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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: General practice threatens to withhold repeat prescriptions until patients have flu vaccine Gareth Iacobucci. 359:doi 10.1136/bmj.j4682

JK Anand's commentary is spot on and makes the case for health care reforms that have long been been avoided. Paternalism, the selfish greed of many medical practitioners, the profit-seeking interests of the pharmaceutical and medical device industry, and the compliant expedience of politicians explain why these reforms have not been adopted.

Paternalism--"the doctor knows best"--is always a moral hazard for physicians and is a clear and present danger for patients in every encounter with a physician.

Payment of fees for service invites fraud and abuse. How could it be otherwise in a system that operates largely on the ill-founded assumption that physicians are committed to their patient's best interests, including the patient's and society's ability to pay?

So-called "quality" is an ill-defined and elusive concept in the practice of medicine, as the BMJ editor recently editorialized when pointing out the unrelieved uncertainty of medicine (1).

And, yes, paying doctors on a fee-for-service basis to report harmful side-effects of the medicines they prescribe would leverage the perverse incentives of the fee-for service system to produce a tad more of enlightened practice of medicine.

1. Godlee, F. Unrelieved uncertainty. BMJ 2017;358:j4347.

Competing interests: No competing interests

13 October 2017
John H Noble Jr
Professor Emeritus
State University of New York at Buffalo
508 Rio Grande Loop, Georgetown, Texas, USA
Re: David Oliver: How much information should patients’ families expect on acute wards? David Oliver. 359:doi 10.1136/bmj.j4295

While I appreciate many of David Oliver's patients will formally lack capacity, he does not mention patient confidentiality and how much information is appropriate for relatives - whom, as he says, may be quite distant. In the 1990s I was an ITU consultant and used to regularly see staff members from all disciplines revealing extremely detailed information to visitors - often without checking who they were, and their relationship to the (generally unconscious) patient. A few years ago I was on the other end of this - an elderly neighbour was admitted to HDU in a distant hospital while visiting family. I phoned to make a general, concerned neighbour enquiry- and got the level of detail I would expect while conducting a ward round. Doctors should always be aware that in most cases, visitors should not be given anything but the most general information. Often the people who want to know the most detail have the least business knowing it!

Competing interests: No competing interests

13 October 2017
Hilary A Aitken
Retired anaesthetist
Kilmacolm, Renfrewshire
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

This paper provides further evidence that most new cancer drugs have not been shown to improve survival or quality of life, and that when survival gains are shown they are not always clinically meaningful.(1)

Wise previously drew attention to over permissive new drug approval systems internationally, and the almost routine offer of chemotherapy without adequate guidance on benefits and risks that deprives patients of deserved empowerment: their potential and right to choose only palliative (best supportive) care rather than drugs.(2)

This paper is a further wake-up call to oncologists, general practitioners and patients for an early palliative care approach integrated with disease-modifying care - that is giving personalised support to patients to help them socially and emotionally as well as whatever cancer medication may be required. This approach should be started at diagnosis of a life-threatening illness, when people start to worry, rather than in the final weeks when it is too late to prevent and treat most problems. This may spearhead the realisation of realistic medicine,(3) and it represents a major contribution to health promotion towards the end of life. Our recent analysis and embedded video gives a rationale for this approach to be triggered earlier than later.(4) https://www.youtube.com/watch?v=vS7ueV0ui5U

If palliative care were a drug, the manufacturers would be busy due to the great demand for such a beneficial treatment with no toxic side-effects. The general public would be calling for it, and patient support groups would be approaching politicians.

However “palliative care” has a bad press as it’s associated wrongly with imminently dying. Promoting early palliative care is to everyone’s advantage: patients, carers and the health service at large. Being able to offer compassionate support that covers all dimensions of need, and communicating and planning openly would prevent many treatments that are likely to cause more harm than good. The expense and toxicity of cancer drugs mean we have an obligation to expose patients to such medication only when they can reasonably expect an improvement in survival or quality of life.(5)

We must offer palliative care or “palliatosin” as an active choice, an alternative therapeutic option to enable people to live well in such difficult situations.

