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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: Cheap, undervalued, expendable: junior doctors in 2017? Rachel Clarke. 358:doi 10.1136/bmj.j3651

It is sad that one year after a high profile dispute brought commitments from all involved to tackle rock-bottom junior doctor morale, the unacceptable behaviour of many NHS employers is still the norm. This includes, but is not limited to:
- little or no advance notice of rotas, hours and pay;
- sometimes even a change in job location with very little notice;
- an expectation that trainees will travel to jobs a long distance apart, with a refusal to provide or support transport;
- a refusal to sanction leave in advance of the August handover, even for e.g. weddings in August;
- pressure on doctors to cover and/or arrange cover for rota gaps, including those due to their own ill health;
- a reluctance to allow trainees to take compassionate leave;
- lack of hot food and rest facilities at night;
- expectation of work being done out of hours for free, including mandatory induction and other training.

This is not a failure to achieve best practice. This is a failure to honour commitments made under the new junior doctors contract (1), and indeed under previous arrangements brokered between Deaneries, Trusts and trainees (represented by Medical Education England, NHS Employers and the BMA respectively) (2).

It is also a failure to do what would be considered the bare minimum in any other industry. I should know, having worked for six years as a management consultant before studying medicine as a graduate. My employers then recognised that their staff were by far their most important asset, a similar situation to healthcare, and treated us accordingly. The crucial difference however is that, unlike professional services firms, the NHS does not have to compete with other employers for talent. With only work for the NHS recognised as training, NHS trusts are a de facto monopoly employer, at least for anyone seeking career progression. Perhaps this has led to complacency.

Morale is now so low that, despite the 5+ years of undergraduate education and associated student debt, junior doctors are leaving the NHS in their droves. This includes half of those just two years after graduating (3), with a subsequent inability to fill specialty training posts across the board (4). Worse, it is leading to burnout, with multiple surveys reporting rates of mental health problems in junior doctors of 60% and over (5) (6). Trainees can no longer be taken for granted.

The NHS is cost constrained, but addressing the grievances above would cost nothing. To do so requires that the CEOs of Health Education England and NHS Trusts must make employee welfare their top priority, much as professional services firms do. If not, they will one day find they don't have enough junior doctors left to run their much-vaunted services.

Dr Hugo Farne
Specialist Registrar in Respiratory Medicine, London

References:

1. Junior doctors terms and conditions of service March 2017. NHS Employers. 31/03/2017.
http://www.nhsemployers.org/case-studies-and-resources/2017/03/junior-do...

2. Code of Practice - Provision of Information for Postgraduate Medical Training. BMA, Department for Business Innovation & Skills, NHS Employers, Medical Education England. 12/09/2010.
https://www.bma.org.uk/-/media/files/pdfs/developing%20your%20career/fou...

3. The Foundation Programme Career Destination Report 2016. December 2016.
http://www.foundationprogramme.nhs.uk/download.asp?file=UKFPO_CDR_v7.pdf

4. Specialty recruitment: round 1 - acceptance and fill rate. Health Education England, last updated 4 July 2017.
https://hee.nhs.uk/our-work/attracting-recruiting/medical-recruitment/sp...

5. Cohen D, Winstanley SJ, Greene G. Understanding doctors' attitudes towards self-disclosure of mental ill health. Occup Med (Lond). 2016 Jul;66(5):383-9.

6. 2017 Survey of Anaesthetists in Training, as reported in RCoA: President's News, February 2017.
http://www.rcoa.ac.uk/rcoa-presidents-news-february-2017

Competing interests: I am a junior doctor.

06 August 2017
Hugo A Farne
Junior Doctor
London
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Re: Community hospitals: still a viable option? Gareth Iacobucci. 358:doi 10.1136/bmj.j3581

Community hospitals are an international vexata quaestio and their closure is more and more requested, but what are the results? First is the increased access to the central hospitals, the increased time needed for a diagnosis, the increased time for families when elderly patients who are in hospital need care and stay 50 or more km far away from home and when the family cannot care there is a need to ensure a carer with special costs. These are costs of families and not of the NHS, but they cannot be ignored. But when we consider also the NHS costs (increased hospitalization, delayed diagnostic times…) it could be useful to rethink health policies considering also personal and family costs.

The experience of the mental health dept of Ascoli Piceno (Asur Marche) in the Ambito sociale XXIV of Marche Region shows that a continuous shared common work of MHD, GP, Amandola hospital, families and all people giving social support to patients (Italian national health system reform of 1978 established this integrated work sul territorio i.e. at patient’s home and community) can reduce acute psychiatric accidents (last compulsory hospitalization was 2103), can reduce the amounts of volunteer hospitalization (in over 120 psychotic patients from 1985 to 2014 we have recorded 5-8 hospitalizations a year), can reduce the need for admission to sheltered facilities (4 over 30 years). All these are economic (material) costs, which we found reduced throughout a 30 year retrospective survey (1985-2014).

