Flying off to Berne to talk about general practice in the future, I met a GP colleague in the airport. A conversation contrasting theory and reality. Asked to talk to Swiss GPs about the best models of European general practice, with particular focus on the UK, I looked back on the effect of the 2004 GP contract, which was designed to help with poor morale and under payment—and introduced radical new changes with a performance related component to income (Quality and Outcomes Framework—QOF) and major changes to out of hours. more…

I cannot have pot plants in the house. The overwhelming smell of pot plants and stale urine is my lasting memory of visiting residential and nursing homes many years ago as a GP trainee in Devon. Rows of pot plants arranged in the hallway and rows of elderly people in front of the television. This memory is, perhaps unfairly, coloured by my lack of experience and feelings of powerlessness at the time—as an inexperienced trainee I hadn’t seen many older people in the community and I wasn’t sure what to do. These homes were often in adapted older buildings which, despite modification, were probably unsuited for purpose and staffed by nurses displaced from mainstream nursing or washed up in a career cul de sac. I didn’t enjoy it. more…

We don’t celebrate success enough in medicine. We sometimes mutter, grumble, and gripe, but we seldom congratulate our friends and colleagues on their success. What a pleasure therefore to attend the Welsh Clinical Teacher of the Year Awards in the beautiful Royal Welsh College of Music and Drama. A gala evening of recognition for those who inspire a generation. Most awards are static, contemporary, or retrospective, but while those nominated enjoyed their moment of recognition, their teaching lasts a lifetime—influencing doctors and helping patient care for years to come. more…

When it all goes wrong, that’s when you are really tested. Quantas pilot Captain David Evans described what happened when an engine disintegrated in mid air on Flight QF32 and three large metal shards pierced various parts of the huge A380 aircraft causing major systems failure. Only one of four engines could operate at normal capacity, fuel spilled from the tanks, and the aircraft was severely disabled. Parts of the engine fell on Indonesia, misreported on Twitter as a crash, which immediately made international news headlines, yet the plane was still in the air. The crew stabilised the plane, but still had to land an overweight aircraft at excess speed, with overheating brakes, leaking fuel and, from their calculations, just 139 metres to spare on the runway in Singapore. And, even when they landed, with one engine failing to shut down, there was still a very high risk of fire. The operation was a success—everyone survived. more…

“Stroke care was woeful,” said Dame Ruth Carnall, former chief executive of NHS London, in her sobering account of efforts to change the system. Less than 1% of patients had thrombolysis, less than 50% were treated in specialist stroke units, and standards were low across a whole range of indicators. Poor care, low standards, and it looked as if it was getting worse. Resource was geographically misplaced too—more strokes occurred in the peripheral population, but the hospitals were central. more…

On welcoming 3300 delegates from 80 countries to the International Quality Forum in London, home of the BMJ, Fiona Godlee (editor in chief, BMJ) asked us to remember the recent marathon trauma at the home of Institute of Healthcare Improvement (IHI) in Boston. All the more poignant as we congregated at Excel, the registration centre for next Sunday’s London marathon. Maureen Bisognano (IHI), in her opening  address, applauded the response of the medical services in Boston and how it highlighted the key attributes of an exemplary health service; reliability, resilience, and empathy. Maureen had some serious questions—when we look at data, are we looking back or are we using the data to predict and prevent problems for the future.  She asked us not to think in terms of  “what’s the matter medicine, but what matters to you.” Medicine tends to focus on efficiency and effectiveness, and we need to think more about empathy. Patient engagement, she said, is the next blockbuster drug. more…

April 6th was World Physical Activity Day—did you miss it? Probably good news. Best to keep doctors out of it. Let me explain: I believe passionately in the benefits of physical activity, have researched it, published, editorialised, practised, and promoted it at every opportunity. The benefits of physical activity are undisputed and physical activity is to be encouraged, supported and facilitated where ever possible. But I am not sure that doctors have a central role. more…

What is a good clinical teacher? Asked to host an awards ceremony, I have been thinking about it. At the BMJ we focus on “Helping doctors make better decisions” and in the education section we produce great content. That’s the easy part. Teaching is much more than reproducing this content. Its about passing on knowledge and its also about encouraging, stimulating, and inspiring future generations. more…

Gathering evidence is clear straightforward science. Right? Not if you believe the speakers at “Evidence Live.” Today’s presentations were a challenge to believers. Fraud, misconduct, non disclosure of data, and conflict of interest were just part of the problem. Peter Wilmshurst (University Hospital of North Staffordshire) whose dedication to the truth in the face of lawyers and pressure from pharma and manufacturers, entranced us with his career long battles for the truth. He catalogued a series of attempts to alter, manipulate, and influence research evidence in both drug and technology development. Tom Jefferson (Cochrane Acute Respiratory Group), who continues to seek the data on Tamiflu, believes that 60% of evidence is not published, and often only part of the information is made available. The public have invested a huge amount of money—we have a right to know what a drug does. more…

Essentialist or consequentialist? Patrick Bossuyt (University of Amsterdam) introduced this concept at the “Evidence Live” conference. Thinking about diagnostic testing he suggested that, rather than focus on the nuts and bolts of a diagnostic test (sensitivity, specificity etc), we might also consider the downstream effects. We know there are benefits to accurate diagnostic testing, but there are also potential harms. In this context, he discussed karyotype testing in recurrent miscarriage and how it might alter a couple’s decision on a further pregnancy and may, for example, dissuade them from considering extending their family. Patrick emphasised the need for further research on the consequences of diagnostic testing but, Richard Saitz (Boston University) reminded us during questions, that the consequences will always be confounded by the prior decision.   more…