Scott A Murray, Sebastien Moine

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;359.
2. Wise PH. Cancer drugs, survival, and ethics. BMJ. 2016;355:i15792.
3. The Scottish Government. Realising Realistic Medicine: Chief Medical Officer's Annual Report 2015-16. http://www.gov.scot/Resource/0051/00514513.pdf.
4. Murray SA, Kendall M, Mitchell G, Moine S, Amblàs-Novellas J, Boyd K. Palliative care from diagnosis to death. BMJ. 2017;356.
5. Prasad V. Do cancer drugs improve survival or quality of life? BMJ. 2017;359 j4528.

Competing interests: No competing interests

13 October 2017
Scott Murray
St. Columba's Hospice Chair of Primary Palliative Care
Sebastien Moine
University of Edinburgh
Usher Institute of Population Health Sciences & Informatics, University of Edinburgh
Re: Government promises “ambitious” science deal with EU Anne Gulland. 359:doi 10.1136/bmj.j4741

1,000,000 highly skilled EU scientists, half of PhD professionals, and half of those with postgraduate degrees, all currently employed in Britain, will permanently leave the UK because of Brexit.
The UK government might be seeking a science agreement with the EU, but there is hardly going to be any science sector left in Britain, after the massive exodus generated by their rhetoric.
References
http://www.independent.co.uk/news/uk/politics/brexit-skilled-workers-kpm...
https://www.theguardian.com/politics/2017/aug/27/million-skilled-eu-work...

Competing interests: No competing interests

13 October 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Hellas
Re: WHO advises blanket anti-worming treatment for children despite lack of benefit Nigel Hawkes. 359:doi 10.1136/bmj.j4589

Hawkes rightly provided robust evidence that the strong recommendation from the World Health Organization to eliminate worm infections with blanket treatment is a nonsense with potential serious drawbacks.(1) However, this is hardly news for the news section.

With regard to developing evidence-based policies, WHO clinical practices guidelines have been characterized by strong recommendations based on low or very low confidence estimates for evidence.(2) This warning was useless: WHO recommended rapid fluid resuscitation for children in shock, although the only large controlled trial available found it increased the risk of death in African children,(3) and also issued recommendations inapplicable to low/middle-income countries.(4)

When recommendations are well evidence-based, as for the 2004 Convention for Tobacco Control, they are a smokescreen. WHO is enduringly failing to shame countries into compliance despite repeated gross violations of basic principles such as article 5.3 of the Convention, which requires protecting public health policies from the influence of the tobacco industry.(5)

1.Hawkes N. WHO advises blanket anti-worming treatment for children despite lack of benefit. BMJ 2017;359:j4589.

2 Alexander PE, Bero L, Montori VM et al. World Health Organization recommendations are often strong based on low confidence in effective estimates. J Clin Epidemiol 2014,67:629-34.

3 Kiguli S, Akech SO, Mtove G et al. WHO guidelines on fluid resuscitation in children: missing the FEAST data. BMJ 2014;348:f7003.

4 Persad GC, Emanuel EJ. The ethics of expanding access to cheaper, less effective treatments. Lancet 2016; 388: 932-934

5 Braillon A. The Framework Convention on Tobacco Control. Lancet 2016;387:1907.

Competing interests: No competing interests

13 October 2017
alain braillon
senior consultant
University Hospital. 80000 Amiens. France
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 line between scientific truth, political correctness and temptation to sensationalise can be a blurred one.

Dr. Weaver beat me in highlighting one of the many important limitations of the Ontario paper, and I have blogged on the matter in CTSNET (https://www.ctsnet.org/jans/female-surgeons-are-less-likely-kill-you-say...)

I wish to respectfully share my concerns on methodology in addition to Dr. Weaver's learned letter.

1. I expect the results of transgender and ambiguous gender colleagues to be the defining sub-dataset.

2. Initial reading of the learned paper suggests that the subjects are not randomized, and the alternative by default methodology is, I have been told, so presumptuous as to limit the clinical validity of conclusions.
I would welcome a suitably powered RCT, robust in defining the lead surgeon as Dr. Weaver recommends (e.g. male attending guided in parts of decision making and/or cutting by female senior counts as a female surgery) and modelling all possible genders, patient gender, emergent/urgent/elective, etc., international risk scores (APACHE, Euro SCORE e.g.), intention to treat gender, patient perceptions and expectations, and so on. I expect the RCT to saw no difference in results, as no robust causation of a difference will EVER be established…..

3. I do not find the adjective 'similar' (fourth line in Result section of Abstract) defining case mix as scientifically robust enough to draw meaningful clinical conclusions...

