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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 95229 published

Re: The “Saatchi bill” will allow responsible innovation in treatment. Michael D Rawlins. 348:doi:10.1136/bmj.g2771

It has been drawn to my attention, since responding to the criticisms of my paper, that Lord Woolf - the former Master of the Rolls and Lord Chief Justice - has an article published in today's (24th April) Daily Telegraph explaining his reasons for supporting the Saatchi Bill. As my learned friends would say, "I rest my case".

Michael Rawlins

Competing interests: None declared

Michael Rawlins, Physician

Royal Society of Medicine, 1 Wimpole Street, London WC1G 0AE

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Re: The “Saatchi bill” will allow responsible innovation in treatment. Michael D Rawlins. 348:doi:10.1136/bmj.g2771

The rapid responses from several lawyers, claiming that the provisions of the Saatchi Bill are unnecessary, underpin its relevance and importance. Other lawyers who have been consulted by Lord Saatchi take a very different view. The Saatchi Bill would therefore at least clarify the legal position for doctors, NHS Trusts and - pace the legal profession - lawyers.

The Bill would not in any way discourage clinical research and I, of all people, would not be lending it my support if it did so. Indeed, Section 2 (8b) states: "Nothing in this Section permits a doctor to carry out treatment for the purposes of reserach or for any purpose other than the patient's best interests".

As far as the point made by my old friends Lester Ferkins and Iain Chalmers, I despair! They take me to task for failing to call for "publicly available documentation" of the effects of intervening in the manner described in the Bill. They seem to have failed to notice that I made this point in the last paragraph of my paper!

Michael Rawlins

Competing interests: None declared

Michael Rawlins, Physician

Royal Society of Medicine, 1 Wimpole Street London WC1G 0AE

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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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