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Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

All rapid responses

Displaying 1-10 out of 95227 published

Re: Minority report: how the UK’s treatment of foreign and ethnic minority doctors needs to change. Tom Moberly. 348:doi:10.1136/bmj.g2838

Few have dared to raise the possibility of differences in patient-centred consulting skills in ethnic minorities or foreign doctors throughout this row on discrimination in general practice. Researchers seem to have taken into account race, ethnicity, language, international graduation and clinical skills but have they considered patient-centred consultation skills in foreign or ethnic minority doctors?

Patient-centred care is a cornerstone of UK general practice. GP trainees passing the RCGP CSA exams have to demonstrate patient-centred consultation skills which include open communication, mutual decision making, understanding, trust and respect. It is the ability of a doctor to manage patients holistically. It is simply not enough to have the clinical ability to able to be able to treat a disease, UK GPs need to incorporate the patients’ illness experience. As an ethnic minority doctor myself who has recently sat the CSA exam, I believe that the ability of a doctor to consult in this manner is influenced by medical training, country of origin, culture and experiences. Doctors trained abroad in countries where a paternalistic model of medicine is the norm may therefore struggle with patient-centredness. Similarly, culture and experience can influence doctor-patient interactions towards more doctor-centred consultation. With this in mind, foreign doctors may struggle with assessment such as the CSA which takes patient-centred consultation skills into account.

Remove race, ethnicity and country of graduation as the only cause of these differences. Instead, measure a doctors’ ability to consult in a patient-centred manner and I wonder if we will find differences between foreign or ethnic minority doctors? There are many patient-centred care measures that have been validated and widely used in general practice.[1,2] Why don’t we utilise these more widely in research to better understand the cause of this issue, and whether patient-centred care consultation skills in foreign doctors or ethnic minorities is contributing to failure of exams. If this is indeed the case, it will help us to understand the problem a bit more and focus our training, support and changes accordingly.

1 Hudon C, Fortin M, Haggerty JL, et al. Measuring patients’ perceptions of patient-centered care: a systematic review of tools for family medicine. Ann Fam Med;9:155–64. doi:10.1370/afm.1226

2 Mercer SW, Maxwell M, Heaney D, et al. The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract 2004;21:699–705. doi:10.1093/fampra/cmh621

Competing interests: None declared

Hajira Dambha, Academic Clinical Fellow in Primary Care

University of Cambridge, Department of Public Health and Primary Care, University Forvie Site, Robinson Way, Cambridge, CB2 2SR

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Re: Targets for dementia diagnoses will lead to overdiagnosis. Martin Brunet. 348:doi:10.1136/bmj.g2224

I have read the Personal View of Dr Brunet and all the responses so far (24 April).

Dr Brunet makes complete sense.

Professor Burns, Mr Hughes, Ms Rasmussen leave me with the following thoughts.

1. Prof Burns and colleagues should spend their existing time and existing resources on a) treating, b) caring for those patients who are already known to their organisations.

2. Please do NOT look for hitherto unknown "cases" if you are not able to care for and treat the known patients.

3. If you engage in screening when you are unable to adequately care for and treat the known cases, then your screening is an immoral, unethical activity.

Thank you, Dr Brunet, for trying to awaken a slumbering public.

Competing interests: Aged

JK Anand, Retired doctor

Free spirit, Peterborough

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Re: Expert views: what the next Indian government should do for health and healthcare. Jeetha D’Silva. 348:doi:10.1136/bmj.g2479

Good drinking water, sanitation and shelter still hold the key in providing primary care to the needy and poor. India has excellent facilities in health care from primary to tertiary care. The corporate sectors have made hightech care reachable to all sections of the population. Certain government institutions provide the best care to patients in need. Therefore the government policy must be directed towards community health care, particularly preventive care. Still we need to concentrate on combating mosquito transmitted diseases, parasitic infections and malnutrition.

India is a huge country with a large population. The Indian government therefore must have an imaginative but practical approach in providing health care to all segments of the population.

Competing interests: None declared

Dhastagir Sheriff, Professor

Faculty of Medicine, Benghazi University, Benghazi

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Re: PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study. I C McManus, Richard Wakeford. 348:doi:10.1136/bmj.g2621

Could Dr McManus/ BMJ kindly give us the actual median MRCP Prt1/ Part2 MRCGP Part1 marks of UK and PLAB graduates.