You, BMJ, have a defined policy on diversity, and it is conceivable that the learned Ontario effort may fall short of the gender equality clause...

Thank you

Aristotle D. Protopapas MSc. FRCS

Competing interests: 1. male surgeon, 2. member of gender-desegregated water polo university team (Imperial College Medics), 3. advocate of absolute gender desegregation in all ways of life, especially sports.

13 October 2017
Aristotle D. Protopapas
Male surgeon
London UK
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

Firstly I would like to thank the authors for writing this stimulating article. I have a few general comments and some critique.

By stipulating that “the care provided by an inpatient internal medicine service is performed by a team” and “by contrast … the primary surgeon has a direct effect on patient outcomes” could be seen to infer that surgery is not a team effort. Which is of course not true. In fact in training hospitals the primary surgeon may be overseeing or supervising a junior colleague carrying out the majority of the procedure. More senior trainees are often responsible for opening and closing with the surgeon of record on site but unscrubbed. So the surgeon of record for analysis may not have performed the entire operation from start to finish.

I am critical of the exclusion of the 8753 patients treated by physicians whose primary declared specialty was non-surgical. I am unfamiliar with how the primary specialty is declared in Canada. However, if the declaration is in any way similar to in the UK this could exclude a vast number of cancer patients. The primary specialty is often the physician overseeing the multidisciplinary team meeting at the time of initial diagnosis, such as haematology, oncology, respiratory medicine, gastroenterology and many more. This exclusion has the potential to augment results relating to all outcome measures given the morbidity and mortality associated with malignancy. There is no mention in the limitations of the large number of patients excluded because the treating institution could not be identified. Allowing for the other exclusions this represents 4.47% of the true sample size and could contain significant data pertinent to the results.

This article contributes to a growing body of observational research into sex and gender issues in the wider medical field. I think it’s important that the authors acknowledged that they were unable to identify transgender surgeons, given that they used biological sex at the time of registration as means of categorisation. Accepting this study limitation, it is possible that trans female surgeons are being analysed within the male group and trans males in the female group. The authors state “female and male physicians differ in their practice of medicine” with “female doctors being more likely to use a patient centred approach and to follow evidence based guidelines”. Given that there is more than just biological determinism of gender, the practice and approach of trans surgeons may differ significantly from their natal sex and align more with their gender. I concede that transgender surgeons who transitioned since registration are likely to represent an incredibly small proportion of this cohort. However, it is my belief that transgender surgeons’ outcomes should be analysed within the category of their self-assigned gender. To analyse them within their natal sex group is to potentially underestimate the results.

Competing interests: No competing interests

13 October 2017
Josephine C Weaver
Junior Doctor
Melbourne, Australia
Re: Do cancer drugs improve survival or quality of life? Vinay Prasad. 359:doi 10.1136/bmj.j4528

As I am bound still by some level of confidentiality and despite semi-retirement and my remote location, I tend to support this authors thesis wholeheartedly (although my experience dates back to 2004 and earlier). Before that I spent a a lifetime in Medicines Development and Regulation in Europe including many oncological therapeutic agents - including chemotherapy and biological agents such as monoclonals, DNA vaccines and Gene Therapies. The latter two at that time were the most promising but not necessarily safe. Many conventional chemical anticancer drugs are extremely toxic with a wafer thin therapeutic margin with often rather theoretical mechanisms of action. One area I found particularly questionable was the first use of new chemical entities and viral vector in Phase I studies in what might be casually referred to as 'no hope' patients with cancer. The studies were much more about establishing the level of toxicity (safety) than giving the assessor any hope of benefit, yet the consent forms presented hope was offered when there was none of scientific credibility. If I should get terminal cancer I will go no-where near a Phase I study and thereafter I will evaluate if am able the evidence before ANY agent is given to me. If I am unconvinced I will refuse.

Both my mother and father developed colon cancer. My mother was offered firstly experimental surgery (2008) and when we refused, simply diagnostic laparotomy (no laparoscopy offered then). On discovering widespread peritoneal metastases she then required a defunctioning colostomy and was offered rectal radiotherapy - where the benefits were at best dubious and the toxicity undoubtedly significant - on the basis that she might live 6 weeks. We refused on that basis and she lived a fairly happy life for over 3 years eventually dying from later medical mismanagement of a benign condition (pain from an obstructed bladder other than cancer). My father on the other hand alas then perished in 2006 from palliative care he did not need. We have hopefully travelled some way since that time but I would suspect very little and this author confirms this. Whereas we might reference chemotherapies in childhood leukaemia as breakthroughs even here the approach of using differential poisoning is the nearest lay term I can use.

