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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 95129 published

16 April 2014

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

During my limited experience as a junior doctor, I have often found myself asking the exact same question Dr. McCartney asks; "where's the joy in medicine?". I was once informed that it could possibly be found somewhere in amongst the virtual piles of online bureaucracy. Maybe it lay beneath that fourth 360˚ appraisal or possibly between the sixth mini-cex and twelfth reflective practice entry? I spent month after month searching, yet to no avail.

Until recently that is. Now, as a junior doctor currently "out-of-training" on the other side of the world in New Zealand, I am reveling in the joy of medicine. Because now I have the opportunity to learn for learning's sake, rather than learn purely to prove to the powers that be, that I am indeed learning.

I no longer waste precious time chasing people to fill out online assessments, which invariably deem me to be simply "average", because to write that I am above average would require my assessor to complete even more boxes with a justification for their assessment. Conversely, to be simply "average" requires no further justification. I no longer spend evenings working half-heartedly on my e-portfolio, whilst the TV lingers on in the background.

Now I am free to read up on my patients' conditions, simply because I wish to update my knowledge, liberated from any ulterior motive. On quiet days on the ward, I am able to observe endoscopy or help assess patients in clinic. I often follow the echo technician to learn ultrasound skills. I am free to badger the radiologists with burning questions about scans I cannot fully interpret alone.

Yet when I return to the UK for further training, I will be forced to forgo a wide range of learning opportunities to ensure that I complete the desired numbers of tick-box competencies (which by no means would deem me competent in any such skill). I will continue to chase down my assessors to fill out yet another online form and collect the required number of certificates to prove that I am indeed training the way the leadership expects me to train. I can only hope that there will be times, in between the monotony of the tick-box exercises that will form the basis of my training, to re-discover moments of joy that will remind me of exactly why I chose a career in medicine.

Competing interests: None declared

Prashant Kumar, Senior House Officer

Timaru Hospital, Queen St, Timaru, 7910, New Zealand

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Re: NHS sight tests include unevaluated screening examinations that lead to waste. Michael Clarke. 348:doi:10.1136/bmj.g2084

The privatisation of the Ophthalmological services in now inevitable, certainly in Wales several hospitals will be reduced to procedure carrying outposts with most ophthalmic care being provided in the settings of high street optometry.

The senior and influential Ophthalmologists have signed up to this enthusiastically by promoting various pathways devised via FOO (focus on ophthalmology) programme that in fact has resulted in fragmentation of ophthalmology, and devalues Eye Units in DGHs.

What is most worrying is that the present day trainee in ophthalmology is not getting adequate opportunities to diagnose and treat various eye conditions. Either opticians manage conditions themselves or refer to Consultants, thus bypassing junior trainees.

It is not inconceivable that the next generation of Ophthalmologists will be seeking expert opinion from the high street opticians.

Such is the nature of change!

Competing interests: None declared

Nikhil C Kaushik, Consultant Ophthalmologist

BCUHB, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham LL13 7TD

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Re: No evidence exists that “anti-dementia” drugs modify disease or improve outcome. Peter J Gordon. 348:doi:10.1136/bmj.g2607

I thank Assistant Professor Tripathi and Dr Kumar for their reply. (1) I do prescribe the “anti-dementia” drugs, explaining to my patients that this is because they may produce mild symptomatic improvements in the short term. We may argue about definitions, but to me this is not “improving outcomes”.

After judicial review in 2010 it was confirmed that National Institute for Health and Care Excellence (NICE) “was not irrational in concluding that there is no cumulative benefit to patients after 6 months treatment with these drugs”. (2)

The Alzheimer’s Society has much more recently stated through its Dementia Ambassador Fiona Phillips that “current treatments only help with symptoms for a short while”. (3)

The point of my letter was to highlight the difference between what evidence shows and what the “prevailing view” can be and also how this can shift in a short period of time.

References:

(1) Tripathi, S & Kumar, A. “Anti-dementia” drugs improve the outcome. 15 July 2014. http://www.bmj.com/content/348/bmj.g2607/rr/694590

(2) Outcome of judicial review for NICE guidance on drugs for Alzheimer's disease. 24 June 2010. http://www.nice.org.uk/newsroom/features/outcomeofjr.jsp

(3) Alzheimer Society film: Dementia Ambassador, Fiona Phillips. 14 Jan 2014 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=...

Competing interests: None declared

Peter, J Gordon, Psychiatrist for Older adults

NHS, Forth Valley

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Re: Climate change is a health emergency. Fiona Godlee. 348:doi:10.1136/bmj.g2546

Relieved to read at last both your editorial and also Eric Chivian's analysis. Climate change is not new news - I was member of Doctors and Overpopulation Group as a student in the 1970s, for instance. I cannot agree more that doctors and nurses must do more to alert 'the world' to the catastrophe that is creeping up on us: they must also act !! Today's climate change IS manmade - we are liquidating the world's resources into a vast damaging plume of CO2, methane and heaven knows what else, acidifying the seas and covering the land with concrete.

