This page lists correspondence with the National Institute for Health and Clinical Excellence. On 3 December 2012 BMJ editor in chief Dr Fiona Godlee wrote to NICE's chair, Professor Sir Michael Rawlins. In her letter she says: "Now that serious doubts have been raised about the evidence behind claims for oseltamivir’s effectiveness and safety, I am asking you to withdraw approval for oseltamivir until NICE has received and reviewed the full clinical trial data and those anonymised data are available for independent scrutiny."
All rapid responses
We thank Dr. Gupta for his letter. As we note in the Discussion of our paper, information on postoperative delirium is unfortunately not well captured in our database. We agree that this is a very important complication associated with hip fractures. As our study found no differences in mortality risk across different types of anesthesia, we believe future investigations should focus on other endpoints of clinical importance in determining what potential risks and benefits may be associated with the type of anesthesia. Postoperative delirium is certainly among the outcomes that deserves further study.
However, we would note that if delirium were causally related to mortality and regional anesthesia decreased the risk of this complication relative to general anesthesia, we would expect a mortality benefit associated with the use of regional anesthesia—something not observed in our study.
I agree with the points of view proposed about imaging of patients with low back pain. My only issue is with the some of the clinical detail in the example that the authors used, of an elderly lady with an osteoporotic compression fracture. The authors suggest that there would be palpatory tenderness in the upper lumbar spine (the fracture on the radiograph is at L1). In my experience, compression fractures are nearly always non-tender to palpation. It is the mismatch between the lack of palpatory tenderness and the degree of pain the patient experiences when moving between the vertical and the horizontal that raises ones index of suspicion of a compression fracture.
The pain-producing tissue (the vertebral body) is relatively deep, and, in my experience, palpation of the spine rarely provokes it, unlike posturally compressing and decompressing the fracture, which does provoke it, often dramatically so.
I completely concur with Mr Harding. I was confused by the tenor of the paper when I know few, if any, UK surgeons carry out early surgery for non-specific back pain.
Yet NHS tertiary neurosurgical and orthopaedic clinics are almost paralysed by referrals of patients with non-specific back pain. The message should be stop referring these patients to surgeons and refer directly to physical therapies, supported by pain specialists. Commissioners should look to configure services to help these patients and move them away from the congested surgical clinics. Patients wait months to be told they should receive physiotherapy or see a pain specialist for an epidural injection. Such services could provide far more effective triage than is presently the case.
I read the summaries of the new NICE lipid guidance with a mixture of befuddlement and dread, so it is reassuring to have my anxieties articulated so clearly by Goldacre and Smeeth. As with most public health interventions, the effect of statin use for low-risk individuals is likely to be minimal - and so the need for effective decision-support and risk-communication tools is all the greater. I try my best to use natural frequencies and visual aids (such as the Cates plots generated by the admirable QIntervention site) to share information with patients who are making decisions about statins, but the options available are time-consuming and not always terribly helpful. Patients need data visualisations to be matched to their individual levels of health literacy and numeracy, and clinicians need far better tools to provide them in the confines of real-world practice.
I read your news item ‘Medical Council of India is corrupt, says health minister’ with great interest. With more than twenty-five years of teaching experience in both Government and private medical colleges, I am not surprised by the news item.
During my long association with medical education, I have seen the standard of medical education deteriorating. Getting a job in a medical college as a faculty member was like a dream come true in my time, as there was neither the culture of corporate hospital nor private medical colleges. Things have now changed. Having joined the medical college, it is still a secondary job for majority of the faculties. The primary concern is private practice. The devotion and dedication of teaching is somewhat lacking. The MCI inspection for any college is like an event management. It has opened up many job opportunities for people who arrange everything from faculties to furniture. Even today the Honourable health minister, Dr. Harshvardhan, has given a statement in Times of India, Delhi edition, regarding ‘racket’ of docs-lab nexus. Doctors as well as the common man are aware of the prevailing corruption not only in MCI but also in other fields of health care sector. It is time that the ‘aware’ government make stringent laws to heal the health services.
Alzheimer’s Disease, Dementia and Homocysteine
One of the most interesting aspects of the article about the “perplexing problem” of Alzheimer’s disease by Chinthapalli(1) is the fact that during a 13 year period, out of 101 drugs tested only 3 reached market, each with minimal therapeutic effects.
Many previous studies demonstrate a relationship between Alzheimer's dementia and the spectrum of cardiovascular diseases, including stroke, an accepted risk factor for Alzheimer's disease. Alzheimer's disease and cardiovascular diseases share a common risk factor, elevated blood levels of homocysteine, an amino acid which becomes elevated by inadequate dietary intakes of vitamins B2, B6, B9 (folate) and B12. Multivitamins reliably lower homocysteine in most if not all; they are the only “therapy”.
