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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles.

Re: Funding boost aims to expand England’s medical school places Adrian O’Dowd. 374:doi 10.1136/bmj.n1998

Dear Editor

Last month, O’Dowd (1), highlighted the proposed expansion in medical school places to meet the demand for the increased numbers of students fulfilling their offer requirements.

Whilst more doctors are clearly needed, simply pouring more newly qualified medical students into the medical workforce bucket does not address the holes and leaks that have resulted in thousands of highly skilled and knowledgeable individuals leaving to work abroad, retire early or leave medicine entirely.

The GMC estimates around 4% (which equated to approximately 4,950 doctors) permanently leave the NHS every year. The European average is 3.2%. Furthermore, many others will seek new opportunities abroad (2).

It is too early to know exactly how the pandemic will affect the number of doctors leaving the NHS. However initial estimates by a 2021 BMA survey suggest that, 21% of doctors were more likely to work in another country, 18% were more likely to leave the profession entirely and 26% were more likely to take a career break as a result of the pandemic (3). But why?

Put simply, we nurture a system which treats doctors badly.

Doctors feel overworked in an underfunded system. This is unsurprising, given that working beyond rostered hours seems to be the norm in the NHS (2). COVID-19 has placed unprecedented strain upon the NHS and its workforce and so it is perhaps predictably, self-reported levels of burnout, anxiety and stress exceed 50% (3).

Throughout the pandemic NHS staff have been portrayed as heroic and selfless. This is of course undoubtedly the case and the efforts of all staff have saved countless lives. However, in portraying staff this way, there can be no meaningful call for additional help. PPE shortages are a key example. In one of the most developed countries in the world, it is astounding that the NHS resorted to donations of equipment from the public. Moreover, 80% of doctors felt unsafe at one or more points during the pandemic, due to a lack of PPE (4). Painting doctors working on the frontline as superhumans working round the clock to save lives, leaves little room for political responsibility for the circumstances which forced them into such a position. To act in a way that is supererogatory requires it to be a choice. Working additional hours without the correct support or equipment because there was no alternative is certainly not a conscious choice. Hence it is no surprise that medics feel undervalued (particularly by politicians) (3).

We strive for a culture of safety and learning at work, but there is remains a lack of psychological safety. Whilst traditional organisations such as the GMC and CQC have continued to demonstrate a tough line on investigating doctors that come to their attention, as in the case of Dr Bawa-Garba and Mr Sellu. There is also a lack of community and trust between colleagues, many doctors fearing complaints and local investigations. In addition to this, the latest NHS staff survey indicating that 12% and 19% of healthcare professional have experienced bullying, harassment or abuse the last 12 months from their managers and colleagues respectively (5). Yet another example of toxicity being allowed entry into a system which was fundamentally created to open the doors to all. A system designed to offer free equitable healthcare for all must also afford the same rights and inclusions to all staff.

Finally, the mass exodus of doctors as they reach 55 years old, highlights the poor planning that is required to ensure that these highly experienced clinicians can continue to offer their knowledge and expertise (2). Measures such as flexible working, coming off on-call at a certain age and working in a mentoring capacity are the rarity rather than the norm.

Whilst we train more doctors than ever before, it seems worthwhile to explore why so many doctors choose to leave the NHS, to ensure that we can retain the doctors we put so much effort into training.

1. O’Dowd A. Funding boost aims to expand England’s medical school places. British Medical Journal Publishing Group; 2021.
2. General Medical Council. The state of medical education and practice in the UK: The workforce report. 2019.
3. BMA. BMA survey COVID-19 tracker survey February 2021.
4. General Medical Council. The state of medical education and practice in the UK. 2020.
5. NHS. NHS Staff Survey 2020 National results briefing. 2021.

Competing interests: No competing interests

03 September 2021
Gabriella S Quiney
Final Year Medical Student
Brighton
Re: Covid-19: 80% of young adults in UK are likely to have antibodies, data suggest Jacqui Wise. 374:doi 10.1136/bmj.n2162

Dear Editor,

Jacqui Wise reports that 80% of young adults in the UK have Covid-19 antibodies derived either from natural infection or from vaccination. (BMJ 2021:374:n2162, September 2) One hopes that the same is true of older adults and that the UK now enjoys a high level of herd immunity. She also reports that the Delta variant doubles the risk of hospitalization compared with the Alpha variant. (BMJ 2021:374:n2152, September 1) The production of broad and durable herd immunity to prevent illness from the highly transmissible and possibly more virulent Delta variant is an important issue…..

