Personal feelings and medical journals
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7440.0-g (Published 11 March 2004) Cite this as: BMJ 2004;328:0-g
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Dear Editor,
Your emotional "Editor's Choice" brought to mind the following saying of
Oscar Wilde (1854-1900): “The old believe everything, Middle age suspects
everything, The young know everything."
Surprisingly, most of what we do to the dying patients in the last
few days(few hours) in the terminal care units has never been audited
using controls or placebo! The Swan-Ganz catheter is a good example. The
uncritical critical care is, probably, consuming most of the medical care
budget of advanced countries.
Thank God, the only thing that the poor in this world get as free
bonus is peaceful death even though, in life, they are at the receiving
end of every single malady that man is heir to. The poor pay for their
poverty with their lives, but thankfully, they die in peace without having
to undergo the torture of untested interventions of no proven value.
It is not surprising that the death rate fell down significantly when
doctors went on strike in Israel a couple of years ago! The divine
interventionalists better keep this in mind.
Yours ever,
bmhegde
Competing interests:
None declared
Competing interests: No competing interests
Perhaps I could make a small suggestion for one way in which the BMJ
could do a better job of promoting the 'online first' facility to readers.
At the moment, the link to online first articles on the BMJ website's
home page is a rather subtle one near the bottom of the page. On my
computer screen, it is off the bottom of the screen and I have to scroll
down to see it. Perhaps if the link were moved to the big blue box of
links in the middle of the screen more readers would be aware of the
facility, assuming they visit the website in the first place.
Competing interests:
None declared
Competing interests: No competing interests
Michael O'Donnell was not alone in wondering where the paper on
acupuncture had appeared. Another friend--highly sceptical of the claims
made in the newspapers--kept turning the pages of last week's paper
edition of the BMJ convinced that the study must be there somewhere.
But it wasn't. The paper was published online yesterday--as one of
our "Online firsts." We are close to publishing all of our original
research online first. The paper will not appear in the paper journal for
a couple of weeks.
We clearly need to do a better job of promoting this new facility to
both readers and the media.
Richard Smith
Editor, BMJ
Competing interests:
I'm the editor of the BMJ and accountable for all it contains online and off.
Competing interests: No competing interests
Yesterday, Monday 15 March, The Independent newspaper published a
full-page article claiming that “the biggest trial of acupuncture outside
China … is published today in the British Medical Journal.”
The results were “strong enough” we were told, “for researchers from
the Royal Homeopathic Hospital in London, who helped to organise the
trial, to urge the NHS to consider an immediate expansion of acupuncture
services paid for by the taxpayer.”
The study, as The Independent describes it, involved 401 patients and
was not “blinded”.
Dear editor, I have scoured the contents page of this issue,
published not yesterday, as The Independent claimed, but on March 13, and
found no such report.
Maybe you are planning to publish such a study in which case your
publication has been pre-empted by a “leak” in a less critical medium.
Could this strange episode be in any way related to the imminent
publication of the German mega-trials of acupuncture, involving some
500,000 patients?
These studies were partially “blinded” in that patients were randomly
allocated to groups treated with “real” acupuncture or “sham” acupuncture
(needles stuck into non-official acupuncture points.)
Preliminary results are said to show that, though sham and real
acupuncture both achieved better results than standard medical care, the
results with both were much the same.
If these preliminary findings are substantiated, those of us of
scientific bent - as opposed to homeopaths - are likely to conclude that
the placebo effect of having needles stuck into you with impressive
ceremony is much the same whether they be stuck into sites defined by
ancient Chinese texts or sites chosen at random.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor
Writing condolence letters is probably the most difficult writing one
can undertake. We fall back, aware of the difficulty, it is easier to
avoid. It is so easy to get it wrong. I don’t just mean by patronizing,
but there is something worse, a fear of being presumptuous, of trespassing
upon memories which are personal, private and in which people are entitled
to their own opinion. Never is one’s own memory more properly inviolate
than when death has taken someone we love. Memory is what we retain of the
person who is gone. We want to share our memories, we don’t want to have
them invaded.
But I want to say Richard that I am sorry to hear that your Dad has
died and I do appreciate the honour you have paid us in sharing the
experience with the people who read what you want to tell them. I didn’t
know your Dad and I can’t interpret him. I can only appreciate him. In the
intangible gifts that pass from parent to child, you obviously apprehended
spirit and guts as your weapons of choice. You built and defended
something rare and remarkable, a democratic forum. Some of the most
important conversations of our time have come to life in the forum you
have built. Thank you for your Dad’s life and what he brought. Thank you
Richard for allowing freedom to happen.
Regards
Competing interests:
Not a single clinical trial on liberty or immortality!
Competing interests: No competing interests
Dear Sir,
Richard Smith's continuing comments on present situation is
stimulating and thought provoking.
To my surprise, many diagnostics are done at modern health care
trusts to solace patients and relatives before informing futile outcomes.
Investigations are repeated for answering questions rather than unwinding
clinical vignette. Consultants and junior staff calculate how many
investigations are not ordered rather than what constructive they have
done from already available investigations.
Modern day medical practise revolve around pleasing patients and more
than that saving our skins. As such, inquisitive relatives are hard to
confront, unless we have whole range of specialist opinions and
sophisticated results. I believe, patients not only require correct
information about their illness, but at the same time require day to day
progress and our primary impression of their condition and future. Most
end of life decisions are made when already more than enough had been done
for the patients. We somehow believe that, if patients and their relatives
see for themselves that so much is being done they can satisfy themselves
and perhaps not litigate us.
