the Health Care Industry |
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George D. Carson, Director of Maternal Fetal Medicine, regina Qu'Appelle Health Region 1440 14th Ave., Regina, SK, Canada, S4P 0W5
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One of the areas of care that should be chosen is antenatal care. We can't get nearer to the beginning of life and the opportunity should be seized. It is a time of engagement with our care system and, for many women, a time of enhanced motivation to improve their own health. Although receiving antenatal care is beneficial, the most useful specific components are not known and the organization and delivery of the care should be improved. The potential is vast and it should be one of the topics chosen to make a difference. Competing interests: None declared |
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Stephen C Harper, General Practitioner Morland House Surgery, Wheatley, Oxford, OX9 3BY
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Continuity of care is valued highly by both patients and doctors [1]. Switching family doctors is uncommon in the UK [2].Continuity of care is much more than good communication skills, it is the place where patient and doctor develop trust, a sense of ongoing responsibility, built on shared experiences and longevity of care [1, 3]. It is the recognition that illness is more extensive than disease, and the role of the doctor, is the relief of suffering [4] It is associated with improved compliance, fewer mistakes, and better health outcomes [1]. Amidst the current health reforms in England, it is vital that the opportunity for, and benefits, of continuity of care are preserved. References: 1. Marshall, M. and T. Wilson, Competition in general practice. BMJ, 2005. 331(7526): p. 1196-1199. 2. Edwards, N., Using markets to reform health care. BMJ, 2005. 331(7530): p. 1464-1466. 3. Mainous, A.G., III, M.A. Goodwin, and K.C. Stange, Patient- Physician Shared Experiences and Value Patients Place on Continuity of Care. Ann Fam Med, 2004. 2(5): p. 452-454. 4. Heath, I. and K. Sweeney, Medical generalists: connecting the map and the territory. BMJ, 2005. 331(7530): p. 1462-1464. Competing interests: None declared |
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Michael D Innis, N.A Home
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Making a Difference? Then bury “Think Dirty” And see the light in her eyes. When fractures and bruises are found Think Infantile Scurvy and Rickets When Retinal Haemorrhages confront you Think Vitamin K is deficient And when the Bell Tolls “HE will not ask your Race or Creed All HE will demand of thee “What hast thou done on Earth.” Anon. Michael Innis Competing interests: None declared |
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J. Deinum, Internist UMC St Radboud, 6525 GA, Netherlands
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Evidence for efficacy of specific treatment for many chronic medical, non-life-threatening conditions is provided by randomized trials. However, it is largely ignored that only a subset of patients respond well to such 'evidence-based' therapy, and some patients may even be harmed by it. Therefore treatment of these chronic diseases should be guided by evidence obtained from the very patient that is consulting you in your office, not from a group result obtained elsewhere in patients that may differ from your patient. A method to achieve this is to treat your patients according to rigourous scientific rules: comparison with placebo, randomisation, double blinding, outcome measures that are both relevant to the patient's life and scientifically sound. These so called n of 1 trials, as proposed by Guyatt and Sackett(1), should be a standard facility in hospitals and GP's offices. They are applicable not only to frequent conditions for which many trials have been performed, but also to rare diseases for which little therapeutic evidence exists. (1) NEJM 1986; 314:889 Competing interests: None declared |
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Benedetto Mangiavillano, MD, Gastroenterologist and Gastrointestinal Endoscopist Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Hospital, 20132 Milan
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An improvement of the home based palliative care might be due to an interaction of different factors like: a) stopping the pain with a correct drugs association; b) having a domiciliary nurse; c) having a domiciliary basic doctor to coordinate the different involved specialists (oncologist, anaesthetist, etc.). The “last days” of a patient, independently from the cause determining the disease, have to reach a good quality of life, because every man must live every day remaining suffering as little as possible. In a terminal patient this aim can be reach only if different factors interact with each other. Competing interests: None declared |
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Anthony J Morkane, Accident and Emergency Royal Cornwall Hospital Trust TR13LJ
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It has to be public health. To significantly improve health care means preventing or minimising the risk of ill health in the first place. Derek Wanless thinks so, the evidence would suggest so and a significant number of 'rapid responders' say so. Evidence shows that the benefits of exercise, weight control, a healthy diet, responsible alcohol consumption and not smoking have a beneficial affect on just about every organ system in the body, by maintaining and even improving physiological organ function and reducing the risks of pathological changes. It is quite simple really! Competing interests: None declared |
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Graham Kyle, Consultant Ophthalmologist University Hospital. Aintree
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No patient's access to healthcare should be at the expense of another, yet that is the inevitable consequence of claiming to offer a universal service, which is 'cash limited'. The urgent need is for an infusion of transparency and honesty into politicians, and other NHS 'controllers'. The BMJ should strive to make those who lie, dodge or obfuscate accountable, by 'naming and shaming'. This would improve NHS staff morale, patient experience and safety. Competing interests: None declared |
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Keugoung Basile, Medical doctor Anwerp
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The best thing the practitioner should do is patient centered care. The doctor should take care of his patient not as a case of a disease but as an individual in relation to social, psychological, environmental factors influencing his or her health.