In a timely email Noel Thomas just sent me a preprint article highlighting the importance of immunity from natural infection. (https://doi.org/10.1101/2021.08.24.21262415) Gazit and colleagues in Israel compared 16,215 never-infected individuals who had two doses of the Pfizer vaccine with 16,215 unvaccinated individuals known to have had a Covid-19 infection. There were 191 symptomatic breakthrough infections with the Delta variant in the vaccinated-uninfected group and only 8 such infections in the infected-unvaccinated group. The adjusted risk of symptomatic breakthrough infections for the vaccinated group was 27.02 (P<0.001), which translates into 96.3% relative effectiveness of natural infection compared with vaccination. The authors’ summary from the data is that “natural infection confers longer lasting and stronger protection against infection, symptomatic disease, and hospitalization caused by the Delta variant, compared to two-dose Pfizer vaccine-induced immunity.”…..In addition, Binkin and colleagues in San Diego, California have observed a recent dramatic increase in Covid-19 infections in a highly-vaccinated health system workforce. (DOI:10.1056/NEJMc2112981, NEJM online September 1)

It is not too late to step back from the push for universal vaccination and allow the continued development of broad and lasting herd immunity from natural Covid-19 infections among the large majority of the population who are healthy and not elderly. (https://www.bmj.com/content/374/bmj.n2029/rr)

ALLAN S. CUNNINGHAM 3 September 2021

Competing interests: No competing interests

03 September 2021
Allan S. Cunningham
Retired pediatrician
Cooperstown NY 13326 USA <crabarbicus62@gmail.com
Re: The ripples of trauma caused by severe pain during IUD procedures Stephanie O’Donohue. 374:doi 10.1136/bmj.n1910

Dear Editor

Steven Ford's response to my r.r. seems to misrepresent my comments. Maybe it would have been clearer if I had said 'some women', but it seemed fairly obvious that I was pointing out that the examination is difficult and sensitive for some, and I would say more women than Steven Ford seems to assume. The bottom line is choice - including obviously of any gender.

I would disagree that using the words 'intimate' and 'sexual conotations' raises any misunderstandings for most medics, women or men. The reason a chaperone is used for what are intimate examinations is exactly that - there is no need to be squeamish about saying so. They can be handled sensitively by male or female nurses or doctors. It is not a problem to ask a woman her choice - bearing in mind all will not be confident enough to state that without being asked. (I have co-ordinated discussions about intimate examinations with mixed groups; more women than men have had distressing experiences.)

Competing interests: No competing interests

02 September 2021
Susanne Stevens
retired
Brecon
Re: Association between characteristics of behavioural weight loss programmes and weight change after programme end: systematic review and meta-analysis Peter Scarborough, Anastasios Bastounis, Anna Dunnigan, Rimu Byadya, et al. 374:doi 10.1136/bmj.n1840

Dear Editor,

As a fifth-year medical student in the United Kingdom, I found the article, ‘Association between characteristics of behavioural weight loss programmes and weight change after programme end: systematic review and meta-analysis’ (1) to be particularly informative. The main limitation found was failure to take into account the psychological aspect of weight loss and mental health support.

The article effectively compared characteristics of weight loss programmes such as: provision of meal replacements, strategies to change diet, and/or physical activity. I acknowledge that the characteristics provided by the article would benefit the review of weight loss programmes. However, I am highlighting the need for further investigation into psychological support.

Literature has established that mental health disorders such as depression can increase the risk of developing obesity with one study suggesting a 26-31% increase in risk (2). The presence of mental health disorders can impact patients’ ability to successfully lose weight or maintain weight loss (3). Therefore, it would be of interest to take into account support provided surrounding weight and mental health.

This emphasises the importance of including psychological support concerning weight and weight loss as a characteristic of the behavioural weight loss programme. Inclusion of this characteristic in the study would allow a more thorough understanding of the efficacy of weight loss programmes. In the future, this research could enable patients to maintain their weight loss for longer periods of time.