Dr Ramkumar Unnipillai

Competing interests: None declared

RAMKUMAR UNNIPILLAI, emergency doctor

QEQM hospital, Flat 128 , QEQM hospital

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Re: Influence of blood prostate specific antigen levels at age 60 on benefits and harms of prostate cancer screening: population based cohort study. Sigrid Carlsson, Melissa Assel, Daniel Sjoberg, David Ulmert, Jonas Hugosson, et al. 348:doi:10.1136/bmj.g2296

In this article, the authors concluded that continuing to screen men with PSA levels >2 ng/mL at age 60 is beneficial for reduction in prostate cancer mortality (percentage of the case in this study population was 28%). In addition, no further screening is recommended for men with a PSA level <1 ng/mL at age 60 (percentage of the case in this study population was not clear). All subjects who underwent annual health examinations at Health Evaluation and Promotion Center, Tokai University Hachioji Hospital are subjected to measure PSA level. In our facility, the average PSA was 1.47 ng/dL for men aged 60 (n=1,729); 869 subjects (50%) had a PSA level <1 ng/dL, 530 subjects (31%) had a level equal to or more than 1 ng/dL but less than 2 ng/dL, and 330 subjects (19%) had ≥2 ng/mL.

According to the same criteria for classification in this study, 19% subjects, which was 9 points less than that of this study, needed to be screened every year, while 50% subjects may not need further screening in our facility. However, further study will be necessary if this is the case, since the percentage of subjects with a PSA level ≥2 ng/mL varied and it is a possibility that this cutoff value may not be suitable for Japanese subjects.

The Japan Society of Ningen Dock has been constructing a database for one million five hundred thousand Japanese subjects and we are going to verify whether this is the case.

Competing interests: None declared

Eiko Takahashi, Physician

Kengo Moriyama

Department of Clinical Health Science, 1838 Ishikawa-machi, Hachioji, Tokyo 192-0032, Japan

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Re: The role of NHS gatekeeping in delayed diagnosis. Nigel Hawkes. 348:doi:10.1136/bmj.g2633

The positive and negative predictive values of any clinical test are influenced by the prevalence of the disease in the population being tested. As the prevalence of the disease falls, so does the predictive value of the test. It is this fundamental pre clinical statistical concept that reduces Hawkes’ argument to rhetoric.

Faced with the morass of undifferentiated pathology that the absence of gatekeeping would allow, the Wizard’s diagnostic acumen would wither and become no more accurate than that of the gatekeepers themselves. The Wizard’s diagnostic skills are a direct function of the highly selected population that he consults.

Specialist doctors are a precious resource in every society worldwide. No society can possibly allow its citizens universal unrestricted access to specialists. Gatekeeping in some form or another is an inevitability. Hawkes recommends not the abolition of gatekeeping but simply a gate which would allow the articulate and privileged (himself amongst them) through first. This is morally wrong. Even more astounding is the naïve belief that turning up in an emergency department allows immediate access to specialist care.

The case of Jake McCarthy is tragic, but the harms of overdiagnosis and overinvestigation although less dramatic are no less tragic and almost certainly much more common. I will wait in the vain hope that one day The Sunday Times will publish an article about the anguish and distress caused to a patient diagnosed with an incidental and harmless anomaly identified by an un-necessary MRI scan entitled “if only I hadn’t had that scan”. It is these harms which good gatekeeping can prevent.

The solution to delayed diagnoses lie not with the abolition of a gatekeeper role, but with a well trained, resourced and accessible gatekeeper who retains the ability to refer and investigate appropriately.

Competing interests: None declared

Daniel Toeg, General Practitioner

Camden CCG, Caversham Group Practice. London NW5 2UP

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Re: Should doctors prescribe cannabinoids?. Michael Farrell, Rachelle Buchbinder, Wayne Hall. 348:doi:10.1136/bmj.g2737

Marijuana and hashish are addictive hallucinogens that trick and trap us by creating the fleeting euphoria of knowledge and wisdom, but the sustained sickness of confusion and paranoia. The euphoria of knowledge and wisdom, and the sickness of confusion and paranoia, are polar opposites that reinforce each other: the euphoria blinds us to the sickness, and the sickness makes us crave the euphoria. Perversely but predictably, marijuana and hashish create, aggravate, and perpetuate the very sickness of confusion and paranoia that they falsely seem to cure, thus placing all hallucinogens in a very bad light.


Competing interests: None declared

Hugh Mann, Physician

Retired, Eagle Rock, MO, USA

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24 April 2014

Re: Fed up with forms. Margaret McCartney. 348:doi:10.1136/bmj.g2519

The puzzle is why on earth an intelligent and caring profession has allowed all this to happen. I have just retired as a GP and an Appraiser and all around arè disgruntled doctors. But the irony is that it is not politicians or managers that are at fault. It is our own colleagues who have introduced and forced upon us this paper chase. Why don't we just say No?

