Editor's Choice

No quick fixes

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4135 (Published 30 July 2015) Cite this as: BMJ 2015;351:h4135
  1. Elizabeth Loder, acting head of research, The BMJ
  1. eloder{at}bmj.com

Three recent research papers in The BMJ have looked at common problems for which there are no easy solutions: falls among elderly people, pelvic organ prolapse, and lapses in handwashing among healthcare workers. The good news is that some progress has been made on each of these fronts. The bad news is that progress is slow, and there are no quick fixes.

A two year programme of balance training reduced the number of injurious falls in older women, but the relative improvement came at the cost of some severe adverse events, which paradoxically included three falls that occurred before or after the exercise sessions, found Fabienne El-Khoury and colleagues (doi:10.1136/bmj.h3830).

The standard treatment for uterine prolapse is hysterectomy with suspension of the uterosacral ligaments, but uterine preservation is gaining popularity. A randomised controlled trial by Renée Detollenaere and colleagues shows that uterus preserving vaginal sacrospinous hysteropexy is not inferior to vaginal hysterectomy, at least as judged by recurrent prolapse within 12 months leading to bothersome symptoms or repeat surgery (doi:10.1136/bmj.h3717). This is encouraging news, but enthusiasm should be tempered by the fact that surgical failure rates were still quite high in both groups.

Improvement is also hard won when it comes to getting healthcare workers to clean their hands. Nantasit Luangasanatip and colleagues found that the “WHO-5” procedures of “system change, training and education, observation and feedback, reminders in the hospital, and a hospital safety climate” did improve rates of hand hygiene (doi:10.1136/bmj.h3728). Nevertheless, our editorialist Matthew Muller observes that “there is still work to be done designing interventions that are better” (doi:10.1136/bmj.h3931).

Layla McCay asks why we continue to rely on rational arguments when appeals to emotion might be more effective (doi:10.1136/bmj.h3968). She cites the SuperAmma study in rural India (doi:10.1016/S2214-109X(13)70160-8), which showed that manipulation of “emotional motivators” such as disgust about contaminated hands produced lasting improvements in handwashing behaviour that exceeded those achieved by studies that provided education about the “rational benefits” of handwashing.

No one need remind England’s health secretary, Jeremy Hunt, about the power of emotional motivators. The backlash to his plan for a seven day NHS is a good illustration of McCay’s point (doi:10.1136/bmj.h4101). The doctors who flocked to social media to protest were clearly motivated by anger: “Mr Hunt harms us by painting us as overpaid, under-worked, Ferrari-driving, golf-playing part-timers,” wrote one in the Guardian (http://bit.ly/1Mwfaaa). But editorialist Mark Newbold suggests that UK doctors need to move away from the fundamentally “negative and uninspiring” position of denunciation (doi:10.1136/bmj.h4082). A lack of clear, unified leadership that could “articulate a positive vision” instead of the “damaging public debate” that is taking place is preventing progress, says Newbold.

There is nothing like a good fight to convince people to make common cause, and sometimes allies are found in the unlikeliest places. It never occurred to me that investment managers might have an interest in clinical trial transparency, but so they do, a news story tells us this week (doi:10.1136/bmj.h4002). A spokeswoman for the financial services company BNP Paribas said that complete and accurate information about trial results was needed to make fully informed investment decisions. A group of money managers will meet with drug companies and encourage them to embrace the clinical trial transparency initiatives of the AllTrials campaign (alltrials.net).

There has been no quick fix to the stubborn problem of selective and misreporting of clinical trials. Yet where rational arguments for full disclosure of clinical trials have failed, this approach just might succeed. Money talks, and it is arguably the most powerful emotional motivator of all.

Notes

Cite this as: BMJ 2015;351:h4135

Footnotes

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