1. Hartmann-Boyce J, Theodoulou A, Oke JL, Butler AR, Scarborough P, Bastounis A, et al. Association between characteristics of behavioural weight loss programmes and weight change after programme end: systematic review and meta-analysis. BMJ. 2021 [cited 2021 Sept 1]; 374(n1840). Available from: https://doi.org/10.1136/bmj.n1840

2. Mulugeta A, Zhou A, Power C. et al. Obesity and depressive symptoms in mid-life: a population-based cohort study. BMC Psychiatry. 2018 [cited 2021 Sept 1]; 18(297). Available from: https://doi.org/10.1186/s12888-018-1877-6

3. Alhalel N, Schueller M, O’Brien MJ. Association of changes in mental health with weight loss during intensive lifestyle intervention: does the timing matter?. Obesity Science and Practice. 2018 [cited 2021 Sept 1]; 4(2):153-158. Available from: https://doi.org/10.1002/osp4.157

Competing interests: No competing interests

02 September 2021
Annareet K Kandola
Medical student
Manchester, United Kingdom
Re: Risk of hospital admission with covid-19 among teachers compared with healthcare workers and other adults of working age in Scotland, March 2020 to July 2021: population based case-control study Jen Bishop, Martin Reid, Jane White, Marion Campbell, et al. 374:doi 10.1136/bmj.n2060

Dear Editor

This is an interesting and informative article that provides a great deal of information and new analysis. However, the authors themselves identify a number of limitations with the study and data gaps. From the perspective on an NGO working with education staff, we would like to flag up the following points:

1. During this period many teachers were either isolating or teaching online which would remove/reduce the risks of infection

2. There remain major issues in schools about ventilation, building design, class sizes, masks in primary schools, physical distancing and pupil numbers and as we have seen now since the return of children to schools after the summer break infection rates will increase if these are not addressed

3. There is a lack of reference to a Zero-Covid solution to the spread of the virus, one that reduces and controls transmission

4. It does not acknowledge that there is a lack of data about how effective ventilation is in all Scottish educational establishments

5. We also know now that many people have been left with long term ill health and disabilities resulting from Covid-19 infections and some that did not require hospitalisation

6. There is also a lack of investigation about the consequences of infections of teachers and the spread of the virus to their family members

7. Vaccination is just another mitigation in the fight against the virus but many people have been double vaccinated and are still infected and infectious and of course children have not been vaccinated and many young people still only had one vaccination

8. The headline of the press release is misleading - 'BMJ Press Release: Teachers not at increased risk of hospital admission or severe covid-19 during 2020-21 academic year'

9. The SAGE SMI-M-O warning and the subsequent significant increase of cases in schools since Scottish schools returned, is a major concern to teaching and school staff, pupils and parents and this article does not address those issues.

With best wishes

Janet Newsham

Competing interests: No competing interests

02 September 2021
Janet A Newsham
Coordinator
Windrush Milennium centre, 70 Alexandra Road, Manchester, M16 7WD
Re: Risk of thrombocytopenia and thromboembolism after covid-19 vaccination and SARS-CoV-2 positive testing: self-controlled case series study Sharon Dixon, Kamlesh Khunti, Francesco Zaccardi, Peter Watkinson, et al. 374:doi 10.1136/bmj.n1931

Dear Editor

This is a very helpful analysis comparing ADRs after the first dose of ChAdOx1 nCoV-19, or BNT162b2 mRNA vaccines, with SARS-CoV-2 infections in the vaccinated population. It shows clearly all vaccines cause adverse events, and these may rarely be lethal, but SARS-CoV-2 infections are quantitatively and qualitatively far more likely to cause more severe outcomes.

It is already established that the risk of infection with SARS-CoV-2 is reduced in vaccinated people, with two doses being more effective than one, particularly after 28 days.(1,2)

It appears that in the small proportion of vaccinated people that develop SARS-CoV-2 infections, there is no difference in disease severity. (3)

I look forward to the next publication that includes follow up after the second dose of each vaccine

References
1. Sheikh A, McMenamin J, Taylor B, Robertson C; Public Health Scotland and the EAVE II Collaborators. SARS-CoV-2 Delta VOC in Scotland: demographics, risk of hospital admission, and vaccine effectiveness. Lancet. 2021;397(10293):2461-2462. doi:10.1016/S0140-6736(21)01358-1
2. Griffin JB, Haddix M, Danza P, et al. SARS-CoV-2 Infections and Hospitalizations Among Persons Aged ≥16 Years, by Vaccination Status — Los Angeles County, California, May 1–July 25, 2021. MMWR Morb Mortal Wkly Rep 2021;70:1170–1176. DOI: http://dx.doi.org/10.15585/mmwr.mm7034e5
3. Butt AA, Yan P, Shaikh OS, Mayr FB. Outcomes among patients with breakthrough SARS-CoV-2 infection after vaccination in a high-risk national population. EClinicalMedicine. 2021;40:101117. doi:10.1016/j.eclinm.2021.101117

