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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, 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. Letters are indexed in PubMed.

Re: Cosmetic industry regulation is only skin deep Sophie Arie. 357:doi 10.1136/bmj.j3047

I fully support the message conveyed by the article of Sophie Arie. The extent of and magnitude of when things go wrong as a result of the vast array of cosmetic procedures carried out by a diverse group of professionals are not fully captured in quantity and nature . These procedures must be governed by the same rigour of clinical governance as other invasive surgical procedures. This entails the following:
• Professional regulation of the practitioners who carry out such procedures by the relevant regulatory body.
• Oversight including regular inspections by the CQC of such procedures, and where they are undertaken, similar to any other form of care provided to patients and the public.
• Implementing the principles of clinical governance at local level where this form of procedure is provided i.e. addressing rigorously the concepts of patient safety, clinical effectiveness and patient experience.

Competing interests: No competing interests

23 July 2017
Walid Al-Wali
Consultant Medical Microbiologist and former Medical Director (2001-2011).
The Rotherham NHS Foundation Trust.
Moorgate Road,Oakwood,Rotherham,S60 2UD,UK.
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Re: Are millennial GPs shunning full time working? . 357:doi 10.1136/bmj.j3059

I have read the article of Anna Gulland and personal view of Stephen Bradley with interest.
Frankly whether it is doctors of Primary Care or Secondary Care i.e. GPs or consultants the same principles of work-life balance and professional attitude and expectation apply. Doctors are facing increasing demands not only of the clinical workload but also of that of governance and regulation. Doctors are also human beings who are fathers, mothers, sons and daughters in addition they have a life with the right to live and enjoy just like other people and professionals.
The more they are assisted and supported in their workplace and whatever they are asked to do should be of reasonable expectation and not purely dictated by the management rules ,performance figures and targets .Finally and most importantly they must be genuinely appreciated , explicitly valued and effectively rewarded when they deliver a good service. The worst thing that can happen is to have a medical workforce, which central to the delivery of healthcare , and is of low morale (1).

1. Al-Wali W.If NHS staff aren’t cared for they can’t care for patients.Soeffective strategies are are needed to raise staff morale.BMJ 2016;354:i4690.

Competing interests: No competing interests

23 July 2017
Walid Al-Wali
Consultant Medical Microbiologist and former Medical Director (2001-2011)
The Rotherham NHS Foundation Trust
Moorgate Road,Oakwood,Rotherham,S60 2UD,UK.
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5
Re: Management of patients after primary percutaneous coronary intervention for myocardial infarction Fatima Dalal, Hasnain M Dalal, Christos Voukalis, Manish M Gandhi. 358:doi 10.1136/bmj.j3237

1 No mention of gastro protection medication, What drug , what dose and ? stop at 1 year when down to single agent

2 No mention about how long for B Blockers. If no reduced ejection fraction ? stop at one year

3 Most importantly manage data in GP system (at least in UK ) Ensure computer prescription records are updated with new medication and importantly add review/stop date to dual therapy as very easy for these to be continued beyond evidence date

In UK practice up-titration of medication often done by cardiac nursing team and potential problems of GP prescription data not matching what the patient thinks they are taking, compounded by the pharmacy supplying possibly having another different record and requesting the wrong dose for the patient

If not totally clear with a written plan for those on triple therapy with an anticoagulant chase the originator on their plans. These are people in a very high risk group and workload pressures may make communication sub optimal

Competing interests: No competing interests

23 July 2017
nicholas j sharvill
GP
Deal Kent
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Re: David Oliver: NHS doctors’ licence to challenge David Oliver. 358:doi 10.1136/bmj.j3276

The autocomplete device on the BMJ website converted me from a retired GP, which I am, into a retired JP, which I am not.

Competing interests: No competing interests

22 July 2017
Michael O'Donnell
Retired GP. Jouneyman writer
Loxhill GU8 4BD
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Re: David Oliver: NHS doctors’ licence to challenge David Oliver. 358:doi 10.1136/bmj.j3276

Like David Oliver I'm uneasy with the assumption made by many a medical committee that all progress will come through consensus.

Consensus is a commendable way to stabilise established positions but is no way to seek ideas.

The full quotation from Bernard Shaw’s Man and Superman explains why.

"The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.;

During the 25 years I spent as the GMC’s Rebel in Residence I noticed that members of committees that wield real power can sometimes become so engrossed in committee-gaming that they lose touch with the purpose for which they were originally convened.