In many cases, the doctor prescribes medicines for a particular disease neglecting those factors affecting the health status. Competing interests: None declared |
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Samy A. Azer, Professor of Medical Education Universiti Teknologi Mara, Malaysia 40450
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Many medical schools still teach that patient's education means providing them with information. However, patients can receive information from a wide range of resources. What is more important is how to help patients make decisions, change their lifestyle and replace habits that can badly affect their health with good habits. Most educators agree that learning occurs when we use the new knowledge learnt to change our attitudes and habits. It does not mean knowing pieces of information. I was astonished, and you might came across similar situations, to see some doctors do smoke but they are willing to discuss with their patients the dangers of smoking. The other points I would like to add here are: I believe that we need a number of new articles in this journal that can help doctors to communicate effectively with their patients, use analogies and simple experiments/demonstrations to enhance patients' understanding. This will be very useful to BMJ readers Competing interests: None declared |
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S. Michael Crawford, Consultant Medical Oncologist Airedale General Hospital , Keighley, West Yorkshire. BD20 6TD
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There is a dichotomy in current NHS development; specialist services are centralised, everything else is delegated to the least qualified worker possible ostensibly to bring care close to home but this also means cheaper staff. Paramedics, physiotherapists, nurses, GPwSI etc must categorise patients; like a diagnostic test, such decision-making has sensitivity, specificity, positive & negative predictive values. These require evaluation. To send patients with myocardial infarction immediately to an angioplasty unit will not benefit every patient unless people without the diagnosis are also sent there; this depends on the effectiveness of the assessment of sudden onset upper body pain. Competing interests: None declared |
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Dr Bimal K Agrawal, Professor & Head, Deptt of Medicine MMIMSR, MULLANA-133203, Haryana,India
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Dear Editor, I fully agree what is emphasised in the article 'most of the health care occurs when doctors and patients meet one to one'.The outcome of this interface depends on good communication skill, which is one of the easiest and most difficult thing.The patient should be satisfied that the doctor has heard and understood him/her well and vice versa.If the patient thinks that you have not paid enough attention ,whatever you do is not likely to work.Sometime we also feel that patient has not understood us properly and sometime because of lack of time and other reasons we just ritually give advice to the patients-not to drink ,not to smoke-without making sufficient effort to bring behavioral changes in the patients. Another area that needs to be focussed is the close scrutiny of studies those are prematurely stopped when it was found that the patients in the intervention group are fairing better! Finally, what BMJ has been doing quite well , more innovation on Medical education. Competing interests: None declared |
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Scott A Murray, St Columba's Hospice Professor of Primary Palliative Care University of Edinburgh EH8 9DX
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Patients with cancer generally receive more comprehensive care than patients with advanced non-malignant illnesses. Calls for euthanasia and medical complaints generally come from patients with non-malignant disease. There are understandable historical, funding and prognostic reasons for such inequalities in care in the last year of life. We must now help everyone in need at the end of life. Triggers for identifying when non-malignant patients might benefit from active palliative care can be identified (such as repeated hospital admissions), and general practitioners and generalists can then change gear from routine chronic disease management to more personalised care and advance care planning. This focus would help put listening, holistic shared care in place for many people with multi-morbidities and frail older persons: aspects considered important in other rapid-responses. Scott.Murray@ed.ac.uk Competing interests: None declared |
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soulaiman elias soulaiman, GP inTeshreen hospital Syria-Damascus-Teshreen hospital
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There are several cardiovascular risk factors in type 2 diabetes still not very well controlled; they could be due to the increasing incidence of cardiovascular diseases and diabetes type 2, and this may be linked to the relationship between doctor and patient and the patient's approach. Good diabetes control is best achieved by diabetologists working in the hospitals more than GPs, however this creates more pressure on diabetologists. So some of the options to improve health care are : 1)More clinic visits in hospital 2)The need for diabetes specialist nurses to give more time to patient to improve patient's education as it is proved that improving patient's education decreases morbidity in diabetes type 2 and complications. This problem is mainly important in our developing countries as we do not have diabetes specialist nurses 3 )based on studies published in BMJ, controlling other risk factors in diabetes patients such as hypertension and hyperlipidemia is still sub-optimal. Giving more time to the patient and their diabetologists is one of the options. As a result we will need health care workers more than increasing the work load on the professionals. Competing interests: None declared |