Adjuvants in breast cancer have also played an important part in treatment. The development of modern monoclonal antibodies is also more heartening because of lower levels of toxicity. But still their benefits are often hugely overstated and limited to subsections of patients we can hardly define. As most therapeutics are designed by commercial developers to be 'blockbusters' or highly 'prestigious' agents - and therefore unbelievably expensive for limited QOL, or even life extension. Such research teams approach therapeutic interventions by focusing primarily on commercial success rather than exploratory science. Well that is their modus operandi. Like many established medicines, we largely need to understand the ones we've got rather than the ones we may get. We use these often quite poorly. Patient's understand them even less. There are no magic bullets for anything. There is only greater understanding. And then from the burgeoning population we will create there will be new dilemmas for the planet - aged care and increasing dementia. If we could develop as a profession a more universal palliative approach to many of the cancers we see - following the simple principles of caring, reassuring, counselling and supporting - we might well do more good than ill and accept that life can be short but it is lived to the full.

Competing interests: Former regulator of Clinical Trials and New Medicines, former Consultant and Executive Director of Medicines Development - various organisations.

13 October 2017
Philip James Harrison
General Practitioner
HUTT CITY HEALTH CENTRES - recently semi-retired
Wellington, New Zealand
Re: David Oliver: How much information should patients’ families expect on acute wards? David Oliver. 359:doi 10.1136/bmj.j4295

Thank you David Oliver for being that person who stands up to say openly what so many are only willing or confident to say behind closed doors.

I remember many evenings and weekends on call as a junior doctor being accosted by eager relatives wanting to know exactly what happened, when, why, and what happens next. Or paged by nurses saying Mrs Z's 3rd cousin has just arrived from Australia and wants to know what's happening. With 20 jobs to do and half a hospital to look after, faced with trying to decipher and then translate the notes of a patient I have never met to ease the guilt-driven anxiety of a prodigal relative, cognitive overload kicks in.

Cold common sense says there is no urgency, I am not the right person to have this conversation, this could be a breach of confidentiality. But inexperience, stress, tiredness, and youthful eagerness to soothe anxious relatives' need for reassurance, leaves young doctors vulnerable. With experience I have come to realise that such conversations with distanced relatives are unnecessary, even harmful. With practice and confidence I can defer to the patient, close relatives/carers, nurses who know what is happening.

There are so many things wrong with the above scenario- work over-load, inappropriate task delegation and bullying, professional self-derogation (why make the FY1 do what the nurse is better placed to do?), and lack of leadership to prepare and support staff for recurrent events. And all this does is perpetuate the unrealistic expectations for endless repeats of information, and denegration of the nursing profession

But on the other hand, relatives deserve compassion, understanding. There is (in most cases) no intent to add to the doctor's stress, or put them on the spot. They just want to know what's happening, what does it mean. What is needed is clear information on the wards to indicate how to get information and duties of confidentiality; nursing staff actively encouraged to use the voices they have as patient advocates and healthcare professionals; and leadership to direct and promote staff support, clear boundaries and realistic expectations.

Communicating with patients is a double-edged sword, but compassion and realism can cut through the suffering of both anxious relatives and tired, stressed doctors.

Competing interests: No competing interests

12 October 2017
Cathy Welch
GP
Arran Medical Group
Re: General practice threatens to withhold repeat prescriptions until patients have flu vaccine Gareth Iacobucci. 359:doi 10.1136/bmj.j4682

Assuming the headline is correct, the GPs concerned were acting unlawfully. They did not seek informed consent. They just demanded that jabs be accepted.

Here is a suggestion. Please give ALL general practitioners a respectable per capita yearly allowance and abolish fee per immunisation, per IUCD, per condom prescription, per every other procedure. Bin the Quality Outcome nonsense.

Here is a challenge. Pay a doctor (hospital or private or NHS GP) a fee for notifying every side-effect of any drug, including imm and vacc products.

I have a hunch that we will see medicine practised with greater conscientiousness.

Competing interests: No competing interests

12 October 2017
JK Anand
Retired doctor
Free spirit
Peterborough

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