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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: Improving patient outcomes after surgery Clare Marx, Derek Alderson. 359:doi 10.1136/bmj.j4580

After discussing the topic published this week by BMJ: Clare Marx and Derek Alderson's Improving patient outcomes after surgery, they motivated us to write some of our considerations on the subject.
Worldwide, some 234 million major surgery interventions are performed annually, roughly equivalent to one operation per 25 people. Each year 63 million people with traumatic injuries, 10 million women with complications related to pregnancy and 31 million patients who need cancer treatment are operated. According to various studies, complications attributable to surgical interventions cause disability or prolong hospitalization between 3% and 25% of patients, depending on the complexity of the operation and the hospital environment. This means that the number of patients susceptible to postoperative complications is at least 7 million per year.
The Global Alliance for Patient Safety includes such important issues as explaining to the patient before surgery risks and the risks of not operating, so that the patient decides about his health and respects himself as a person. Its goal is to achieve "safe surgery".
We consider that there are multiple factors that intervene in the results after surgery, some depend on the cause that motivates, others depend on whether it is urgent or elective and much depends on the patient's condition, physical condition and co morbidities. Without neglecting that a part no less important depends on the skill and experience of the surgeon, the frequency, in a certain time, with which it exposes itself to solve situations similar to those that motivate the surgery in a patient.
No less despicable is the safety of operating theaters and the team of anesthesiologists involved in the operative event, without discarding the important of the immediate and immediate post-operative.
We should never forget to involve patients throughout the surgical process and this would be able to achieve a positive balance in a surgery performed.
Ensuring patient safety is essential in surgical care.

References:
1. Santos-Peña Moisés A, Rocha-Hernandez Juan F. La calidad y seguridad del paciente. Un derecho de la salud pública cubana. México DF: CIESS. Boletín Informativo. No. 14. Enero- Marzo 2016.
2. Centro Colaborador de OMS. Programa de Seguridad del Paciente: cirugía segura en el sitio adecuado. Hospital Gustavo Aldereguía Lima. Cienfuegos. Cuba 2014.
3. Santos-Peña Moisés A. La importancia de las personas en la sanidad. NC le actualiza. ISSN 2309-5253. La Habana2016. No.03.

Competing interests: No competing interests

14 October 2017
Moises A. Santos-Peña
Chief Organizational Quality Unit
Quintana-Galende María L.
Gustavo Aldereguia University General Hospital
Ave 5 de Septiembre and 51-A street. Cienfuegos city. Cuba 55100
Re: A Big Sister society? Fiona Godlee. 359:doi 10.1136/bmj.j4690

You can’t say “…female surgeons are particularly good at communication, collaboration, and patient centredness” and then claim that there is no difference between the genders. Clearly there are differences between the genders and I think we should celebrate these: things work best when we collaborate instead of competing - as nature intended!

It is about time that people got serious about equality in employment: if we are to have it (and we have a long way to go in the UK) then we must not favour one group over another ("positive discrimination" is as bad as its opposite) - and it is vital that selection procedures are as fair as we can make them.

If a disparity is identified between the numbers from different groups entering a particular speciality (and I wonder if such examination is helpful) we should not assume it is because of bias rather than another reason. To insist that it is due to discrimination is both damaging and hypocritical.

Competing interests: No competing interests

14 October 2017
Peter J T Balfour
Locum Addiciton Psychiatrist
-
OL7 9NS
Re: Margaret McCartney: Nuclear weapons do harm, even if never used Margaret McCartney. 358:doi 10.1136/bmj.j3978

Dr McCartney’s admitted forgetfulness about her student membership of the Medical Campaign against Nuclear Weapons perhaps explains her view of the purpose of IPPNW.

IPPNW was a Soviet front organization whose purpose was not ‘to present the medical case for preventing nuclear war’ – there is plenty of such appalling evidence from Hiroshima and Nagasaki – but to call for unilateral disarmament by the west. Fortunately, in this treasonous quest it failed.

