Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Editorial independence and the BMJ
- Chris Twine (30 May 2007)
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Re: Editorial independence and the BMJ
- Tony Delamothe (30 May 2007)
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Lessons from the MTAS disaster
- John J Turner (30 May 2007)
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Re: Editorial independence and the BMJ
- Jay Ilangaratne (1 June 2007)
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Response from the BMA
- Sam Everington, Jonathan Fielden, Michael Rees, Jo Hilborne, Hamish Meldrum, Chris Spencer-Jones (19 June 2007)
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Mental Health of MMC applicants
- Gregory J Lydall, Amit Malik, Dinesh Bhugra (20 June 2007)
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Re: Mental Health of MMC applicants
- Woody Caan (21 June 2007)
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Twine twisted
- Oliver R Dearlove (9 July 2007)
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Chris Twine, Registrar, General Surgery Royal Gwent Hospital, NP20 2UB
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I do not feel that the tone of the editorial by Fiona Godlee1 reflects that of the medical profession in the UK. This reiterated a question I have had for a number of months; how editorially independent of the BMA is the BMJ? Following the initial uproar when MTAS results came out in late February, it was three print issues until the BMJ ran articles on the topic.2;3 Yet MTAS was all that most of the profession was talking about in these three weeks, and has been incredibly emotive subsequently. It was almost a month until the next major coverage,4 this article expressing distain over the role of the medical colleges in the MTAS fiasco. Following the stance of the BMA over MTAS, no editorial has adequately conveyed the general feeling of the profession since that time, and there has been little negativity towards MTAS or subsequent outcomes (e.g. the review group) within the printed BMJ. Considering the vast amount of negative general press coverage, shouldn’t such a widely distributed UK medical journal have significant coverage reflecting the sentiment of the profession? I understand that any journal should retain unbiased views; however in my opinion the BMJ has been apathetic. Some topics incite such emotion that it deserves to be reflected. 1 Godlee F. The future of specialist training. BMJ 2007; 334(7603):1067-1068. 2 Delamothe T. Why the UK's Medical Training Application Service failed. BMJ 2007; 334(7593):543-544. 3 Brown MJ. Raging against MTAS (UK Medical Training Application Service). BMJ 2007; 334(7593):549. 4 Hawkes N. The royal colleges must up their game--or die. BMJ 2007; 334(7596):724. Competing interests: None declared |
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Tony Delamothe, deputy editor, BMJ BMA House, Tavistoock Square, London WC1H 9JR
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We believe the journal has devoted adequate space to the coverage of MTAS - both in its News columns and elsewhere. Dr Twine's summary is far from complete: A "This Week in Medicine" article focussed exclusively on the topic in the 10 March issue (ie a week before Dr Twine's first sighting[1]. Between 10-17 March two articles were published online, the second of which was published in the following week's BMJ Careers.[2.3] A week later came an extra page of Letters in the BMJ, containing nothing but the profession's opinions.[4] Because of the fast moving and complicated nature of events, journalist Lynn Eaton was commissioned to write a regular blog on the topic on bmj.com. [5]Heavily promoted both on the website and in the pages of the print journal, she has posted 32 despatches between 15 March and today. Searching bmj.com for "MTAS" turns up 30 articles originally published in the print BMJ on the topic between March and May this year.[6] Apathetic? Hardly. [1] http://www.bmj.com/cgi/content/full/334/7592/508 [2] http://www.bmj.com/cgi/content/full/334/7592/499-d [3] http://careerfocus.bmj.com/cgi/content/full/334/7593/100 [4] http://www.bmj.com/cgi/reprint/334/7594/599 [5] http://blogs.bmj.com/category/comment/mtas/ [6] http://www.bmj.com/search.dtl Competing interests: deputy editor, BMJ |
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John J Turner, Consultant Physician University Hospital Aintree Liverpool L9 7AL
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Some painful but vital lessons must be swiftly learned from the MTAS experience. The BMA and the Academy of Medical Royal Colleges have been made to look feeble and ineffectual after entering into 'partnership' roles with the Department of Health. The Postgraduate Deans have been notably silent and have behaved as willing accomplices in the promotion of MTAS. The Deaneries have declined as an independent force in medical training and are struggling to fulfil their correct role in providing quality educational leadership because of over dependence on political approval linked of course to their funding mechanism. The reputation of UK medical training has taken a damaging hit. The Royal Colleges threatened by loss of power and influence and undermined by the emergence of PMETB appear to have been all too easily lured into partnership agreements using a set of desirable motherhood