There is epidemiological evidence for both a declining dementia / Alzheimer’s disease epidemic and for improved stroke deaths since folate food fortification.(2,3) The authors of the Framingham Study concluded that homocysteine is “a strong, independent risk factor for the development of dementia and Alzheimer's disease”, a statement based on the finding of an almost doubled rate of dementia in the highest quartile of plasma homocysteine.(4)
Recent data show that B-vitamin supplementation virtually halts grey matter atrophy in areas of the brain related to Alzheimer’s disease while slowing some cognitive decline.(5) These observations support the concept that blood homocysteine and the B vitamins that influence the level of homocysteine are potentially causal and modifiable risk factors. Moreover, these parameters must be determined in future studies as confounding risk factors regarding Alzheimer’s disease.
Eddie Vos, M.Eng., Kilmer S. McCully, M.D.
1. Chinthapalli K. Alzheimer's disease: still a perplexing problem. BMJ. 2014 Jul 8;349:g4433. doi: 10.1136/bmj.g4433. PMID 25005430
2 Larson EB, Yaffe K, Langa KM. New Insights into the Dementia Epidemic.
N Engl J Med. 2013;369(24):2275-7. PMID 24283198
3. Yang Q, Botto LD, Erickson JD, et al. Improvement in stroke mortality in Canada and the United States, 1990 to 2002. Circulation. 2006;113(10):1335-43. PMID 16534029
4. Seshadri S, Beiser A, Selhub J, et al. Plasma homocysteine as a risk factor for dementia and Alzheimer's disease. N Engl J Med. 2002;346(7):476-83. PMID 11844848
5. Douaud G, Refsum H, de Jager CA, et al. Preventing Alzheimer's disease-related gray matter atrophy by B-vitamin treatment. Proc Natl Acad Sci USA. 2013;110(23):9523-8. PIMD 23690582
I thank Drs. Saripanidis, Sharma, Mann, and Dubey for their interest in my article.
Drs. Saripanidis and Sharma describe the many benefits of computer devices and the Internet. I completely agree, and I have written on this topic in the past (1).
The thrust of my article was narrower. The practice of medicine depends on what a physician brings in his or her mind to a patient's bedside. A physician’s greatest challenge is to make right decisions based on inferences about clinical information. In turn, physician decisions are based on an understanding of biological processes. While understanding is based on a number of factors, foremost amongst these is knowledge (2). The acquisition of knowledge requires concentrated, analytical thinking while reading fundamental texts. Reading a dense, detailed account of complex biological processes demands uninterrupted attention. It is at times like these that our attention – and commitment – is at greatest risk of faltering. Our mind wanders even if there are no interruptions, and it becomes impossible to maintain concentration when competing temptations flicker in front of our eyes.
In more than 100 studies, researchers in psychology and education have demonstrated that the medium of presentation has a major impact on the cognitive processes involved in reading and learning (3). Despite improvements in screen technology, studies consistently show that people understand material better and remember it better when they read text on paper than on a screen (4). The difference is partly related to what psychologists call metacognitive learning regulation, which involves setting specific goals, re-reading difficult sections, and checking how much one has understood along the way (4). Whether readers realize it or not, they approach a screen with a state of mind less conducive to learning than the mindset they bring to paper (3). Students’ estimates of the material they have learned from reading on a screen are inflated, whereas estimates based on reading on paper are accurate (4).
Psychologists also distinguish between “remembering” (a relatively weak form of recall) and “knowing” (a stronger form of memory, entailing more certainty). Experiments reveal that people reading on a screen embed more material in the weaker form of memory (5).
Physicians need not be constrained by binary thinking: we do not need to choose between screens and physical books, but instead use everything at our disposal. Computer technology is vastly superior when tracking down specific detail on rare clinical conditions. But this narrow objective should not be conflated with the task of embedding fundamental concepts in one’s memory. Adding curlicue flourishes to the ceiling is a different task from laying the foundation stones of knowledge. The screen is a good choice for superficial and speedy reading. People realize that screen information is fleeting – but are less aware that it also disappears quickly from memory. Physician decisions are based on knowledge embedded in memory, and, for comprehension and the internalization of knowledge, a physical book is superior to the screen.
1. Tobin MJ. The official copy of AJRCCM is posted but not printed. Am J Respir Crit Care Med 2002,166: 905-906.
2. Ackoff R. From data to wisdom. Journal of Applied Systems Analysis 1989;16:3-9
3. Jabr F. Why the brain prefers paper. Scientific American 2013; 309 (Issue 5):48-53.
4. Ackerman R, Lauterman T. Taking reading comprehension exams on screen or on paper? A metacognitive analysis of learning texts under time pressure. Computers in Human Behavior 2012;28:1816-1828
5. Garland KJ, Noyes JM. CRT monitors: Do they interfere with learning? Behaviour and Information Technology 2004;23:43-52.