Competing interests: No competing interests

02 September 2021
(W) Jane Smith
GP and Academic
Bond University, Gold Coast, Queensland, Australia
Re: Should I take an “F3” year? Abi Rimmer. 374:doi 10.1136/bmj.n2081

Dear Editor,

As undergraduate medical students, we enjoyed the perspectives recounted in the article ‘Should I take an F3 year?’ and found them helpful in considering the future of our own professional careers. The article highlights the absence of opportunities provided during both foundation and undergraduate training, including the chance to experience different specialities in their day-to-day unfiltered state. The accounts of F3 training documented by Rimmer mention the benefits of taking an F3 year.[1] However, we felt the editorial doesn’t address some of the perceived disadvantages, as well as the reasons for reduced appeal of taking up specialty training posts following foundation training.

As the article mentions, many medical students leave university undecided on their future career. The UK foundation programme itself provides only a short snapshot of life as a doctor in an even more limited pool of specialties. As students due to graduate in under a year, this comes as a disheartening prospect.

Opportunities for realistic experiences, in addition to ‘observing on the side’ for the ‘interesting’ events, would give students an insight into how different specialities function. For example, students taking on job roles as healthcare assistants found that they were able to witness a new perspective; not only allowing themselves to gain a better understanding of the department that they were working in, but also providing them with enhanced learning opportunities[2].

Furthermore, the popularity of F3 programmes is in part due to the increasing discontent with specialty training posts within the UK. The number of foundation doctors entering specialty training immediately after F2 has declined since 2011, hitting a low of 34.9% in 2019. [3] Many doctors in these posts feel undervalued and overworked compared to those in F3 positions.[4] Training programmes may be able to learn from these “F3” programmes to provide doctors with the support and autonomy highlighted in this editorial.

Despite recounting ample reasons in favour of taking an F3 year, the article does not highlight many specific disadvantages. Some training pathways may look unfavourably upon an F3 year if one has not provided evidence of personal or professional development during their time out of formal training. This puts pressure on individuals who may wish to be taking an F3 year to pursue personal milestones, or simply to explore other endeavours.

References:

1. Rimmer, A. Should I take an “F3” year?, bmj. 2021, 374.
2. Nolan H, O. K. Qualitative exploration of medical student experiences during the Covid-19 pandemic: implications for medical education, BMC Medical Education. 2021, 21, 1-11.
3. Programme, U. F. 2019 F2 Career Destinations Survey Report See https://foundationprogramme.nhs.uk/resources/reports/ for further details. Accessed September 01 2019.
4. AC Hollis, J. S., Van CV, Milburn L, Alberti H The new cultural norm: reasons why UK foundation doctors are choosing not to go straight into speciality training, BMC Medical Education. 2020, 20, 1-9.

Competing interests: No competing interests

01 September 2021
Kate E M Gibbons
5th year medical student
Olivia B K Helston, Hugh C Dalton
University of Manchester
Manchester
Re: Partha Kar: Jealousy, rivalry, and disdain—the toxicity of specialty stereotyping Partha Kar. 374:doi 10.1136/bmj.n2080

Dear Editor,

To a point, human and natural, and with a rising number of sub-specialities, the phenomenon described by Partha Kar is decidedly on the rise.

In the Institute set up, it's the PhDs versus clinicians; furthermore, medical (docile) versus surgical (cutting) are some arbitrary divisions within the mind, unspoken but on occasions vigorously debated.

Anaesthesiologists as 'people behind the curtain' appear to be not duly credited by the patient community as well. Within Cardiology, 'Interventionists' are bold heroes till a cardiac surgeon is required for CABG.

Within Radiology, often derided as passive in the past, currently 'Interventional 'Radiology' sub-specialists enjoy glory with access to practically all organs and blood vessels. In other specialities, where the 'endoscope' prevails, the skilled ones are considered 'privileged' by patients and 'selves'. Proving oneself is the general aim, but basking in glory, and perpetually, is the 'mission' of many an ambitious professional.

Observing these people at work, with comments that are 'mixed ' can be both amusing and occasionally disturbing, if crossing the limits of 'toxicity'. Professional life need not be drab and dull, but adding humour and colour is possible without hurt or insult or rivalry.

Dr Murar E Yeolekar, Mumbai (Fmr Dean / Director, King Edward Memorial Hospital, Mumbai).