and apple pie objectives that were seductively easy to sign up to. The trap was then sprung and the poorly drafted and unworkable operational details released deliberately late in the process. The timetable of the action plan became a higher priority than the quality of the project itself. Web site design and selection procedures were unfinished and consultation on details was token or non existent. Bullying tactics were used to create an unstoppable momentum for MTAS implementation regardless of the obvious problems piling up and the well based objections of a majority of consultants. The Colleges are protesting that they have been misrepresented although manipulated would be more accurate with junior doctors feeling disconnected and unsupported until it was too late. The government anxious to displace blame elsewhere insist they were fully on board. These ‘partnership’ arrangements have become a damaging form of pseudo collaboration. The end result has been a major system crash between the Department of Health and the profession which is now much deeper than the single catastrophe of MTAS. Competing interests: Cosultant and Educational Superviser |
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Jay Ilangaratne, Founder www.medical-journal.com
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The editorial independence at the BMJ is an issue which has been raised before[1]. Dr Twine is right to raise his concerns about the same issue with some sound evidence and arguments.The Chairman of the BMJP Group has already said[2]"But I do think there are at least some areas that there should at least be discussion with the owners of the publication. I don’t think there’s any [publication] in the world that has absolute freedom".With such frank revelation,I think it is entirely reasonable to assume that in relation to MTAS saga, BMJ might have had some discussion with their owner--BMA--in view of the BMA's intricate and as is now clear,their controversial involvement in the MTAS debacle.Outcome of such discussions with its owner may have led to the rather mild tenor of this editorial without properly addressing the heart of the unprecedented controversy which the BMA stepped into by going against a large group of doctors(including BMA members) at a last-ditch legal hearing against the SoS for Health.Perhaps, the above might assist Dr Twine understand the BMJ's rather lethargic stance on this occassion, which I might add, is nothing new under the editorship of Dr Godlee. Clearly,there is no 100% editorial freedom.And when it comes to issues invoving the BMA, I guess, such 'freedom' the BMJ has, drops to conspicuosly low levels which one cannot help noticing. Given the above,wouldn't it be sensible for the BMJ to--openly--adopt a policy that it would not under any circumstances publish/post material that would even remotely be critical of its owner BMA,irrespective of whether such criticism is just or not;I believe such an approach would be an honest expression of its real policy which many would understand and accept. References [1]There is No Absolute Ediorial Freedom(http://www.bmj.com/cgi/eletters/329/7459/190-b#68696) [2]Lynn Eaton. BMA appoints new chief executive and publishing group chairman BMJ 2004; 329: 190-b-0-b Competing interests: Sceptical about the editorial freedom,the BMJ claims to have, and I personally believe(and have evidence) the BMJ adopts customized pressure-tactics to minimise/prevent critical opinions about the BMA in rapid responses. |
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Sam Everington, Acting Chairman of BMA Council BMA, London WC1H 2JP, Jonathan Fielden, Michael Rees, Jo Hilborne, Hamish Meldrum, Chris Spencer-Jones
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The MTAS debacle is the worst insult visited on the profession by any government in many years. The priority now is to get as fair and transparent a solution as possible, which minimises further damage whilst also protecting patients. The BMA can and will support the estimated 18000 applicants now left hunting for jobs in round 2. We have achieved a small number of extra posts to increase the chances in some of the most competitive areas, but we will lobby the government to find some more. These must be posts with real training and opportunities to progress to consultant (or GP) status, not an artificial expansion that forces trainees into a dead end subconsultant grade. As Round 2 kicks off it must be fair and transparent and contain both ST and FTSTA posts across the specialities and regions. If not, a swathe of talent will be potentially lost to UK medicine. It is vital that there is a robust appeals mechanism opened forthwith to ensure that those unfairly treated by the system can be identified and given a secure return to training. This is all the more important for those chasing an academic career, who have been grievously hit by the failings of MTAS. As some of the best research talent available they are not only vital to the future of patient care, but also to the success of the UK economy. There must be an undertaking to expand immediately the number of academic training posts, to prevent a continuing shortfall of applicants to replace an ageing clinical academic workforce. There must also be a real opportunity for those separated by the process from family, or with other significant reasons, to transfer between deaneries - a “job