Whilst this is going on at breakneck speed we are also reproducing with unprecedented success, so much so that earnest attempts to change to less damaging life styles are swamped by human numbers increasing exponentially. The US Census bureau points out that human population has grown by 5 billion to 7 billion in the last 75 years and predicts that world population will still be growing by 40m by 2050.

The United Nations states that over one billion people are suffering from hunger, and that by 2015 two thirds of the world will be 'water stressed'.

Here's my point - we know how to control human fertility but it is not happening enough. Even in the UK 40% of conceptions are unplanned and 30% unwanted - the same figures can be applied to almost all countries. The UN knows 200 million women have unmet contraceptive needs. This is biological folly on a huge scale. More and more people only able to consume less and less as we continue to plunder our finite planet!! - that will end very nastily. We should be shouting from the roof tops - but is this vital and core aspect of climate change mentioned by the BMJ or almost any other reputable journal - NO! Not only is it the worst possible start in life to be at best unplanned and at worst actually unwanted - we have countless opportunities to help parents avoid that scenario, but on the topic of survival of our species, positively pushing for better fertility control, a paradigm shift to smaller families, getting this centre stage with society and politicians is vital and must underpin any other attempts to change to a greener lifestyle.

Competing interests: None declared

Penelope A Watson, GP and FP, MSc public health

now retired, previously Lothian Health

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Re: Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. Hermann Brenner, Christian Stock, Michael Hoffmeister. 348:doi:10.1136/bmj.g2467

Brenner et al [1] use the random effects (RE) model for the meta-analysis of the heterogeneous study results. In case of heterogeneity, the RE model produces a wider confidence interval (CI) around the pooled estimate then fixed effects models, such as inverse variance (IV) and Mantel Haenszel.

The wider CI is intended. What is presumably not intended, and not realized by many researchers, is that the RE model achieves the wider CI by tampering with the individual study weights. As heterogeneity increases, the RE model moves from IV weights towards equal weights. Figure 1 shows the relative risk of incidence (any site) of colorectal cancer after colonoscopy (data from Brenner et al). The five observational studies are very heterogeneous (I2=94%), and the RE model assigns each study about 20% weight.

In practice this means that the RE model puts more trust in small studies as heterogeneity increases, up to the point when all studies get virtually the same weight regardless of size. This makes no sense, and there is no justification for this behaviour.

Figure 2 shows the same studies but then meta-analysed with the inverse variance heterogeneity (IVhet) model, implemented in MetaXL (www.epigear.com). Individual study weights are as in the IV model, and vary from less than 10% to almost 47%. Consequently, the pooled estimate is the same as the IV one at 0.22 (against 0.31 for the RE model). But while the IV model produces a CI of [0.18 – 0.27], the IVhet model boosts this to [0.07 – 0.66] (See the MetaXL User Guide for method and evaluation).

A second alternative to the RE model implemented in MetaXL is the quality effects (QE) model. This allows incorporating the results of the risk of bias assessment in the meta-analysis. Using the results from Brenner et al, the QE model produces a pooled estimate of 0.21 [0.12 – 0.36], virtually the same pooled estimate as the IVhet model but with a narrower CI, possible because added information reduces uncertainty.

In conclusion, the RE model is seriously flawed and should be abandoned, and clearly, when meta-analysed properly, screening with colonoscopy is even more beneficial than reported by Brenner et al.

Jan J Barendregt
Suhail A. R. Doi
School of Population Health
University of Queensland
Herston Road, Herston
QLD 4006, Australia
Email: j.barendregt@sph.uq.edu.au

References

1. Brenner H, Stock C, Hoffmeister M. BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2467 (Published 9 April 2014) .

Competing interests: None declared

Jan J Barendregt, Associate Professor

Suhail Doi

University of Queensland, School of Population Health, Herston Rd, Herston, QLD 4006, Australia

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Re: Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. Paul Little, Michael Moore, Jo Kelly, Ian Williamson, Geraldine Leydon, et al. 348:doi:10.1136/bmj.g1606

While the case for reducing unnecessary antibiotics in acute respiratory tract infections including lower respiratory tract infections is indisputable there are nevertheless potential risks,[1].

Firstly all blinded prospective studies conclude that it is impossible to clinically distinguish pneumonia from other lower respiratory tract infections,[2].

Secondly pneumonia can be not only impossible to diagnose clinically but can also be fulminating or rapidly progressive. One study that looked at deaths in adults between the ages of 15 and 44 years found that 95% of those deaths occurred in patients with underlying chronic illness. However, in the 5% who were previously healthy their illness often presented in a non-specific manner and was rapidly progressive with a third dying within 24 hours of hospitalisation,[3].