Competing interests: None declared

Robert D Walker, Retired GP

None, Workington, Cumbria CA14 1TS

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Re: Does it work to pay people to live healthier lives?. Sarah Strickland. 348:doi:10.1136/bmj.g2458

Universal provision of primary health care is the prime duty of every national Government. Over the years, the Indian Government has also made efforts to realize this dream. However, it is observed that Government spending on health care in most low- and middle-income countries is much lower than need. Analysis by Stenberg et al (1) suggested that low-income countries need to spend $54 per capita for basic health care services, whereas the average actual per capita health expenditure in these countries is only $27. While some countries such as Thailand and some Latin American countries have made considerable efforts and had success in achieving universal health coverage, others such as China and Vietnam are focusing on improving access. As per the World Health Organization's (WHO) World Health Statistics, 2007(2), public health spending by India was about $29 and India ranked 184 out of 191 countries. This was about one third that of Sri Lanka, 14% that of Thailand, etc. (3)

Public health spending in India remained at about 1.2% of GDP. This is much lower than the 6% recommended by the World Health Organization for public spending on medical, public health, and family welfare. In 2007, private spending in India on health was 74% of the total health spending, which is in contrast to 18% in the United Kingdom (3). In 2008–09, the level of public spending on health in Bihar was the lowest in the country, and it was less than half the level in Kerala and Tamilnadu, which are top in terms of health spending.

The government of India has initiated a series of reforms including changes in the health care delivery system. The prominent and ambitious flagships have been the launching of the National Rural Health Mission (NRHM) in 2005 and the introduction of Rashtriya Swastya Bima Yojana (RSBY), a national health insurance scheme for people below the poverty line. Some states have not accepted RSBY but have initiated similar health insurance schemes in their own ways--e.g. Andhra Pradesh has launched Aarogyasri and Karnataka has implemented Vajpayee Aarogyasri.

NRHM has promised universal health care for the population residing in rural areas. The central funding was 30% for the first two years of implementation followed by 40% until 2012. The states supposedly were to contribute 15% of the central Government allocations or increase by 10% in the health budgets every year during 2007 to 2012. For smooth fund transfer state health societies have been formed bypassing the state budgets. However, due to fiscal deficits the increase in public health expenditures couldn’t be met.

The provision under the national health insurance scheme, RSBY again, is an ambitious programme of the Government of India. This scheme is for the people living below the poverty line and it covers health expenditures for hospitalization and daycare procedures with a provision to cover up to a maximum of Rs.30,000 ($ 500 approximately) per annum. The scheme is valid for treatment in certain select hospitals, for a family up to five members on a floater basis. There is a provision of Rs.1000 ($17) as transportation allowance, with a maximum of Rs.100 per visit under this scheme. Insurance companies have been roped in to provide the facilities. Eligible families are provided smart cards by the insurance companies and the treatment in select health centres is cashless using the card. The family has to pay a nominal premium of Rs.750 ($13) per annum for availing the health insurance, and this is shared by the Central Government and State Government in the ratio 75:25. The share increased to 90% in northeastern states and Jammu and Kashmir. The additional cost of Rs.60 ($1) is borne by Central Government. The family only needs to contribute Rs.30 ($0.5) per annum as a registration fee. While the scheme has been gradually implemented all over India, the actual utilization has been under speculation at present.

Do these schemes - NRHM, RSBY - actually change the face of health financing in India? We are still yet to see the results.

References

1. Stenberg K, Elovainio R, Chisholm D, Fuhr D, Perucic AM, Rekve D et al. Responding to the Challenge of Resource Moibilization Mechanisms for Raising Additional Domestic Resources for Health,Background Paper No. 13,Geneva, World Health Organization, 2010.

2. World Health Organization. World Health Statistics 2007, Geneva, World Health Organization.

3. World Health Organization. World Health Statistics 2010, Geneva, World Health Organization.

Mongjam Meghachandra Singh
Professor, Department of Community Medicine
Maulana Azad Medical College, New Delhi

Reeta Devi
Assistant Professor
School of Health Sciences,
Indira Gandhi National Open University, New Delhi

Niharika Yedla
Ex-Student,
Sikkim Manipal Institute of Medical Sciences, Gangtok
Sikkim (India).

Competing interests: None declared

Mongjam Meghachandra Singh, Professor

Reeta Devi, Niharika Yedla

Maulana Azad Medical College, New Delhi; co-author- Indira Gandhi National Open University, New Delhi, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India. Co-author : School of Health Sciences, IGNOU, New Delhi (India)

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Re: Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys. Renata Micha, Shahab Khatibzadeh, Peilin Shi, Saman Fahimi, Stephen Lim, et al. 348:doi:10.1136/bmj.g2272

This is the latest in a series of articles in the BMJ [1] [2] [3] (and other health publications) attempting to measure the diets of countries, in order to show associations with diseases or the effects of possible preventive policies, like food taxes.