Martin J Tobin, MD,
Editor emeritus, American Journal of Respiratory and Critical Care Medicine, and Professor of medicine, division of pulmonary and critical care medicine,
Edward Hines Jr. Veterans Affairs Hospital, and Loyola University of Chicago Stritch School of Medicine, Hines, Illinois 60141
Medical Council of India (MCI) has been facing a number of allegations about the way it works for the past several years. A number of lobbies within and outside the medical fraternity have been trying to control the way it works. These lobbies include private medical colleges, pharmaceutical companies, bureaucracy and professional organisations.
While it cannot be denied that India needs more Medical Colleges to optimise the doctor patient ratio but mushrooming of these institutions has diluted the quality of medical education. The lobby of these private colleges, which includes a number of well-connected politicians uses its influence to force MCI to relax or modify norms of admission, hospital bed requirements, requirement of faculty and even annual inspections. A large number of Medical Colleges with dismal infrastructure manage to get permission not only to admit students but also increase their intake.
The doctor-pharma industry nexus continues to flourish despite stringent rules. This is on blatant display during annual conferences and even on weekend meets organised by pharma industry in almost every major city in posh hotels where liquor and food are up for grabs.
Mr. Harsh Vardhan who himself is a doctor is aware of all the ills that plague the MCI or medical fraternity in India. The working of MCI needs to be made more transparent and the hush-hush way of working deserves to be dispensed with. He has to initiate a dialogue with all the stakeholders to identify the issues and way these may be dealt with. The least he can do is to appoint men with impeccable track record as office bearers of MCI.
It was shocking to hear about the tragic loss of such extraordinary individuals who were travelling to discuss better understanding of the HIV pandemic and its control at the 20th International AIDS Conference in Melbourne, Australia. These individuals had dedicated their lives to the study and management of one of the most significant global problems of our times which has affected more than 30 million people around the world and causes more than 3 million deaths per year.
Many of these experts were involved in studies of HIV infection and AIDS, designed to advance our understanding of the virus-host interaction with a view to improving its treatment and prevention. They will not be easily replaced.
The unfairness of losing such precious individuals at the prime of their careers in such a freak and unfortunate accident will never be properly explained. As members of the wider healthcare community we feel their untimely passing in a personal sense. However, we trust that they are at peace now.
We would like to convey our deepest sympathy and condolences to their families, friends and colleagues.
Sayed Subhan Bukhari
Leicester, United Kingdom
NHS is a great Institution and over the last 30 years I have had an amazing career and done various leadership roles and met a lot of wonderful people from all walks of life. I have done a lot of work on racism and given advice to the GMC, Manchester Metropolitan Police, DOH, BMA and many others on racism and its impact on staff well-being. Many good leaders have taken some of my advice and have made changes, many have ignored me. I have come across a lot of glass ceilings and people in very powerful positions who talk the talk but don't walk the walk and do not want to see any changes. Many of these leaders are nice people, always smile and say the right thing, produce wonderful documents but in reality nothing changes some actively make sure nothing is going to change.
There is a close correlation between BME staff in the NHS and patient safety and staff well-being. The relationship is simple. Michael West has clearly demonstrated that Happy staff - happy patients. BME staff are 3 times more unhappy in our NHS. They are more often bullied, harassed. victimised, discriminated, not promoted, not supported to do training and not rewarded properly and disciplined more often and severely. So gradually they lose interest, caring and compassion and they just do a job. This puts patients at risk. Many BME staff are under stress, demoralised and some are frightened even to raise concerns about patient safety or their own well-being for the fear of intimidation. One has to look at what happened to BME Whistle Blowers whose lives are destroyed and many struggle to find jobs.
Then there is club culture and old boys network, racism and sexism and NHS appoints many poor leaders on the basis of these cultural issues. Many doctors are trained to be leaders and many do bad job as leaders. Most of them are not bad people and in fact many are good clinicians and good people but simply not good enough to be leaders. Many good doctors with potential to be leaders are not appointed because of their race or gender.
Most of the time discrimination is subtle and subconscious/unconscious. As it is subconscious even those who discriminate are not aware of it. They are good people. It is prejudices of good people that is the fundamental problem in this country and more so in the NHS. Be it discrimination in day to day life, be it exam results, be it disciplinary action, be it promotions or clinical excellence awards. Poor leaders fail to tackle poorly performing doctors for a long time and these doctors keep on harming patients. Patients suffer.
This article is timely and hope this will wake the conscience of some good people and they recognise their own prejudices and make sure that the NHS has good leaders who promote good culture and all staff are looked after well so that NHS can be a great Institution both for patients and for staff irrespective of race, gender, ethnicity or place of qualification.