Maybe the honourable course is not to join them but to accept the definition proposed by Sir Barnett Cocks, Clerk of the House of Commons in the 1960s — "a committee is a cul de sac down which ideas are lured and quietly strangled" — and devote our energy to trying to curb committee power.

In my book The Barefaced Doctor I suggest one answer might be to create enough committees to accommodate the games players, reward them with honours rather than power, and feed them enough paperwork to keep them out of the hair of the unreasonable people whose ideas might lead us to greener pastures.

Competing interests: No competing interests

22 July 2017
Michael O'Donnell
Retired JP. Journeyman writer,
Loxhill GU8 4BD
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31
Re: Protesters show support for assisted dying campaigner Abi Rimmer. 358:doi 10.1136/bmj.j3475

The majority of the public back physician assisted dying:see Dignity in Dying website. The Professionals' organisations like the BMA and Royal College of Physicians of London refuse to support it.
Is it not hypocrisy to preach patient-centred care and yet when a sane UK adult and his carers know s/he has a diagnosis of a soon to be fatal disease asks to be enabled to commit suicide these organisations refuse to countenance relief of supreme suffering?
The organisations are in effect saying "We will not campaign to change the law so that our members can enable you to relieve yourself from your suffering.. You will have to continue suffering until you die".
For the fortunate few there have always been patient-centred doctors who bravely and compassionately end the pleading patient's life rather than following the cowardly instructions of our doctor-centred organisations. For the many we can but bewail our shame in not following Oregon and others.

Competing interests: No competing interests

22 July 2017
christopher j burns-cox
Consultant Physician Retd
Emeritus North Bristol Trust
southend Farm, Wotton-under-Edge GL12 7PB
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Re: Defenders against overdiagnosis Richard Hurley. 358:doi 10.1136/bmj.j3487

Let us stop doctors from indecently assaulting English language. There is no such thing as overdiagnosis.It is false diagnosis.
Diagnosing " hypertension" in an old chap or chapess and labelling it as such borders on mental cruelty. The person becomes a "patient." Perhaps starts counting days to his funeral.
The GP probably gets a pat on the back.
Luckily, my GP consented to leave me alone and not to call me for routine blood pressure checks, about ten years ago.

It is curious, by the way, that HYPOtension, once recognised on the Continent at least, as Dis.......Ease, was dismissed as a Mittel Europische whim. Anglo-Saxon Medicine ( ? anticipating BREXIT) did not recognise it.
Funny. High blood pressure is a " disease" even the person is at ease. Low BP, without pathologies( such as Addison's ) is nothing to shout about.

Competing interests: I am all for treating DIS EASE, but asymptomatic PATHOLOGY sometimes only.

22 July 2017
JK Anand
Retired doctor
Free spirit
3 Wayford Close, Peterborough
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Re: UK doctors re-examine case for mandatory vaccination Tom Moberly. 358:doi 10.1136/bmj.j3414

I read with concern Tom Moberly's report that the British Medical Association is trying to open a debate about mandating vaccines in the United Kingdom [1] having already made a number of relevant observations under an earlier article [2]. Most fundamentally, I would urge the medical establishment to exercise a little humility when today's scientific orthodoxy could so easily in retrospect become tomorrow's horrific misjudgement. It does not help when we see all vaccine critics dismissed by the Guardian newspaper or, by CEO of Gavi, in the Spectator in abusive terms as "anti-vaxxers" [3, 4], when it is far from clear that every issue in vaccine safety has been resolved - or that we can even begin to assess the risks while denying a respectful hearing to patients or their families, which pre-empts both evidence and argument in an inappropriate way. In my experience the most vociferous vaccine critics hitherto have not so much been people with an ideological objection to vaccination as people who had had their children vaccinated and regretted it. Such indiscriminate (scorched earth) strategies scarcely command the moral high ground.

Moreover, disregarding the highly intolerant atmosphere which is being generated in some quarters it is not evident that even if the science involved could approach the level of being definitive that it is anywhere near that at present. For example, three successive reports by Cochrane on the safety of MMR have declared [5,6,7]:

"The design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate."

which would indicate that the science has never been done (and some might consider it a bit late now). I also note the current complaint to the European Ombudsman regarding HPV vaccines and the European Medicines authority from Nordic Cochrane [8,9]. Though HPV vaccines may or may not be mandated the complaint partly relates to the uncertain science surrounding aluminium adjuvants which are also used in scheduled infant vaccines such as Infanrix Hexa [10], Prevenar [11] and Bexsero [12]. Yet this science is being publicly promoted as if infallible. There are surely lessons here from history. Meanwhile, it is far from apparent that Dr Farah Jameel who proposed the motion at the BMA had the remotest idea of these shortcomings [1].