This is the grandest of the lot, positively heroic in assembling data on individual diets from 113 countries, and breaking new ground by breaking down “fats” into constituent types.

The extended description of their data analysis techniques may bemuse many BMJ readers (and perhaps some BMJ editors too). Surely authors of such statistical sophistication must know what they are talking about?

In fact, this research suffers from the same fundamental flaw as all such studies -– the poor quality of the primary data on food consumption. But the authors are less than fully candid about the causes and consequences of the problem.

While diet surveys vary in their methods, all effectively rely on subjects telling researchers honestly what they eat. But all such “self-report” data suffer from a deficiency that has been known to nutritionists for decades. In the trade, it is called “under-reporting”. In plain English, people lie.

Subjects respond normatively, not truthfully, more in line with the conventions of appropriate eating in their culture. In the West, these days, they claim to eat a healthier diet than they actually do, smaller in volume and a more nutritious mix.

These are not malicious lies. They are the ordinary lies that we all tell every day – putting our best foot forward, showing ourselves in the best possible light.

Nonetheless, they can be large lies. In the UK, for example, which does better diet surveys than most, separate research using a biomarker, “doubly-labelled water”, showed that adults under-report their calorie intakes by 25%,[4] late adolescents by 34%.[5]

In one study of soft drinks, subjects in the National Diet and Nutrition Survey claimed to be drinking barely a quarter of the products that manufacturers reported they were selling.[6]

In the US, a recent review of 39 years of the American national diet survey (NHANES) found that “data on the majority of respondents (67.3% of women and 58.7% of men) were not physiologically plausible”.[7] That is, subjects were claiming to eat less than is necessary to stay alive.

Readers receive no inkling of such problems from this text. The page-and-a-half section on “Methods” describes much subsequent effort, but not the methods used to gather the primary intake information.

They are only mentioned at the bottom of a diagram on the sixteenth page of the article. All consumption figures -- from all 113 countries -– started as various forms of “self-report” data (multiple diet recalls 14%, food frequency questionnaires 31%, single diet recalls 27%, and household availability/budget surveys 29%).

Nor does the word “under-reporting”, or anything like it, appear anywhere in the text. Still less is there any indication of the scale of possible mis-information.

The now conventional way of getting round the problem is to mention the issue briefly in a “Strengths and weaknesses of study” section towards the end of papers. Even that fig leaf does not appear in this article.

This is not just a matter of propriety, but of substance. No secondary data manipulations, no matter how sophisticated, can correct such gross flaws in the primary data.

The consequence is that the numbers presented here for fat consumption are not credible. With the current limitations of diet surveys, no one knows the true consumption of fats, but these estimates are almost certainly wrong.

The authors conclude by saying that they plan to continue the work. Before they do so, they might consider the recent advice of 17 obesity experts on the same problem in measuring calorie consumption (energy intake/EI).[8]

“Going forward, we should accept that self-reported (energy intake) is fatally flawed and we should stop publishing inaccurate and misleading (energy intake) data”.

1 Te Morenga L, Mallard S, Mann J (2012), Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies, BMJ; 345:e7492.

2 Briggs A, Mytton O, Kehlbacher A, Tiffin R, Rayner M, Scarborough P (2013), Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study, BMJ; 347:f6189.

3 Basu S, Babiarz K, Ebrahim S, Vellakkal S, Stuckler D, Goldhaber-Fiebert J (2013), Palm oil taxes and cardiovascular disease mortality in India: economic-epidemiologic model, BMJ; 347:f6048.

4 Rennie K, Coward A, Jebb S (2007), Estimating under-reporting of energy intake in dietary surveys using an individualised method, British Journal of Nutrition, 97, 1169–1176.

5 Rennie K, Jebb S, Wright A, Coward W (2005), Secular trends in under-reporting in young people, British Journal of Nutrition, 93, 241–247.

6 Briggs et al, op cit.

7 Archer E, Hand G, Blair S (2013), Validity of U.S. Nutritional Surveillance: National Health and Nutrition Examination Survey Caloric Energy Intake Data, 1971–2010, PLOS ONE, 1 October, Volume 8 | Issue 10 | e76632.

8 Schoeller D, Thomas D, Archer E, Heymsfield S, Blair S, Goran M, Hill J, Atkinson R, Corkey B, Foreyt J, Dhurandhar N, Kral J, Hall K, Hansen B, Lilienthal Heitmann B, Ravussin E, Allison D (2013), Self-report–based estimates of energy intake offer an inadequate basis for scientific conclusions, Am J Clin Nutr 2013 97: 1413-1415.

Competing interests: None declared

Jack T Winkler, Professor of Nutrition Policy

formerly London Metropolitan University, 28 St Paul Street

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