I drew attention to all this, with references, in a letter published in the BMJ as long ago as 1991(1).

symonds@tokyobritishclinic.com

1. https://doi.org/10.1136/bmj.303.6803.651

Competing interests: No competing interests

14 October 2017
Gabriel Symonds
General practitioner
Tokyo
Re: Antenatal nutritional supplementation and autism spectrum disorders in the Stockholm youth cohort: population based cohort study Craig J Newschaffer, Kristen Lyall, Christina Dalman, Brian K Lee, et al. 359:doi 10.1136/bmj.j4273

Dear colleagues,
The multivitamin supplement used in this study contained most likely vitamin D and this is most likely to be the significant contributor to the reduction in ASD occurrence. Vitamin D has been found to play a neuro-protective role (1) and mid-trimester vitamin D blood levels are inversely related to later development of ASD in the off-spring. (2)

It seems sensible to recommend or even prescribe this vitamin to all pregnant women in view of this and the many other benefits coming from avoiding vitamin D deficiency in pregnancy.

1. Eyles, D.W., et al. Vitamin D, effects on brain development, adult brain function and the links between low levels of vitamin D and neuropsychiatric disease. Front. Neuroendocrinol. (2012),
2. Vinkhuyzen, AA, et al. Gestational vitamin D deficiency and autism spectrum disorder. British Journal of Psychiatry Open Apr 2017, 3 (2) 85-90

Competing interests: No competing interests

13 October 2017
Helga M Rhein
General Practitioner
n/a
Sighthill Health Centre, 380 Calder Rd, Edinburgh EH11 4AU
Re: Fear of missing out on conferences Margaret McCartney. 359:doi 10.1136/bmj.j4515

The poet/surgeon George Bascom spoke for many of us when he wrote this short poem about attending a medical conference in Colorado ~ 3 decades ago:

Seminar at Breckenridge

The peaks are frozen gold
above the gritty streets. Boots
grate briskly on the way
to lectures about lungs.
The holy heights
cry down to use, but inside under tinted glass
we file like mourners
to the conference room.

I am sure Dr. McCartney would concur.

Competing interests: No competing interests

13 October 2017
David Elpern
physician
Massachusetts
Re: Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by European Medicines Agency: retrospective cohort study of drug approvals 2009-13 Ashlyn Pinto, Ajay Aggarwal, et al. 359:doi 10.1136/bmj.j4530