Thus while it is appropriate to minimise and/or delay antibiotic use in respiratory infections including lower respiratory tract infections in the context of intellectually competent patients in first world communities this may be an unsafe model for third world countries with rudimentary health resources or even in socially disadvantaged communities in general.

Patrick J Bradley

1. Little P, More M, Williamson I, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014;348:g1606.

2. Kelsberg G, Safranek S. How accurate is the clinical diagnosis of pneumonia? J Fam Pract 2003;52(1):63-73.

3. Simpson JCG, Macfarlane JT, Watson J, et al. A national confidential enquiry into community acquired pneumonia deaths in young adults in England and Wales. Thorax 2000;55:1040-45.

Competing interests: None declared

Patrick J Bradley, retired general practitioner

Nil, P.O. Box 5397, Wollongong, NSW 2500, AUSTRALIA

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

I appreciated Martin Brunet's thoughtful comments on potential harms of over-diagnosis of dementia as momentum gathers for earlier diagnosis of same. This momentum is driven at least in part by commercial interests as he notes. In the U.S., for example, three drugs are now approved for the detection of amyloid in the brain, misconstrued by some as as a way to diagnose Alzheimer's disease. The imaging drugs are groundwork themselves for the up and coming drugs designed to disrupt the amyloid cascade. (The hypothesis for which hope and big bucks spring eternal.)

I thought that Dr. Brunet's "scene," of being pressured to diagnose more people with dementia, to get the numbers up for his district or such, was one from some imagined dystopia, some brave new world of medicine (Aldous Huxley was, after all, a Brit, and set his story in London). To diagnose people to hit some bureaucratic target number is indeed, the most concerning aspect of his article. Perhaps it was satire? Perhaps I'm missing some odd bit of British humor here?

In reference to the commentary by Dr. Burns, I expect that "survey after survey" of those with many chronic diseases may find "palpable dissatisfaction with existing services." Everyone would like more services.

Competing interests: None declared

Susan Molchan, Geriatric psychiatrist

N/A, 8723 Ridge Rd., Bethesda, MD, USA 20817

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Re: Patients and nurses are confused by doctors’ titles, survey finds. Zosia Kmietowicz. 348:doi:10.1136/bmj.g1950

What is in a name? The names of people, organisations, brands, etc. ideally need to be very simple, clear and prominent to convey the message they stand for. Unfortunately, this did not happen with respect to job titles of training doctors introduced by Modernising Medical Careers a few years back. Rather it created a lot of confusion amongst health care professionals and patients alike as this study has confirmed. A similar study titled “Junior Doctors Titles following Modernising Medical Careers” published on line by the Journal of the Royal Society of Medicine (2011) revealed similar results. Interestingly, after searching on-line, we find that confusion about job titles is also common in other walks of life, including job titles of nurses.

We would like to make some suggestions that would not only make it easier for nurses to identify and communicate with the required grade of doctor but also eliminate any patient confusion as to what grade of doctor they are interacting with.

• It is quite clear that the current system of job titles needs improving or even replacing with an alternative system

• A survey should be conducted amongst trainee doctors regarding what titles they would like to be addressed by at the various stages of their training. The GMC is going to seek opinions of junior doctors about their future postgraduate training soon and a question of job titles could also be included in that survey. Other organisations, such as the BMA, should also be involved in seeking the opinions of junior and senior doctors regarding this issue.

• One option could be that the old system of terminology could be reinstated with some modification. For example Junior House Officer (HO Year1), Senior House Officer (SHO Year 1, SHO Year 2), Registrar (Registrar Year 1 to 3) and Senior Registrar (SR Year 1 to 3) totalling 8 or 9 years of training as it was before MMC. GP registrars my add year numbers to their titles according to their seniority.

• Another option could be that along with the name of the doctor on the badge the simple term ‘Trainee doctor Year 1 – Year 8/9’ may be added according to the seniority. Everybody would understand the stage of training the doctor is at and this would remove the confusion associated with the prefixes FY/SHO/CT/ST/etc.

• Further opinions should be sought on any other simpler forms of addressing doctors in their training.

Competing interests: None declared

Mohammad Siddiq, Locum Consultant Anaesthetist

Faisal Siddiq, Final year medical student, Birmingham Medical School

University Hospital North Staffordshire, Newcastle Road, Stoke-on-Trent UK ST4 6QG

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Re: Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. Tom Jefferson, Mark Jones, Peter Doshi, Elizabeth A Spencer, Igho Onakpoya, et al. 348:doi:10.1136/bmj.g2545

The BMJ and Cochrane Collaboration have revealed serious generic failings in our system of publishing full trial evidence. The lessons in relation to antiviral drugs and future pandemics still need to be properly debated. Service insights from the last pandemic have been little in evidence in the current debate.