Nor is it immediately obvious that the threat from infectious diseases has increased in any degree to justify such an abrupt change in policy (and in a way which could antagonise people presently much more well disposed to the vaccine programme than I might be myself). A greater problem which presently demands attention from health officials is the steep, unexplained rise in neurological disorders such as autism, which even now seem to be gathering dramatic momentum [13, 14, 15].

[1] Tom Moberly, 'UK doctors re-examine case for mandatory vaccination', BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3414 (Published 18 July 2017)
[2] Rapid Responses to Peter Doshi, 'US government website for collecting adverse events after vaccination is inaccessible to most users', http://www.bmj.com/content/357/bmj.j2449/rapid-responses
[3] Editorial: 'The Guardian view on vaccination: a matter of public health' , The Guardian 7 July 2017, https://www.theguardian.com/commentisfree/2017/jul/07/the-guardian-view-...
[4] Seth Berkley, 'Anti-vaxxers have embraced social media; we paying for fake news with real lives' Spectator Health 28 June 2017, https://health.spectator.co.uk/anti-vaxxers-have-embraced-social-media-w...
[5] Jefferson T, Price D, Demicheli V, Bianco E, 'Unintended events following immunization with MMR: a systematic review' 2003 https://www.ncbi.nlm.nih.gov/pubmed/12922131
[6] Demicheli V, Jefferson T, Rivetti A, Price D., 'Vaccines for measles, mumps and rubella in children', 2005 https://www.ncbi.nlm.nih.gov/pubmed/16235361
[7] Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C, ''Vaccines for measles, mumps and rubella in children', 2012.
[8] Stephane Foucart , http://www.lemonde.fr/planete/article/2016/12/09/papillomavirus-les-auto...
[9] Gøtzsche P, Jørgensen K, Jefferson J, Auken M , Brinth L,  'Complaint to the European ombudsman over maladministration at the European Medicines Agency (EMA) in relation to the safety of the HPV vaccines', http://nordic.cochrane.org/sites/nordic.cochrane.org/files/public/upload...
[10] http://ca.gsk.com/media/537989/infanrix-hexa.pdf
[11] https://www.medicines.org.uk/emc/medicine/22689#COMPOSITION
[12 ]http://www.medicines.org.uk/emc/medicine/28407/SPC/Bexsero+Meningococcal...
[13] Helen McArdle, 'Call for investigation as 20 young Scots a day are rejected fro mental health care', Sunday Herald 20 December 2016, http://www.heraldscotland.com/news/14975962.Call_for_investigation_as_20...
[14] Brett Campbell, 'Autism assessment list now at crisis level, says MLA', 22 December 2016, http://www.belfasttelegraph.co.uk/news/northern-ireland/autism-assessmen...
[15] Jane Dreaper, 'Autism diagnoses 'could be reduced under NHS plan'', BBC News 27 May 2017, http://www.bbc.co.uk/news/health-40058482

Competing interests: No competing interests

22 July 2017
John Stone
UK Editor
AgeofAutism.com
London N22
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7
Re: Defenders against overdiagnosis Richard Hurley. 358:doi 10.1136/bmj.j3487

A FURIOUSLY, FAST GROWING CHALLENGE
==================================

While sciences are moving in all possible dimensions, although it is a beneficiary of such
advances ' medicine ' has a major nonscientific dimension. In successfully dealing with health and disease,
the professionals in the field of medicine encounter science and nonscience. The horizons of this dual dilemma
are moving further and faster and the challenges for the professionals need to be appreciated by the society
seeking support in health and disease at the highest possible level.

All of us are in this !

Competing interests: No competing interests

22 July 2017
A.A.W. Amarasinghe, M.D.,
Psychiatrist
Self-employed
250, Corporate Centre Court, Stockbridge, Ga 30281, USA.
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27
Re: Protesters show support for assisted dying campaigner Abi Rimmer. 358:doi 10.1136/bmj.j3475

Interesting that the BMJ gave a 2 page spread to pro-assisted dying campaigners, but not a mention of campaigners against assisted dying such as Not Dead Yet. Anyone would think that the BMJ is biased in favour of assisted dying - surely not....

Competing interests: No competing interests

22 July 2017
Chris Wayte
recently retired GP
11 Englishcombe Way, bath
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27

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