In their recent article, Davis et al1 show that nearly three quarters of the anticancer drugs approved by EMA in the years 2009-2013 do not attain a meaningful survival benefit or a quality of life improvement in spite of very high costs. The article gives voice to many medical oncologists and hematologists around the world who are alarmed by the escalating cost system without significant demonstration of efficacy and cost effectiveness.
The authors rightly point to the responsibility of regulatory authorities such as EMA in approving expensive drugs with little if any survival benefit. The situation is not different in the United States, where between 2008 and 2012 the US Food and Drug Administration approved most uses of cancer drugs without evidence of survival or improved quality of life (67%, 36/54)2. In her commentary, Cohen3 underlines the potential conflict of interest of EMA who receives 89% of its entire budget from the drug industry fees, thus creating doubts over the independence of the agency. Here we would like to add to these issues our responsibility as cancer clinicians in perpetrating this vicious circle of unsustainable costs in spite of limited efficacy and increasing financial burden to the health care systems.
In medical oncology, financial relationships have increased through the years and have influenced clinical research, scientific visibility and career development.4 The issue is particularly important in our discipline given the increasing volume of investments made by the pharmaceutical industry in cancer treatment.5 In this escalating prize system6, pharmaceutical companies tend to orient a significant part of their investments towards marketing and promotional activities (at least 20-30% of the final drug price)7,8, rather than to research and development, a notion which is rarely publicly available. In a recent analysis on 10 approved cancer drug in the US9, the median cost to develop a drug was $648.0 million, a figure significantly lower than prior estimates, and the revenue since approval was substantial (median, $1658.4 million; range, $204.1 million to $22 275.0 million).
Direct financial relationships between industry and physicians and/or researchers, consisting of stock options, advisory fees, honoraria, speaking fees, travel and lodging expenses, have become common practice in modern medicine but represent an important source of conflict of interest and avoidable expenditures. In addition, they violate the first principle of the Hyppocratic oath to make the patient’s interest first without undue external influences, thus blemishing the concept of medical professionalism.
What can be done to stop this ill system? First of all, we propose a stringent policy of conflict of interest by the governments which should ban direct financial relationships between pharmaceutical industry and individual doctors as well as regulatory authorities, scientific journals, academic societies and patient advocacy groups. This may be a concrete approach to select better treatments and reduce drug prices.
References
1. Davis C, Naci H, Gurpinar E, Poplavska E, Pinto A, Aggarwal A. Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by European Medicines Agency: retrospective cohort study of drug approvals 2009-13. BMJ. 2017 Oct 4;359:j4530.
2. Kim C, Prasad V. Cancer drugs approved on the basis of a surrogate end point and subsequent overall survival: An analysis of 5 years of US Food and Drug Administration approvals. JAMA Intern Med 2015;359:1992-4. doi:10.1001/jamainternmed.2015. 5868 pmid:26502403.
3. Cohen D. Cancer drugs: high price, uncertain value. BMJ. 2017 Oct 4;359:j4543.
4. Moy B, Bradbury AR, Helft PR et al. Correlation between financial relationships with commercial interests and research prominence at an oncology meeting. J Clin Oncol. 2013 Jul 20;31(21):2678-84.
5. Global Oncology Trend Report a Review of 2015 and Outlook to 2020. IMS Institute for healthcare informations. http://www.imshealth.com/en/thought-leadership/quintilesims-institute/re....
6. Saltz LB. Perspectives on Cost and Value in Cancer Care. JAMA Oncol. 2016;2(1):19-21.
7. Socolar D, Sager A. Pharmaceutical marketing and research spending: The evidence does not support PhRMA’s claims. Presented at the American Public Health Association Annual Meeting (session 2018.0), Atlanta, GA. 2001.
8. Anderson R. Pharmaceutical industry gets high on fat profits. By Business reporter, BBC News 6 November 2014. http://www.bbc.com/news/business-28212223
9. Prasad V, Mailankody S. Research and Development Spending to Bring a Single Cancer Drug to Market and Revenues After Approval. JAMA Intern Med. 2017 Sep 11. doi: 10.1001/jamainternmed.2017.3601. [Epub ahead of print] PubMed PMID: 28892524.

Competing interests: No competing interests

13 October 2017
Andrea DeCensi
Medical Oncologist
Gian Mauro Numico, Fausto Roila
Galliera Hospital, Genoa, Italy
Mura delle Cappuccine 14, 16128 Genova, Italy
Re: Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study Allan S Detsky, Raj Satkunasivam, et al. 359:doi 10.1136/bmj.j4366

The striking male dominance of surgical specialities is difficult to miss, and this appears to have at least partially motivated this study’s research question. While I acknowledge the study’s methodologic and statistical rigor, I respectfully submit that there are some serious philosophical concerns with its general line of inquiry that deserve consideration.

First, the variable in question is an effectively non-modifiable one. Rather than examining specific attributes or behaviours (e.g., communication skills, adherence to guidelines) which any physician -- regardless of sex -- could manifest, the authors studied sex and subsequently speculated on what behaviours may have driven the small difference observed. If one’s goal is quality improvement, then a focus on adjustable attributes or behaviours that all physicians could theoretically be taught to develop would be more fruitful.

Second, as the authors state, “These results do not support the preferential selection of a surgeon of either sex in clinical practice”. Indeed, if the within-group differences in outcome exceed the between-group differences (and this is almost certainly the case), one truly could not conclude that any individual surgeon of a given sex is better or worse than his or her counterpart based on sex alone. Unfortunately, the subtlety of such an argument is compromised in the era of “sound bites” and tweets. The headline of a prominent article about this work on time.com, for example, is “Researchers Find Women Make Better Surgeons Than Men”. 1 This effect is exacerbated by the phenomenon of “stereotype threat,” in that the group expected to have worse outcomes comes to underperform over time, essentially participating in a self-fulfilling prophecy.2 This would clearly be a undesirable outcome.

Third, given the provocative nature of the study’s findings, it is nearly impossible not to wonder about a political subtext. I question, for example, whether this paper would have been published (or even submitted for publication) had the opposite result been found. Similarly, would the authors have felt as comfortable encouraging female surgeons to learn from the behaviour patterns of their male counterparts? I suspect not.