How much we should do and how far one can go in treatment of chronic
incurable disease is a very difficult issue to address. What to tell, when
to tell and how much at a time, are difficult issues for doctors to
decide. Our attitudes are shaped by the initial experiences we have in
hospitals and they are very difficult to change. Timely decisions direct
resources effectively and reduce sufferings.
I am appreciating the change in doctors’ attitude towards tackling
difficult patients. We want to do so much for the patients in spite of
knowing its outcome, as we believe more futile attempts to salvage the
situation push an individual to accept final jolt. This might prepare them
for eventuality. We talk death when we have to and when it is seemingly
visible. I do not wish to comment on this situation but I am afraid of
loosing my primary duty of doing no harm and always doing benefit to my
patients.
Purist argue that additional investigation just to answer their
questions even when overall diagnosis is evident, still go along with the
notion of doing no harm. I disagree with this thinking. Being a patient, I
would like to be told everything by my doctors promptly rather than
waiting for a scan report or MRI. Even when we defer such conversation,
considering that we want to give them full details, we fail to realise
that patients are dying in apprehension and uncertainty till reports are
available.
Information without investigations can not be accurate and clinical
impressions are not unequivocally perfect. When these facts are told to
patients they can accept any change in their diagnosis and prognosis with
relative ease. Unnecessary pressures are being put for prompt, accurate
information & present day situation is a natural defence reaction of
the system.
Most patients walking out of their first out patients’ consultation
lack adequate information. In a bid to provide more information to our
patients, it is provided very late. Most investigations are still done to
answer irrational questions by difficult accusive relatives rather than to
treat.
Ruchir Trivedi
Competing interests:
None declared
Competing interests: No competing interests
Dear Richard,
As usual I enjoyed reading your Editor's Choice this week but why do
you use 'percentage' when 'proportion' is more appropriate. "The
percentage of patients who saw 10 or more doctors varied from 17% to 59%"
surely reads better as "The proportion of patients who saw 10 or more
doctors varied from 17% to 59%". After all 'percentage' is a specific form
of 'proportion'.
Yours sincerely,
Peter Pharoah
Competing interests:
None declared
Competing interests: No competing interests
Re: Re: Original papers are now published online first
Dear Editor
I write with regard to the final report of the Independent Review of Paediatric Neurology Services in Leicester. Richard Smith, editor of BMJ, wrote advising me that the BMJ editorial team by accident did not cover the release of that report- it got missed. Mr Smith invited me to send a rapid response on the subject. Accordingly, I submit this statement.
The report of the Independent Review of Paediatric Neurology Services in Leicester was presented to the public in October 2003. It sets out an account of how the situation at the University Hospitals of Leicester NHS Trust consequent to the high rates of misdiagnosis of childhood epilepsy made by Dr Andrew Holton had been allowed to develop. The Review, commissioned by Professor Lindsey Davies, the Regional Director of Public Health for the Trent Region, and having the status of a statutory Private Inquiry under Section 2 of the NHS Act 1977, took 18 months to complete.
The Review Panel's key conclusion was that "insufficient weight was attached to the accumulation of concerns about Dr Holton's practice" and that "the response of the Leicester Royal Infirmary NHS Trust and the University Hospitals of Leicester NHS Trust to the issues and concerns raised by the clinical practice of Dr Holton could, and should, have been more decisive at an earlier stage." The Panel concluded that a move to external review of Dr Holton's clinical practice should have been pursued with vigour by May 2000; a decision taken in Leicester Royal Infirmary in the autumn of 2000 not to proceed to external review was, in the Panel's view, a serious error of judgement.
One significant aspect of the way by which concerns emerged around Dr Holton's practice was the role played by local paediatricians who were not employed by Leicester Royal Infirmary, in particular the consultant community paediatricans in Leicester. The Panel was impressed by the clarity with which the consultant community paediatricians identified the issues for consideration, noting that they were increasingly able to form a collective view that strengthened their joint resolve to take decisive action. The Panel concluded that concerns expressed by the consultant community paediatricians were not given the weight they deserved, noting that the fact that the initial concerns around Dr Holton's practice arose from clinicians within the community Trust in Leicester, rather than the acute hospital Trust, appears to have diminished their impact. However, although recognising the role played by clinicians whose employment lay external to Leicester Royal Infirmary, the Independent Review Panel does not comment upon the approach taken by that arm of the NHS which, at the time concerns were emerging around Dr Holton, had responsibilities for external monitoring, for challenging poor performance and for intervening to correct situations in which clinical services were assessed as struggling or failing; namely, NHSE Trent Regional Office.
The Regional Director of Public Health for NHSE Trent had been alerted to the emergence of concerns around Dr Holton in March 2000.(Personal correspondence: letter from Professor Lindsey Davies to Dr M A Edgar, December 22nd, 2003) However, the Independent Review report does not present any account of actions taken by the NHSE Trent Regional Office in the light of that alert during the course of the subsequent 14 months leading up to Dr Holton's suspension in May 2001. Indeed, the Director of Public Health for NHSE Trent is not listed as having been interviewed by the Independent Review Panel.
In this regard, the Panel's report differs in content from the reports of inquiries carried out by the Commission for Health Improvement. The examination of the role played by relevant organisations responsible for external monitoring is a significant component of CHI's systematic investigative approach.
Dr M A Edgar
Formerly, Medical Director of Leicestershire and Rutland Healthcare NHS Trust
Competing interests:
None declared
Competing interests: No competing interests