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A. O'tayo Lalude, Primary Care Physician Louisville, Ky, 40241-2131, USA
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ENDOTHELIOLOGY (E-V) is what I call it. What is Endotheliology? It is the science of the conversion of Normal to Abnormal Endothelium: the etiology and pathophysiology of endothelial and vascular dysfunction leading to atherosclerosis. The Triad of Hyperglycemia, Hyperlipidemia, and Hypertension constitute the etiologic elements of Insulin Resistance Syndrome (IRS) and hence the pathway to Stroke, Retinopathy, Cardiovascular crisis, Chronic/End-Stage Renal Disease, Neuropathy, Peripheral Vascular Diseases, and etc. All Primary Care Physicians world wide should learn the basics of E-V and EBM/SOC (evidence-based medicine/standard of care) for treating their patients and BMJ should be the torch bearer. Competing interests: Forrest/Sankyo; Pfizer; Novartis; Novo Nordisk; |
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Kandiah Senthilnatha, Echocardiographer Toronto, On; Canada M1W 2N2
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Successful way of treating a patient is to co-relate the clinical evidence with the findings from the laboratory results. Sometimes artifacts in imaging techniques could lead to errors. Almost 85% of the diseases could be clinically diagnosed and treated by a physician. The rest 15% need laboratory tests in order to exclude one by one from the differential diagnosis(DD). If BMJ could publish DD for some common diseases in a peridiocal manner that would be helpful to most of the new physicians who are busy in the clinics. Physicians should spent enough time with patients and educate them how to prevent or manage their chronic diseases. There are confusing messages appear in the media everyday. BMJ should be able to identify them and provide scientific based evidence to explain the truth in those messages. For example, a treatment for type 2 diabetes has combination of two or more active components. One active component is acting on pancreatic beta cells to enhance insulin secretion by exocytosis while calcium ions are moving into the cell. The same component acts on cardiomyocytes as well and allows calcium ions to seep into cardiomyocytes. Depending on various pathological conditions on the heart and vascular system the same tablet would have caused many heart attacks. Lowering the dosage to very minimal level might be helpful is my thought and surely not the advice to the medical system. Knowledge on Nutrition, exercise, happiness and living in a family system will further enhance the health of individuals and also each and every nation as well. BMJ should coax all the politicians to pursue this evidence based health care. Competing interests: An ounce of Prevention Pays off tons in Future |
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Thomas Heidegger, Head of Department of Anaesthesia Spitalregion Rheintal Werdenberg Sarganserland, 8880 Walenstadt, Switzerland
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Assuming that several several million anaesthetics are performed worldwide every year it is indeed a topic which might concern a lot of patients. Besides the question ‘Is anaesthesia really as safe as we think or wish?’ it is, above all, the issue whether patients are satisfied with the anaesthesia care they have received? Certainly, this implies that we must know – from the patients’ point of view – what patient satisfaction really is (1,2). At an annual meeting of the European Society of Anaesthesiology some years ago, Roger Goss, a patient advocate pointed out, ‘To be satisfied, I need to be informed!’ 1. Heidegger T, Husemann Y, Nuebling M, Morf D, Sieber T, Huth A, Germann R, Innerhofer P, Faserl A, Schubert C, Geibinger C, Flückiger K, Coi T, Kreienbühl G. Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria. Br J Anaesth. 2002; 89:863-72 2. Heidegger T, Saal D, Nuebling M. Patient satisfaction with anaesthesia care: what is patient satisfaction, how should it be measured, and what is the evidence for assuring high patient satisfaction? Best Pract Res Clin Anaesthesiol 2006; 20:331-46 Competing interests: None declared |
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Lucianoi Tarantino, Director of Hepatology and Interventional Ultrasound Unit S.Giovanni di Dio Hospital- ASLNA3- 80027 Frattamaggiore (NA) - Italy
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There is no single action or perfect prescription. Although many things changed in patients' care, the obvious statement of Dr.Peabody reported from Dr.Hutchinson (rapid response "Real Patient Care"), is still the cornerstone of an effective medical approach to patients. However, mixing this with complete (as much as You can) knowledge of Evidence Based simple preventive effective measures is mandatory (Real care is not enough). A list of these measures is strongly required rather than stressing a single procedure or recommendation. Competing interests: None declared |
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dominic j stevens, Salaried GP South lambeth rd practice SW8 1UL
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unsure? reassurance not working- find a website. You learn from rereading the science, and you can give convincing explanations. How did we manage without it? Competing interests: None declared |