The non economic (immaterial) values of this integrated work (a continuous shared common work of MHD, GP, Amandola hospital, families and all people giving social support to patients) are mainly the increased chance for a safe expression of patients in their home and community, the possibility of true integration (based on and respecting their own possibilities), the potential to help our most vulnerable patients who do not feel themselves refused or tolerated but an active part of a community, in respect of personal objective and subjective possibilities of tailored work.

Until 2016 August 24th, first earthquake in middle Italy, this common work gave such results, not only in reducing health system costs but also increasing social and personal satisfaction (measured with qol-proxy and sf 36). Further result is the growing network of sheltered facilities in Ambito sociale XXIV of Marche Region: Montelparo has cared for adult autistic patients for several decades, Amandola has also had for several decades a therapeutic community for addicted patients, in 2011 Force opened a sheltered facility for 12 guests (only one from Ambito territoriale XXIV) and in July 2016 Comunanza did open a new facility for 20 patients; in Montefortino there is also a sheltered facility for young people without families who arrive by sea in Italy.
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Another result of this kind of shared work is the integrated domiciliary care system, surrounding Amandola hospital, which has reduced hospitalisations for patients with complex clinical and psychosocial complaints, ranging from acute decompensated COPD to anxiety, heart failure, and urinary tract infection, through the work of specialists and paramedics.

In conclusion, the common work in Ambito territoriale XXIV shows that a care model based on shared integrated work (Amandola hospital, MHD, specialists families and all who can give social support to the patients) “facilitates adaptation to the varied needs of diverse community environments, creating a crucial access point to engage patients in effective care outside of institutional settings” and can indice a “true integration of patient-centered clinical care with social supports, delivered in the home, for the most vulnerable patients”.

The health consequences of the earthquake of August 24th last year, which caused closure of Amandola hospital, remain to be seen, especially in the most vulnerable patients, until the opening of a new hospital.

Competing interests: No competing interests

05 August 2017
tiberio damiani
psychiatrist
mental health department, Ascoli Piceno, Asur Marche
via degli iris , Ascoli PIceno
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Re: Management of chronic pain using complementary and integrative medicine Lucy Chen, Andreas Michalsen. 357:doi 10.1136/bmj.j1284

The truth is nobody is doing a very good job with chronic pain. I now use a biopsychosocial approach. I use relaxation, exercise advice (graded activity/ exposure), examine beliefs (which tend to be catastrophic), behaviours (which are often fear avoidant) and use encouraging/ hopeful messages for positive change. You need to look at sleep hygiene and basic dietary advice. I have the luxury of time that doctors often don't, but for too long there has been a biomedical approach to pain that simply ignores the new understanding of pain neuroscience.

It should be also noted that most orthopaedic operations for chronic pain that have been tested do not outperform placebo and that the biggest reason for positive outcomes appears to be the "therapeutic alliance", the ability of the clinician to allow the patient to tell their story, to form a trusting, compassionate relationship and to create agreed actionable goals for change based on values. If every clinician got these basics right we would see a marked decline in chronic pain suffering.

Chronic pain sufferers are frightened by the medical system (MRIs being abnormal in almost everyone including those without pain). I believe a lot of pain is iatrogenic.

Like a previous comment, I am very upset that hypnosis still isn't getting the recognition it deserves. It is simply not acceptable to have such a powerful and truly side effect free treatment not being utilised by the NHS when there is such a wealth of evidence, especially for central sensitization and neuropathic pain.

Competing interests: No competing interests

05 August 2017
graham yates
Osteopath/hypnotherapist
General Osteopathic Council
Deal, Kent
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63
Re: Antidepressants and murder: case not closed Gwen Adshead. 358:doi 10.1136/bmj.j3697

As a member of the online support community for prescribed drug dependence, you can imagine the dismay that has rippled through our ranks in the past week. We waited in anticipation to view the Panorama programme: "Prescription for Murder?" The links between SSRI drugs and violent acts are nothing new. I was advised of such risks some 30 years ago when first being prescribed an SSRI. The criticism of the documentary from certain quarters seemed unwarranted and exaggerated. As patients who have been significantly harmed by drugs of dependence, we are in no doubt that SSRIs can cause altered behaviour and many other terrible symptoms. Many of us live with them every day, tortured by neurological symptoms, altered states of consciousness, memory loss, inability to perform simple daily tasks, burning brain and so on and so forth. We are also very aware of the increasing body of evidence that suggest lack of scientific evidence that support the use of these drugs. We are told that antidepressants save many lives. Yet the suicide rates have recently increased at a time when antidepressant prescribing is at an all time high. (1)

