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When suspicions turn to real evidence

BMJ 2019; 365 doi: (Published 11 April 2019) Cite this as: BMJ 2019;365:l1704
  1. Tom Moberly, UK editor
  1. The BMJ
  1. tmoberly{at}
    Follow Tom on Twitter @tommoberly

Clinical studies sometimes surprise us, upturning conventional wisdom and forcing us to rethink our understanding of a condition. At other times they can disappoint, when promising treatments turn out not to have any real benefits for patients.

A study reported this week (doi:10.1136/bmj.l1255) fits another tradition: supporting and quantifying a link that has long been suspected to exist but for which evidence has proved hard to find. In this case, the question is whether severe stress can trigger a cardiac event. Studies to date have been too small to provide more than limited evidence about any link between post-traumatic stress disorder—the most widely studied form of stress related disorder—and specific types of cardiovascular disease.

Huan Song and colleagues from the University of Iceland sought to rectify this by using the national health registers in Sweden, which provide almost complete information about medical diagnoses and family relationships among people in Sweden. The team were able to support the idea of an increased risk of acute cardiovascular event in people with a diagnosed stress related disorder.

They also estimated the scale of this risk, finding that the risk of cardiovascular disease is elevated in the first year after diagnosis of a stress related disorder. Detailed information about the risks of cardiovascular disease in these patients could help to mitigate those risks.

But the study was unable to rule out the possibility that people with underlying cardiovascular disease are more prone to stress related disorders, as explained in an accompanying commentary by Simon Bacon.

Elsewhere in this week’s journal, Melissa Clarkson and colleagues make a strong case for abandoning the term “second victim” when it refers to doctors involved in medical error (doi:10.1136/bmj.l1233), as they find that it promotes a mindset that is incompatible with patient safety and accountability. They say that many physicians are also uncomfortable with the term.

“There is a seductiveness to labelling yourself as a victim,” argue the authors. “Victims bear no responsibility for causing the injurious event and no accountability for addressing it . . . We know who the actual victims of medical errors are because we arranged their funerals and buried them.”