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Takuya Watanabe, Lecturer/Clinical doctor Dept. of Internal Medicine, The Nippon Dental University School of Life Dentistry at Niigata
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Doctors should spend as much time as possible with their patients, including physical examinations, explanation of their conditions, medical tests, and treatment. It is essential for doctors to take the time to communicate with their patients, which allows for more reliable medical information and improved patient adherence. Better communication may also result in early detection of disease and improved care. At present, there is a shortage of doctors in Japan, especially in hospitals, and the working conditions are in need of much improvement. I believe that a prerequisite for improving patient care is to decrease the strain on doctors working at general hospitals by increasing the overall number of doctors in Japan. Given that many of Japan's working doctors are too busy, they have little time to communicate with their patients. A doctor is a human being and not a medical machine. A more humane attitude toward patients should replace the technical improvements in medicine. These changes will lead to an overall improvement in patient care. Competing interests: None declared |
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mark r stacey, consultant anaesthetist university hospital of wales
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how about leaving us alone (ie. no government interference for a minimum of 5 years) to do the job that most of us aspire to do well, and manage despite the large amount of interference? Competing interests: None declared |
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Richard L Nelson, Consultant Surgeon Northern General Hospital, Herries Road, Sheffield,S5 7AU, UK
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It is easy for a British writer to ignore this most significant and much maligned advance in medical care. Too easily taken for granted. But I am from the United States. We have 50 million uninsured, an A&E system that has collapsed trying to absorb them, and most of the rest of the population have enough problems paying for their care that they might be called marginally insured. Money comes directly into every interaction. Every day I come to work in Sheffield, I let out a belly laugh, not of cynical humor, but of joy, getting at last to practice medicine, with the focus only on medicine. Nye Bevan deserves the Nobel Prize for everything. Competing interests: None declared |
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Hasnain M Dalal, General Practitioner Truro TR1 2LZ
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A farmer from Cornwall writing in the BMJ[1] said: “My experience of care after my heart attack was like being led through a fog by someone who knew the way. I suddenly felt very fragile and feared a repeat attack. I was eager for more information. How did I come to be in this situation? What was going to happen to me? I needed to know”.Sadly many heart attack patients are not offered any cardiac rehabilitation despite recommendations from national guidelines. Offering patients a choice of home or hospital based rehab could improve uptake and reduce morbidity. References Dalal, H., Evans, P. H., & Campbell, J. L. 2004, "Recent developments in secondary prevention and cardiac rehabilitation after acute myocardial infarction", BMJ, vol. 328, no. 7441, pp. 693-697. Competing interests: I was the principal investigator for CHARMS [Cornwall Heart Attack Rehabilitation Management Study]:a randomised trial with patient preference arms comparing home based versus hospital based rehabilitation. |
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Jan Pitha, physician, treatment and research in atherosclerosis Institute for Clinical and Experimental Medicine, Videnska 1958/9, 140 21, Prague, Czech Republic
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Substantial benefits could be obtained by better education of our patients; their cooperation is critical, especially in dealing with chronic diseases; in overcrowded out-patients departments we cannot answer all our patient´s questions/concerns. This could be possible during seminars focused on patients with a particular disease and could be led by experienced staff. In the field of research one of the most important areas to understand is drug interactions and it is essential to have relatively easy-to-use tools for their applications. The reason for this is the increasing frequency of polypragmasy in the ageing population, with negative impact on their health. Competing interests: None declared |
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Saskia Holtslag, Physician Assistant in training Meander Medical Center, Dep. of Orthopedic Surgery, P.O.Box 1502, 3800BM Amersfoort, the Netherlands, and Peter E Westerweel, MD; University Medical Center Utrecht, the Netherlands
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Limitations of human and financial resources for health care are a reality and put pressure on the time and means available to care for our patients. Shortages of qualified doctors and their high cost have initiated a trend to transfer specialized tasks to novel health care professionals such as the specialized nurse, nurse practitioner and physician assistant. Although well-established in some pioneering countries, others are now catching on. Implementing these novel positions whilst continuously providing patient care of optimal quality is one of today’s greatest health care challenges for which it is essential to share experiences on an international level. Competing interests: None declared |
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Finn Edler von Eyben, consultant in internal medicine DK-6270 Toender Denmark