The Royal College of Psychiatrists announced a Twitter-based Q&A session on 3rd August. The online support community submitted many, many intelligent and probing questions. The responses were few in number and lacking in substance. We were advised that the Royal College "thinks" the benefits of antidepressants outweigh the harms but no supporting evidence was provided. Today I read with even greater dismay an article entitled "Pharmacological iatrogenesis: substance/medication-induced disorders, that masquerade as mental illness". (2) Although the study was conducted in Australia it is confirmation of what many already suspect here in the UK, that SSRI drugs are causing significant harm to many patients and this has become a major public health issue. In October 2016, the BMA announced the need for a national helpline to help and support patients withdraw from drugs of dependence. (3) The Department of Health however insists there is insufficient evidence that such a service is warranted. The reality is that most patients who are trying to come off these drugs cannot find a doctor with sufficient knowledge of the adverse effects of psychotropic drug withdrawal and when patients describe their horrendous symptoms they are generally met with disbelief and often labelled as mentally ill. This causes deep distress to patients who are already suffering so very much. It seems that many GPs are quite simply out of their depth and have no idea what to do for such patients. Often more drugs are offered which only serves to make matters worse. Personally, I have withdrawn from a benzodiazepine and an SSRI and am physically and cognitively disabled. No doctor will acknowledge the cause of my symptoms or my disability.

(1) https://www.samaritans.org/about-us/our-research/facts-and-figures-about...

(2) https://www.researchgate.net/publication/299355176_Pharmacological_Iatro...

(3) https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p...

Competing interests: No competing interests

05 August 2017
Fiona H French
Retired
Member of online support community for drugs of dependence
Aberdeen
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Re: Reduced radiotherapy is as effective as whole breast treatment for early breast cancer, study finds Susan Mayor. 358:doi 10.1136/bmj.j3759

This study [1] confirms that women with breast cancer can be effectively treated with reduced radiotherapy. It, like others such as the earlier TARGIT trial, [2] was based on evidence that recurrence is likely to occur close to the site of the original tumour.

But it is necessary to consider costs – in the widest sense - especially to the women themselves, but also to the health service providing the treatment, in a range of geographical settings both in the UK and abroad. It is constructive to consider this by comparison with intra-operative radiotherapy, such as INTRABEAM, [2] which can deliver an effective dose at the time of the operation, thus avoiding the burdensome costs of repeated radiotherapy treatments. There is endorsement of this method by women who have benefited. The saving in time, money and effort from avoiding revisiting the breast centre for repeated radiotherapy treatments from conventional equipment is plain. Furthermore, repeated visits to receive post-operative radiotherapy are impossible for many women: geographically, financially and/or practically. This can cause some to opt for mastectomy.

The cost to the health provider of installing intra-operative equipment can be offset by the general savings in clinic time and resources in this time of overcrowded clinics and financial constraints.

[1] Coles CE, Griffin CL, Kirby AM, et al. Partial breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5 year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet2017.doi:10.1016/S0140-6736(17)31145-5.

[2] Vaidya, JS, Wenz, F, Bulsara, M..., and on behalf of the TARGIT trialists' group. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014; 383: 603–613

Competing interests: No competing interests

05 August 2017
Hazel Thornton
Honorary Visiting Fellow, Department of Health Sciences
N/A
University of Leicester
"Saionara", 31 Regent Street, Rowhedge, Colchester
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Re: Sex and disability: time to treat all women as individuals . 358:doi 10.1136/bmj.j3454

Health workers, patients and relatives share a very confused view about sexuality and disabilities. If we consider sexuality and mental health patients, we find a strong fear of supporting women's reproductive right when they are taking neuroleptic treatment. The fear is about their capacity to have "safe parental responsibility". There are inside this fear several motifs. The first is "the patient is now in a good status, when pregnant does she need a change of medicaments... will she get a relapse of psychosis ?" The second is about the parental responsability of women with a child. Furthermore is a long history of denial of sterilisation (https://en.wikipedia.org/wiki/Compulsory_sterilization). When we speak about sexuality and disability or autism storm clouds gather because all these questions are extended.

The small experience of the mental health dept. in Ambito sociale XXIV of Marche Region since 1998 is that we have had several patients whith succesful pregnancies because they have followed regular neuroleptic treatment and been involved in a therapeutic relationship including with a GP and their families. This enlarged therapeutical team works with the patients, and when they decide with their partners to get pregnant, it is not always formal but substantive for all.

The second point is the sexuality of patients when they live in a sheltered facility. It is a good topic of actual debate with the team of sheltered house Don Rino Vallorani in Comunanza (ATS XXIV Mrche Region). A personal view is that the sexuality of patients cannot be forced and is a freedom and awareness of sharing affection. The role of the psychotherapeutic and educational team of this sheltered house is to ensure efforts to help patients to develop awareness and freedom also in this expression of personal life. And it is a complicated long way considering sexual abuse which has commonly been experienced by patients.