Oseltamivir was considered, even in 2009, to be a drug of hope, of weak benefit if given within 48 hours of symptoms, ‘free of side effects’ and ‘ the best we have got’. The limited evidence base around seasonal flu use was the basis for pandemic planning. But even this was sacrificed by Governments, their Departments of Health and the WHO when their ‘expert committees’ encouraged use of the drug, once the pandemic was declared, in people who may have been ill for a week. This led us into massively expensive over reliance on a drug of marginal, if any, benefit during the 2009/10 H1N1 pandemic.

Apologists for Roche are already mounting a rearguard argument that the Cochrane analysis relates to trials undertaken on seasonal flu, not pandemic flu. But this is a bizarre reinterpretation of history given it was precisely the evidence about seasonal flu trials which was used to determine national policy for pandemic stockpiling. The evidence was extrapolated by Departments of Health and governments, advised by experts, paid for by the industry, that said ‘antiviral distribution may be the best we can do’, ‘we don’t have the evidence for these circumstances but we have to make best guesses’, ‘we have to take action in case it becomes a serious infection’. Like Cochrane, like the ALLTrials campaigners we conclude that there would have been even less justification for use in the pandemic, had the limited evidence for its use in seasonal flu been known from the start.

We remain concerned however, that the insights of service providers on the ground during the pandemic have not been given the same level of public consideration. It is well documented that even drugs which may be effective in clinical trials can be inefficient, or fail to deliver the patient benefit predicted by trial results, when subject to limitations of general service use. The lessons from service insights in the pandemic are: the wanton abandonment of first principles such as isolation, basic control of infection measures and clinical assessment in favour of the stubborn insistence on managing ‘England as a single epidemiological unit’ [1]; and the irrational maintenance of the ‘containment’ phase which led directly to perverse and damaging interventions and over-reliance on antivirals in mass prophylaxis exercises particularly in schools. Anti-viral collection centres became loci for the spread of infection as thousands of symptomatic and sub-clinical cases (there is good evidence that flu can be spread by asymptomatic patients [2, 3]) and unaffected contacts convened for a wonder drug with serious potential side effects [4],and which would now appear to be no more effective in pandemic management than paracetamol [5].

It would be irresponsible for these lessons not to underpin current planning for pandemics and any subsequent responses. We believe there is no place for antiviral distribution in a pandemic based on the current evidence of the effectiveness of the drugs, their ineffectiveness for mass prophylaxis and the likely spread of infection brought about by bringing people to a centre for the drugs.

[1] Chambers J, Barker K, Rouse A. Reflections on the UK’s approach to the 2009 swine flu pandemic: Conflicts between national government and the local management of the public health response. Health Place 2012; (18): 737–745.


[2] Centers for Disease control. Additional Information about Vaccination of Specific Populations. Influenza Prevention and Control Recommendations. Published for the 2010-11 Influenza Season; Adapted for the 2012-13 Influenza Season http://www.cdc.gov/flu/professionals/acip/specificpopulations.htm last accessed 13th April 2014.


[3] Chao D-Y, Cheng K-F, Li T-C, Wu T-N, Chen C-Y, et al. Serological Evidence of Subclinical Transmission of the 2009 Pandemic H1N1 Influenza Virus Outside of Mexico. PLoS ONE 2012; 6(1): e14555. doi:10.1371/journal.pone.0014555

[4] Jefferson T, Jones M, Doshi P, Spencer E, Onakpoya I, Heneghan C. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014; 348:g2545

[5] Tamiflu: Millions wasted on flu drug, claims major report. BBC News. http://www.bbc.co.uk/news/health-26954482. Last accessed 13th April 2014.

Competing interests: None declared

Patrick J Saunders, Professor of Public Health

John Middleton

University of Staffordshire, 444, Quinton Rd West, Birmingham, B32 1QG

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Re: Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. Tom Jefferson, Mark Jones, Peter Doshi, Elizabeth A Spencer, Igho Onakpoya, et al. 348:doi:10.1136/bmj.g2545

In the BNF it clearly states that Oseltamivir is licensed for use in the first 48 hours following the onset of symptoms, and that it is a prescription only medicine.

If Oseltamivir had been effective there is no way that the public could have accessed it rapidly enough.

If people had died in large numbers then there would have been a panic at every GP surgery in the country with the possibility of people dying in the crush.

Even if an effective drug comes on the market it would be useless unless it could be distributed and taken rapidly in accordance with its instructions for use.

Competing interests: None declared

Philip M. Gilbert, Plastic and burns surgeon

Queen Victoria Hospital, East Grinstead, Holtye Road, East Grinstead, RH19 3DZ

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