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The Change Page

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39161.561736.55 (Published 22 March 2007) Cite this as: BMJ 2007;334:0
  1. Fiona Godlee, editor
  1. fgodlee{at}bmj.com

    To change one's life, said the psychologist and philosopher William James, start immediately, do it flamboyantly, and allow no exceptions. In medicine, flamboyance may not be a prerequisite, but change we must, and continuously, if we are to take in new knowledge and ensure the best possible care for our patients.

    So in case you missed it the first time round, let me introduce you to a new regular feature in the BMJ—the Change Page. Developed from an idea from Joe Collier, former editor of the Drug and Therapeutics Bulletin (www.dtb.org.uk), the Change Page does what it says on the tin. The idea is to provide doctors with a single page highlighting a change in practice—either to stop or start doing something—for which the evidence is clear and where practice lags behind. As it says in the blurb, “the change must be implementable and must offer therapeutic or diagnostic advantage for a reasonably common clinical problem. Compelling and robust evidence must underpin the proposal for change.”

    In the first Change Page, published a few weeks ago, Paul McManus and Ike Iheanacho alerted clinicians to the need to stop using minocycline as first line antibiotic treatment for acne (doi:10.1136/bmj.39048.540394.BE). This week, A John Camm and Irina Savelieva say that some patients with paroxysmal atrial fibrillation should carry flecainide or propafenone to self treat to avoid hospital admission ( doi:10.1136/bmj.39143.720602.BE). The Change Page will appear once a month initially, but if it proves popular our aim is to go weekly. If you want to propose an evidence based change in practice, please email changepage{at}bmj.com. Your proposal, and the strength of the evidence behind it, will be evaluated by Joe Collier and the Change Page team before we commission an article.

    We have no doubt that some of the changes suggested will prompt debate. Is the evidence robust enough to give such a strong recommendation for change? The recommendation on minocycline was based on a Cochrane systematic review of 27 randomised controlled trials. Not so this week's recommendation. While there is good evidence for using flecainide and propafenone for paroxysmal atrial fibrillation in hospital, the authors report only one study outside hospital, and this used the patients' own historical data as controls. The effect on hospital admission, however, was substantial (a 10-fold reduction), and we and our peer reviewers judged that the evidence was compelling. Helpfully, the recommendation concurs with international guidelines.

    As for knowing (and showing) whether practice lags behind the evidence, this may prove even more contentious. The Change Page team rely on data about current practice from proponents, which is checked and augmented by peer reviewers. An important feature of the Change Page is that it addresses potential barriers to change. We would like to hear from you if implementing the recommended change presents problems for you, and why.

    Of course not all change is an improvement. A near contemporary of William James, Robert Frost wrote that “most of the change we think we see in life is due to truths being in and out of favour.” Theodore Dalrymple recalls a comment by one book reviewer, that Recent Advances in Psychiatry might be better titled Recent Activity in Psychiatry (doi:10.1136/bmj.39157.666806.47). We hope the Change Page will provide a sound basis for improvement in this ever changing world.

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