swap” now will prevent many future problems. We have an assurance from the Secretary of State that no one will be left unemployed in England between rounds 1 and 2. We will hold the Secretary of State to this promise and vigorously support any member made unemployed in this way. [askBMA telephone number : 0870 60 60 828]. We have achieved an independent review of the process under Sir John Tooke and are contributing to his interim report due out in September. However a more fundamental review of the costs and failings of the MMC/MTAS process must be undertaken. We call on the Health Select Committee to take this up urgently. It is also vital that the Secretary of State heeds our calls, made last month, for a new body to design the future of postgraduate training. This work must start now, if this painful episode is not to fester on, further sapping the morale of the profession and having a negative impact on patient care. Yours faithfully, Dr Sam Everington, Acting Chairman of BMA Council
Competing interests: None declared |
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Gregory J Lydall, Locum Staff Grade in Addictions Psychiatry East Herts Community D&A Service, Yew Tree Lodge, 2a Baldock Street, Ware, Hertfordshire, SG12 9DZ, Amit Malik, Dinesh Bhugra
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In response to the editorial of 26 May (BMJ 2007; 334:1067-1068) we are surveying the impact of Modernizing Medical Careers (MMC) and the Medical Training Application Service (MTAS) on the mental wellbeing of junior doctors. Previous studies have reported a greater incidence of stress and affective disorder (1,3,5), suicide risk (2), and problematic substance use amongst doctors compared to the general population (4). Research in Europe also suggests that mental distress and job stress are predictors of suicidal thinking in junior doctors (7). Little evidence currently exists regarding the mental health of UK junior doctors, and no studies exist on the impact of the recent systemic changes to postgraduate training. An anonymous online survey of the self-reported mental health experiences of MMC applicants is currently being conducted. Whilst data collection is ongoing, preliminary results from the 680 responses received to date are disturbing and require an urgent response. Although it is not yet complete, we believe this to be the largest such survey to date. 49% of respondents were female, 79% held UK/EEA passports, and 66% were aged 25-29 years of age. Most worryingly, 21.4% of respondents agreed or strongly agreed with the statement: “I have been having more thoughts of ending my life than usual.“ A previous Norwegian study reported a 14% year-prevalence of suicidal thoughts in medical students and young physicians (7). Our results suggest an increased level of suicidal risk in an already vulnerable professional group. 94% of surveyed trainees admitted to higher than usual stress levels over the last 6 months. Of these, when asked to attribute their higher stress levels to a variety of factors, 99% agreed with “MTAS/MMC”; compared with 54% agreeing with “Financial” problems. Respondents agreed, or strongly agreed, with disturbances in their sleep (total 67%), appetite (43%), and energy levels (73%). A significant proportion agreed to experiencing anhedonia (68%); less enjoyment of sex (45%); tearfulness (66%), irritability (88%) and a sense of future hopelessness (53%). Respondents also reported physical (53%), and psychological (86%) anxiety symptoms. Whilst the survey was not designed as a diagnostic questionnaire, the experiences surveyed are generally accepted as symptoms of depression and anxiety (8). Significant numbers of juniors surveyed admitted to increased alcohol (35%) and recreational drug (2.27%) consumption in the last 6 months. These responses are even more significant given the higher baseline incidence of substance misuse within the medical profession (6). The survey suggests that in addition to an effect on junior doctors’ health, the last 6 months might have impacted negatively on patient care. Compared to their usual clinical practice, 32% of responding juniors admitted that they made more mistakes at work; 43% agreed that they cared less about patient care; and 86% disclosed reduced work enjoyment. While previous studies suggest that doctors are less likely to take sick leave than other groups, 23% of our respondents admitted to taking more sick leave than usual in the last 6 months More worryingly, only 7.5% of respondents disclosed that they had sought professional help for their difficulties, which echoes previous findings(6). The Royal College of Psychiatrists has set up support mechanisms for affected Psychiatric trainees via the College Tutors and by offering advice to both trainees and trainers. The College through its membership of the Academy of Medical Colleges plans to present the findings of the completed survey to all Medical Royal Colleges so that they can consider establishing appropriate support mechanisms for trainees in their specialty. A variety of helplines have already been established and trainees are being encouraged to seek help appropriately. As a result of this survey, the College intends to explore regular monitoring of the mental health of junior doctors. MMC applicants should have easy access to robust support during this time. Their supervisors, colleagues and General Practitioners are asked to think more proactively about the mental health of these junior doctors, and to offer early help where appropriate. Dr Gregory J Lydall MRCPsych