Competing interests: No competing interests

01 September 2021
Murar E Yeolekar
Consultant Physician
Fmr Prof & Head of Internal Medicine, KJSMC &LTMMC
Sion, Mumbai 400 022
Re: Nine in 10 female doctors in UK have experienced sexism at work, says BMA Abi Rimmer. 374:doi 10.1136/bmj.n2123

Dear Editor,

Thank you for this article, and to the BMA for conducting such an important study.

As female medical students, it does not surprise us that nine out of ten female doctors have experienced sexism at work. It would also not be surprising if similar statistics were found among female medical students. In this year (2021) alone our experiences include, but are not limited to, being told not to pursue certain specialties because they are too difficult, being signposted to specialties more appropriate for women, receiving comments that our uniform is too tight, and having clinicians speak only to our male counterparts and not to us.

If medical students, at the start of their career, are being educated in an environment which is already discriminating against women, then is it surprising that new generations of male doctors are adopting the behaviours of their seniors? Or that their female equivalents are learning that sexism is just part of the job?

We are often told that sexism will phase out as older generations retire. However, some forms of discrimination come directly from our male student colleagues, this can be even more upsetting as it comes from our peers. How is the NHS meant to limit the spread of sexism within the workplace if medical students are already discriminating against their female counterparts?

By incorporating education on sexism into medical school curriculums, and creating an environment of equality in clinical placements, the amount of discrimination experienced by female doctors could be reduced. This could impact both today and the future. This is a difficult battle to fight, but one which we are prepared to take on, aided by our future employer - the NHS.

At the end of the day, we all go through the same training, there is nothing that separates us other than the attitude and education of our peers.

Competing interests: No competing interests

01 September 2021
Freya E Web
5th Year Medical Student
Kate Gibbons, Nina L el-Ahwany
Manchester University, Oxford Rd, Manchester, M13 9PL
Re: NICE approves new cholesterol lowering drug after NHS strikes deal with manufacturer Jacqui Wise. 374:doi 10.1136/bmj.n2143

Dear Editor,

Has the world gone mad?

The NICE recommendation starts from a presumption that the more you can lower LDL-C the better the cardiac protection. This is total nonsense, as I pointed out last year (see "Do PCSK9 inhibitors do anything more than reduce LDL cholesterol? BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1159). The original inclisiran drug trial was terminated early. It showed that there was a massive reduction of LDL-C, but up to the point of termination if anything (and one cannot use data from trials where the protocol has been breached) that there was an increase in cardiovascular events.

Statins have an anti-inflammatory action and lower cholesterol with a small cardiac benefit

Inclisiran does not have an anti-inflammatory effect, lowers cholesterol more than statins, but does not appear to influence cardiac events.

The only conclusion I can draw from these pieces of evidence is that cholesterol levels have nothing to do with cardiac risk, but inflammation does. The corollary is that using inclisiran is an expensive and useless exercise. It is noteworthy that the appraisal includes a large number of pre-publication comments by the manufacturer and the British Cardiac Society, but does not include any of the critical research that refutes the cholesterol- LDL link. I reference three examples which provide compelling evidence that cholesterol and cardiac risk are not directly related..

References:

1. Tuñón J, Badimón L, Bochaton-Piallat ML, Cariou B, Daemen MJ, Egido J, Evans PC, Hoefer IE, Ketelhuth DFJ, Lutgens E, Matter CM, Monaco C, Steffens S, Stroes E, Vindis C, Weber C, Bäck M. Identifying the anti-inflammatory response to lipid lowering therapy: a position paper from the working group on atherosclerosis and vascular biology of the European Society of Cardiology. Cardiovasc Res. 2019 Jan;115(1) 10-19. doi:10.1093/cvr/cvy293. PMID: 30534957; PMCID: PMC6302260.

2. Serious flaws in targeting LDL-C reduction in the management of cardiovascular disease in familial hypercholesterolemia. Ravnskov, Uffe, Lorgeril, Michel, Kendrick, Malcolm, Diamond, David M.
Expert Review of Clinical Pharmacology 2021; 14 doi: 10.1080/17512433.2021.1889368

3. DuBroff R, Malhotra A, de Lorgeril MHit or miss: the new cholesterol targets
BMJ Evidence-Based Medicine Published Online First: 03 August 2020. doi: 10.1136/bmjebm-2020-111413

Competing interests: No competing interests

01 September 2021
Andrew N Bamji
Retired consultant rheumatologist
None
Rye

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