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I have seen many patients where a history of use of tobacco was a hint as to the correct diagnosis. Wuthin the last year I saw three patients with chest pain diagnosed without information as to smoking. One was treated for fracture of a rib, and two discharged from departments of cardiology with treatment for ischemic heart disease. These patients had been smoking and were examined for lung cancer. The suspicion was confirmed in the three cases. This illustrates the impact from asking all patients for their smoking history. Today a substantial proportion of acutely admitted patients to departments of internal medicine have exacerbations of chronic obstructive pulmonary disease. Many have stopped smoking earlier but some might not. For these patients, counselling might open for longterm oxygen therapy. Competing interests: Sold 500 samples of a booklet on smoking cessation to the Danish GlaxoSmith Kline. |
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Sung Hyuk Choi, M.D., PhD (Asssociate Professor) Korea University Guro Hospital (152-703)
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As an emergency physician, I considered that making a quick accurate diagnosis and then applying appropriate treatment for the patient's condition are important to enhance the patient care and prognosis. For this reason it is necessary for hospitals to conduct research into the distribution of patients who are admitted in the emergency center so that they can forecast and be prepared for possible outbreaks of particular conditions. Besides, telemedicine must be accelerated to promote pre- hospital treatment and interconnection between hospitals. In order to provide appropriate treatment in the hospitals, quicker diagnosis and cooperation among the medical staffs are considered essential. In conclusion, I consider that an integrated system, where the diagnosis and treatment are done from the outbreak of the medical condition, must be established to improve the patient care. Competing interests: None declared |
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Alan A Woodall, GP Registrar Shawbirch Medical Practice, Telford, TF5 0LW
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Assisting parents adopt healthy behaviours that impact on their unborn children by helping them quit smoking. Watching their foetus form in a womb free from carbon monoxide, being born at a healthy birth-weight, grow as a child in a smoke-free household without running the gauntlet of respiratory disease, as teenagers learning from their parents to avoid peer-pressure to smoke, mature into non-smoking adults with healthy parents who are also around see their own healthy grandchildren being born. This behavioural intervention can change the health trajectory of future lives for the better: I cannot achieve anything more productive in a consultation. Competing interests: None declared |
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Patricia J Peterson, Physician, CMO St. John Medical Center, 98632
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So much of what really makes a difference in my patients' decision to act on my recommendations comes down to their understanding the connection between what I want them to do (eat less, move more, make different food choices, etc) and the potential outcome (eg: improved cholesterol, lowered blood pressure). For example, I present weight loss as a math problem (eat 200 calories less a day for 365 days equals 70,000 calores lost, or 20 pounds in one year). If I suggest specific concrete steps to take, he/she is much more likely to follow through and the next visit I can build on that first step. With diabetics, for example, checking glucoses twice a day helps them to see the relationship between their eating and the resulting blood sugar level. They are much more aware of that direct connection and are more likely to make course corrections to get the glucose in control. Keeping it simple works for a large percentage of patients. I can ramp it up for the patients with the capability and willingness to do more. My goal is to get them to buy in and, thus, get the benefits of their efforts. Competing interests: None declared |
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Larry A. Green, Physician Denver, Colorado 80238
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Given the estimates that approximately 40% of premature death and avoidable suffering is attributable to unhealthy personal behaviors, a focus on helping people adopt healthier behaviors is a particularly high impact focus for improving practice. Given that much work is being done to redesign frontline practice NOW, such a focus would be timely. Physical inactivity, unhealthy diet, smoking tobacco, and risky drinking could be the initial targets. Given that these behaviors are important to primary prevention, secondary prevention, and chronic disease, this emphasis might even help with efficiency. What's not to like about a focus that could improve the lives of so many millions of people? Competing interests: None declared |
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Ken Checinski, Senior Lecturer in Addictive Behaviour St George's, University of London, London SW17 0RE, Ferhal Utku
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Alcohol misuse contributes to 150,000 hospital admissions annually in the UK, yet medical school curricula place little systematic emphasis on teaching prevention, screening and brief intervention to students, as if the problem cannot be assessed, quantified and treated. Rather than going away, it is increasing to Gin Lane proportions at times across the country.
