Some help with your clinical dilemmas
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l693 (Published 14 February 2019) Cite this as: BMJ 2019;364:l693All rapid responses
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My usual Sunday morning flick through the BMJ and the BMJ Confidential profiles on the last page threw up an interesting observation. All the (wonderful) women of colour featured in the issues I looked at are in Rwanda -Agnes Binagwaho, US -Esther Choo, Malaysia - Pascale Allotey, Australia- Dr Ranjana & Scotland- Dr Chakrabarti.
We know that 40% of NHS hospital doctors & 28% of GPs are people of colour (NHSE data) and that around half will be women. We also know that evidence shows that diversity enhances creativity and leads to better decision making and problem solving. A recent Harvard Business School study on gender diversity concluded that the most talented individuals go to places that do better with diversity, and this may be what is driving diverse firms to perform better.
Roger Kline's report on the ‘Snowy White Peaks’ of the NHS states that " There is increasingly robust evidence that a diverse workforce in which all staff members' contributions are valued is linked to good patient care.”
We have to address this tilt and unequal playing field in order to deliver the Long Term Plan, retain our workforce and attract the best to work for the NHS. The recent Topol Review of the NHS digital workforce strongly emphasises the need to develop teams with the skills, confidence and leadership to transform how use use data and technology. It fails to mention that there are only around 3 women of colour in Chief Clinical Information Officer (CCIO) or Chief Information Officer (CIO) roles in the NHS although the NHS frontline using the technology will frequently be people of colour and female. This disjoint will not help us break down the barriers and resistance to change to deliver the change the NHS needs.
So it would be good if the BMJ could lead the way in profiling a more diverse group of leaders that better reflect the NHS workforce - it's hard to be what you can't see. We are out there - you just have to look.
Competing interests: No competing interests
Dear Author,
I read with interest what you mentioned as a Clinical dilemma. Actually some of the decisions taken by healthcare authorities up till now have been based on no really solid data. RCTs are frequently imperfect with a lot of confounding factors, and many of the studies in meta-analysis studies are discarded and many are really unreliable (Ref 1). The second is that many of the those studies are very expensive and can be flawed by the randomization itself when patients whom the treating doctor knows will benefit from a procedure like surgery will be directed to physiotherapy by blind randomization. Some may argue that these patients may still have surgery if they don't improve but the main concern "from the ethical point of view" if the reverse happens casts a shadow of ethical concern in the era of "Patient Centered Care". Those studies are recommended to be replaced by "Registry based research" (Reference 2), which can be randomized as suggested by a group of researchers in Sweden.
The second issue is which research to fund? In basic science such as physics, when Einstein described his equation E = mc^{2}}
it was received with enthusiasm, but did anyone then imagine that it would lead to the invention of the linear accelerator?
Most new ideas in medicine have been received badly by experts on panels and referees in famous medical journals, even with verbal insults when the techniques have been made public. For example, the work of Professor Bill Heald, who invented the TME in rectal cancer, and quoted Woodrow Wilson: “If you want to make enemies, try changing something” (Reference 3), and Haber-Gamma, who introduced the watch and wait policy in the same topic after complete clinical response after neo-adjuvant CRT. This is contrary to what happened to Einstein as there is a more embracing attitude towards research in the basic sciences.
Health authorities, panelists and referees have to change their attitude. I think we need a new start by involving patients and communities in decisions and stopping behaving like Gods and admitting that we are using tax money collected from the community which is intended to go back to the community in the form of better health care.
Unfortunately till now those decisions to publish or not, to accept or not and to fund or not are flawed by a lot of emotional superiority, background judgement "bias" and personal backgrounds.
Let us have a new start by having a campaign of "Arrogance is against Science" and make the community decide.
I know that you will never publish this but It is the truth, the whole truth and nothing but the truth but it is hard to accept. If you are not willing to publish this, at least read it carefully at least 3 times and let your real conscience decide to publish or not and imagine the effect on the community of your decision.
Sorry for being sharp as a scalpel. I always say I am a surgeon in the OR and outside the OR.
Yours,
Ahmed Farag
References:
1. Systematic Reviews and Meta-analytic Methods: Not All Are Created Equal, Karim, M.D., M.P.H. Diseases of the Colon & Rectum: November 2018 - Volume 61 - Issue 11 - p 1241–1242
doi: 10.1097/DCR.0000000000001199
Editorial
2. Quality register-based research revisited: Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, 371. doi:10.1111/codi.12957
3. A Surgical Plane: Now "Holy" In 4 Specialties Heald, Richard J., Diseases of the Colon & Rectum: September 2018 - Volume 61 - Issue 9 - p 1003–1009 doi: 10.1097/DCR.0000000000001179
4. Not Taking “No” for an Answer Habr-Gama, Angelita, M.D., Ph.D. Diseases of the Colon & Rectum: January 2018 - Volume 61 - Issue 1 - p 8–13 doi: 10.1097/DCR.0000000000000988
Competing interests: No competing interests
Re: Some help with your clinical dilemmas
Dilemmas in investigative approach (modalities and individual tests), therapeutics (choice, first line, empirical), surgical interventions (invasive, minimal, endoscopic, robotic) are almost an integral part of medical practice, likely to rise with advancements that may be plentiful, including AI. Be it invariably remembered that guidelines may be population, region, period specific and need not be considered 'sacrosanct' as translation to bedside practice can often be difficult. Clinician's past experience / standing coupled with individual patient profile and the guideline recommendations make a reasonable trio to sort out a dilemma that may arise.
Further major controversies, for instance, related to statins or angioplasty, may add to indecision. A few rules that may help: a) decision being balanced after weighing pros and cons; b) consistent with the recent / latest 'evidence'; c ) no harm or least harm, with patients' interest and well being uppermost in mind. In health policy - say, the vaccination programme, fortification of foods - the public good of the most may appear a sound guiding principle when controversies and dilemmas require to be resolved.
Dr Murar Yeolekar, Mumbai
Competing interests: No competing interests