I challenge our profession to avoid the “slippery slope” of physician identity-based research questions. Should we compare outcomes of Asian providers to those of Caucasian or Hispanic ones, for example? Physicians, like all populations, can be fragmented into an infinite number of subcategories; deciding which, if any, of these are worthy of study is not a trivial task, particularly when results are either not actionable or almost certain to be misinterpreted and misapplied.

Respectfully submitted,
Diana Toubassi, MD, CCFP

1. http://time.com/4975232/women-surgeon-surgery/ Accessed October 12, 2017.
2. Spencer SJ, Logel C, Davies PG. Stereotype threat. Annu Rev Psychol 2016;67:415-37. doi: 10.1146/annurev-psych-073115-103235. Epub 2015 Sep 10.

Competing interests: No competing interests

13 October 2017
Diana Toubassi
Physician
University of Toronto
University of Toronto, Department of Family and Community Medicine
Re: Which pain medications are effective for sciatica (radicular leg pain)? Rafael Zambelli Pinto, Annemieke J. H. Verwoerd, Bart W. Koes,. 359:doi 10.1136/bmj.j4248

We all know that which might be the most effective medication to treat patients with sciatica or radicular leg pain is unclear.

The best guide remains self-report by the patient in front of you for whom you are carefully delivering evidence backed individualised care [1].

Unfortunately our efforts to do this are severely hampered by guidance (and payment for adherence) that is based upon one size fits all.

1. Lake APJ. Every Prescription is a clinical trial. British Medical Journal 2004; 329: 1346

Competing interests: No competing interests

13 October 2017
Alfred P J Lake
Consultant in Pain Medicine
Abergele Hospital
Llanfair Road, Abergele, Conwy LL22 8DP
Re: Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study Allan S Detsky, Raj Satkunasivam, et al. 359:doi 10.1136/bmj.j4366

As active clinicians and professionals in healthcare finance, we read with interest the article comparing post-operative outcomes of different male and female surgeons by Wallis et al [1]. In the choice of surgeons, post-operative outcomes are one of the key criteria that patients value. Small differences can serve to sway patient/consumer decisions on choice.

We feel that the study did not quantify the absolute level of morbidity at the point of surgery adequately. The use of the John Hopkins ACG is a system which provides an idea into the co-morbidity of the patient over a period of the year [2]. It does not provide any idea as level of severity of the surgical condition which the patient was admitted for; which in surgery could be much more severe than the co-morbidities of the patient in the year.

While not well studied in medicine, research in economics consistently finds that men are more risk tolerant, or even risk loving, than women [3]. It is hence possible that the male surgeons could have taken on cases with a higher level of surgical severity hence affecting the patient selection. This which could inherently contribute to a worse surgical outcome.

To prevent this confounding, we feel the absolute level of morbidity of the patient should include co-morbidities and the surgical severity of the condition the patient is admitted for surgery. This can be measured by combining a co-morbidity scoring system like the John Hopkins ACG with a surgical severity score like the American Academy for Surgery of Trauma Emergency General Surgery Anatomic Severity [4]. Another approach is to use the well validated surgical audit tool POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) [5] which provides a score based on the patient’s co-morbidities and surgical severity.

References
1. Wallis, C.J., et al., Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. 2017.
2. Hospital, J.H. Johns Hopkins ACG® System. 2017; Available from: https://www.hopkinsacg.org/.
3. Acunto, F. Risk tolerance of men and women. 2015; Available from: http://voxeu.org/article/risk-tolerance-men-and-women.
4. Tominaga, G.T., et al., The American Association for the Surgery of Trauma grading scale for 16 emergency general surgery conditions: Disease-specific criteria characterizing anatomic severity grading. J Trauma Acute Care Surg, 2016. 81(3): p. 593-602.
5. Copeland, G.P., et al., POSSUM: A scoring system for surgical audit. British Journal of Surgery, 1991. 78(3): p. 355-360.

Competing interests: No competing interests

13 October 2017
Shunjie (Sean) Chua
Medical Affairs
Sani Zuni, David Baker, Thongcai Metharom
Clearbridge Health
Singapore
13 October 2017
David Kerr
Director of Innovation and Research
William Sansum Diabetes center
Santa Barbara, CAlifornia

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