Competing interests: No competing interests

05 August 2017
tiberio damiani
psychiatrist
mental health dept. Ascoli Piceno, Asur Marche
via degli iris, ascoli piceno
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56
Re: Parkinson’s disease: summary of updated NICE guidance Gabriel Rogers, Debbie Davies, Joshua Pink, Paul Cooper. 358:doi 10.1136/bmj.j1951

The print version includes an unlabelled image which appears to be from a DaT scan. This gives a misleading message because NICE does not recommend the routine use of DaT scans.

This otherwise excellent review omits information on DaT scans which I think have become overused. It is understandable that clinicians seek apparent objective confirmation of a clinical diagnosis. A DaT scan is usually helpful in distinguishing essential tremor (worse on posture or action, in a patient with otherwise fluid movement) from tremor in Parkinson's disease (worse at rest and inevitably in time accompanied by bradykinesia): arguably not so challenging for a clinician of modest experience. The DaT scan however distinguishes Parkinson's disease neither from Multiple Systems Atrophy nor from Progressive Supranuclear Palsy.

I suggest that clinicians considering ordering a DaT scan should instead seek the opinion of one experienced in the clinical diagnosis of Parkinson's, giving a approximately 90% cost saving (assuming £150 for a consultation and £1500 for a DaT scan).

Competing interests: I am an old-fashioned clinician concerned about the invasion of unnecessary and expensive tests into clinical practice.

05 August 2017
Giles M Elrington
Neurologist
Oaks Hospital, Colchester CO4 5XR
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58
Re: NHS England’s plan to reduce wasteful and ineffective drug prescriptions Azeem Majeed. 358:doi 10.1136/bmj.j3679

I thank Kathryn Potter for her response. Patients with hypothyroidism who are currently taking liothyronine are understandably very concerned about the proposed restrictions on its future use in the NHS in England. Guidelines from specialist societies do not generally recommend routine use of liothyronine in patients with hypothyroidism but it is possible there are some specific groups of patients in whom it may be helpful. Previous trials of liothyronine need to be reviewed carefully to examine the inclusion and exclusion criteria to determine if these studies were sufficiently well-powered to examine outcomes in these subgroups. NHS England also needs to address the high cost of liothyronine in the UK, as the drug is considerably expensive here than in many other countries.

Competing interests: I am a GP principal in an NHS general practice in Clapham, London.

05 August 2017
Azeem Majeed
Professor of Primary Care
Staff Member
Department of Primary Care and Public Health, Imperial College, London W6 8RP
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Re: Pharmacological therapies for opioid induced constipation in adults with cancer Jason W Boland, Elaine G Boland. 358:doi 10.1136/bmj.j3313

Nausea/vomiting, constipation, dry mouth, sedation, miosis and respiratory depression are common ADRs associated with opioid treatment.

Apart from constipation & miosis, tolerance develops to most of the ADRs during opioid therapy.

The treatment of opioid induced constipation is required in patients with and without cancer. However, in patients with cancer due to polypharmacy and other cancer specific interventions, the treatment of constipation is difficult and needs attention.

Strategies [1] and a holistic approach are required in patients with cancer.

We thank the authors for the "infographic", and it is true that authors are responsible for their paper as per policy.

Regards,

References:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418642/

Competing interests: No competing interests

05 August 2017
Dr. Rajiv Kumar
Faculty
Dr.Sangeeta Bhanwra, Faculty, Dept. of Pharmacology, Government Medical College & Hospital, Chandigarh. India.
Dept. of Pharmacology, Government Medical College & Hospital Chandigarh 160030. India.
DRrajiv.08@gmail.com
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84
Re: Should doctors work 24 hour shifts? Steven C Stain, Michael Farquhar. 358:doi 10.1136/bmj.j3522

This is a controversial subject. I would say, first, it depends on:

1- The hospital workload
2- The type of hospital, type of specialty and number of beds
3- The ability of doctors
4- The rota, whether one in 3/ 4 or one in 9/12

Therefore practically the shifts must be flexible, each hospital staff member with to the liberty to plan their own shifts 24, 12, or 8 hours. I don't think there are many who would accept going to or leaving hospital at 8 pm or 10 pm in winter when it is a risky time to drive: in that case I would prefer to continue for 24 hours.

For the continuity of care, I prefer to see my surgeon who discussed my consent when I recover from anaesthesia, not a different surgeon.

It is not impossible for a doctor to have a nap for half an hour during his or her on-call time.

Let us be realistic, we sometimes spend evening hours listening to songs or a symphony.

M E Tageldin

Competing interests: No competing interests

05 August 2017
Mohamed Tageldin
Retired orthopaedic surgeon, BMA member
London
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