Dr Amit Malik MRCPsych
Prof Dinesh Bhugra MA MSc FRCPsych M Phil PhD
References: (1) Caplan RP. Stress, anxiety and depression in hospital consultants, general practitioners, and senior health service managers. BMJ 1994; 309: 1261-1263 (2) Hawton, K., Clements, A., Sakarovitch, C., et al (2001) Suicide in doctors. Journal of Epidemiology and Community Health, 55, 296–300 (3) Graham, J. & Ramirez, A. (1997) Mental health of hospital consultants. Journal of Psychosomatic Research, 43, 227–231 (4) Fowlie DG , Alcohol & Alcoholism. Vol. 34(5)(pp 666-671), 1999 (5) Firth-Cozens J. The psychological problems of doctors. In: Firth- Cozens J, Payne R, eds. Stress in health professionals: psychological and organizational causes and interventions. London: Wiley, 1999. (6) Donaldson LJ. Sick Doctors. BMJ 1994;309:557-558 (7) R. Tyssen. Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. Journal of Affective Disorders, Vol. 64(1),pp 69-79 (8) International Statistical Classification of Diseases and Related Health Problems 10th Revision, World Health Organization, 1999 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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The profession owes a debt to Lydall et al [1] for their timely study of current mental illness (mainly depression) linked to the MMC stressor. Exceptional occupational health risks (including suicide)during the medical careers of some women have already given cause for concern, in relation to the MMC mess. [2] Our work on depression in the caring professions (e.g. 500 social workers [3])suggests that timely Psychotherapy or Counselling by someone trusted and independent of the workplace leads to good outcomes at both personal and occupational levels. However, in a work environment enduring high stress levels, Secondary Prevention of depression in high risk Employees may also be a shrewd long- term investment for Employers. [3] Models from 'positive psychology' may be helpful for 'healthy' medical careers. For example, Lynne Friedli drew on years of experience promoting mental health at the HEA and Mentality to deliver her 'Critical Analysis' to the Faculty of Public Health annual scientific meeting in June 2006. [4] She called one key, protective factor Influence: * 'opportunities to participate, being consulted, shared decision making, advocacy, complaints procedures' How different from the experience of most junior doctors during MMC! However, it is still not too late for Consultants, Trust Medical Directors and professional Policy-Makers to develop three workplace elements of positive mental health: * Mastery of the work environment, Purpose in life, Negotiating relationships. [4] The alternative to a Valued workforce is an Invalid workforce. [1] Lydall GJ, Malik A, Bhugra D. Mental health of MMC applicants. BMJ Rapid Response 20 June 2007. [2] Caan W. Re: Distinguished women doctors - is fame detrimental to your health? BMJ Rapid Response 6 March 2007. [3] Caan W, Stanley N, Manthorpe J. Depression and persistent effects on work: an ‘expert patient’ survey of 500 social workers. Journal of Public Mental Health 2006; 5 (4): 38-44. [4] Friedli L. Promoting public mental health: a critical analysis. FPH 2006: accessed on 21/07/07 at http://www.fphm.org/policy_communication/downloads/events/faculty_events/2006/ASMpresentations2006/A_friedli.pdf Competing interests: None declared |
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Oliver R Dearlove, Consultant Anaesthetist Royal Manchester Children's Hospital M27 4HA
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Editorial sitting on one’s butt. I can only agree with Mr Twine’s opinion (above) that the BMJ editorial staff have been apathetic to the point of unconsciousness when it comes to MTAS. As Tony Delamothe comments, ‘Dr Twine’s survey is far from complete…’ and indeed it is. So is Tony Delamothe’s. What they both lack is my contribution. I pointed out the editorialists’ lamentable lack of interest in MTAS and the troubles it was likely to cause in a catchily titled, “Learned helplessness’ (1) piece in early May of this year. This got a muted squawk from Delamothe. Earlier, I had attempted to goad an otherwise complacent editor with a short email unlikely to exhaust the attention of the most uninterested, jaded or otherwise engaged, “Quite a lot happening in MTAS this week for you to ignore, Fiona.” This was ignored, of course, on Mar 7 – I did rather think it would be, on past performance. How true, how true it was for one councillor of a Royal College (me again, I’m afraid), to comment: “There are no knighthoods in medical regulation.” But look on the bright side of this, Reader. In medical regulation there’s always someone to blame, and hey with the standard of proof coming down to balance of probabilities, it could be anyone ! I have waited a month before penning this: totally consistent the BMJ's own response time, I think Oliver Dearlove FRCA COI: All the usual. GMC warning. RCA councillor, not the views of my employer and so on and so on. – not the view of the fearless, outspoken and campaigning BMJ either, I suppose. 1. Learned helplessness http://www.bmj.com/cgi/eletters/334/7598/834#164978 Competing interests: as script |
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