Much would be achieved by equipping tomorrow's doctors with the key skills shown to reduce alcohol consumption in excessive drinkers, namely brief, motivational interventions. Common things are common and deserve attention, perhaps as Foundation Year competences.
Now we should call time on ill-informed responses to this toxic epidemic.
Reference Academy of Medical Sciences (2004) Calling Time: the Nation’s Drinking as a Major Health Issue. Academy of Medical Sciences, London, UK. Competing interests: None declared |
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George Peat, Senior Lecturer in CLinical Epidemiology Primary Care Musculoskeletal Research Centre, Keele University, Keele, Staffordshire, ST5 5BG
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The origin of the word 'doctor' is to teach. One of the main roles of a medical doctor is to teach the patient about their health and illness. Doctors are effective teachers given sufficient time. Patients and family members are the main agents of positive changes in health at a population level. My answer: 'a longer general practice consultation' over any of the current motley collection of magic bullets. Little high-quality evidence to back it up though, so dangerously non- evidence-based (Wilson & Childs, 2006). Competing interests: None declared |
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Aldo Riani, Emergency Service-General Practice U:S:L. 5. 09170-Oristano(Italy)
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Probably I won't be wrong if I recommend to ameliorate the existing therapies(and find new better ones, too),screening methods,surgery,prophylaxis and make them available to as most people as possible.However,my conviction is that only by moving the core of healthcare concern from the remedies towards the patient it would be possible to obtain a remarkable improvement.It doesn't mean less interest in therapy and prevention but simply that each person is unique and different and thus needs a proper and well-balanced approach. Competing interests: None declared |
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Frank Bender, Physician Will-Grundy Medical Clinic
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Sorry to be late but I think the most important area for information has to be therapy of hypertension because good control can benefit so many conditions
Competing interests: None declared |
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Stefano Bellentani, Director Liver and Nutrition Center -, Stefano Bellentani, M.D., PhD
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Try to communicate empathically with the patients as he can feel that you understand his/her situations, problems, and feeling. Listen to all his problems, and try to have enough time during the visit to do this. Try to always visit him/her, even if you do not think is necessary: the non- verbal communication of “touching him/her” is very important. Treat all the patients with courtesy, and without “authority”. Try to correct all his/her unhealthy behaviour with a collaborative evaluation of their problems and with an individualized step-by-step accordance on the modification to be adopted in a due time. Promote and support self- efficacy in achieving the aim you agreed with the patient. Be always sensitive to their stigma and problems. Try to simply explain and detail all the aims, the duration of the procedures or the therapy you propose to him/her, and the final results you would like to obtain, in order to strengthen the engagement in his/her compliance. Competing interests: None declared |
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Wanderley Marques Bernardo, Evidence Based Guidelines Developer Brazilian Medical Association - São Paulo - Brasil - CEP: 01333-903
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Today the health professional is more and more pressured to make decisions attending to a lot of pressure sources, lost and decentralized from the patient’s needs and expectations. What is more important to the editor’s choice related to health care is that anywhere on the planet, we can develop a clinical practice based on universal parameters. These parameters depend on a vision that considers always three components: the best current evidence available, the clinical experience and the patient’s expectation. The decision sustained by these elements immunizes the professional and the patient from unnecessary and undesirable risk and harm. Competing interests: None declared |
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Mohamad Said M. Takrouri, Consultant Riyadh KSA
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It was a brilliant idea to incite responses by giving practitioners a chance to talk about the important scope of evidence bases and editorial and maybe purpose built research to solve humanity's suffering. I am thinking of my diabetic patient who suffers the endogenous destructive process of diabetes and struggle for his life between many axis the blood sugar the endogenous insulin the exercise the fatigue the destructive process affecting his heart brain vessel eyes kidney. Even in normal life he is in trouble. What happens if he is in a disaster region like war or civil disturbance of tornadoes striking cities. I think there are many funds wasted on destruction but little is paid to relieve human suffering. I think there is no single item we can say about this important issue. There are all issues of human cruel behaviors and all unhealthy world of pollution and hungry wealthy corporations BMJ 2007;334:1055 (19 May), doi:10.1136/bmj.39216.420625.DE Competing interests: None declared |
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