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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: 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
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

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