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Mark Mikhail: The death of bedside teaching

15 Dec, 16 | by BMJ

mark_mikhailTeaching in medical school has thankfully and quite rightly changed. Gone are the days when a consultant in a three piece suit, bow tie, and braces would float from bed to bed, without any discussion or consent, pointing out painful and disfiguring pathologies on traumatised patients, and only revealing the eponymous syndrome after 17 anxious, but eager medical students had, with trembling hand, fully demarcated the extent of the disease. There are of course obvious disadvantages with this method. Most importantly the patient feels degraded, isolated, and no more informed about their condition. This being said there are huge advantages, and a similar “bedside teaching” as described above still occurs with great effect in less economically developed countries. This has been witnessed by myself, with discomfort, on a recent trip to Africa. more…

Katherine Sleeman: The price of life

15 Dec, 16 | by BMJ

katherine_sleeman“More life with your kids, more life with your friends, more life spent on earth—but only if you pay” was the message of AA Gill’s posthumous essay published in the Sunday Times this week. His death from lung cancer, at 62, saddened and shocked readers of his column, where he had announced less than a month before that he was suffering from “an embarrassment” of cancer.

The “paying” Gill referred to was for Nivolumab, an immune checkpoint inhibitor shown to be effective as a second line treatment in NSCLC. A 2015 NEJM RCT showed Nivolumab increased survival in NSCLC by a modest but significant three months. [1,2] But Nivolumab is expensive, costing around £60,000 per year. How much is three months of extra life worth? For any one individual desperately hoping for more life spent on earth, this is an unanswerable question. But for our population the answer is more clear: the NICE threshold for recommending treatments to be used in the NHS is between £20,000 and £30,000 per Quality Adjusted life Year. And this rules out Nivolumab. more…

Tara Lamont: Seize the day or the decision maker—making research count

14 Dec, 16 | by BMJ

Tara_Lamont_3Timing can be everything. A policymaker once said to me that a perfect piece of analysis arriving the day after a decision has been taken is useless. Obvious, but worth repeating. Because in discussing how we maximise the impact of research, we often overlook the role of serendipity and timing. We advise researchers on careful planning, identifying audiences, and tailoring findings to particular communities and making use of different platforms. But sometimes it can be about providing “good enough” evidence at the right time in the right form to the right people. more…

Mary Higgins: Where dartboards and dominos meet after an adverse event

13 Dec, 16 | by BMJ

IMG_0701Occasionally, when talking to women who have experienced an adverse outcome, I come across someone who takes me completely by surprise with their kindness and generosity.

These are people who entered pregnancy expecting only one outcome, and exited with a completely different one—their dreams in shreds. And yet these amazing people can ask how a staff member is, wondering if they are okay after everything.

The reason this generosity and kindness completely floors me every time it occurs is that there really isn’t any reason this woman needs to think about others, because frankly this should be about her. more…

Jonathan A Michaels: Bridging the gap between academics and practitioners

13 Dec, 16 | by BMJ

jonathan_michaelsDuring my career as a clinical academic I have seen considerable changes to the clinical, academic, and financial structures within the NHS associated with the introduction of evidence-based practice and elaborate systems for evaluating and recommending on the use of healthcare technologies. [1] Whilst the improved use of research evidence and explicit consideration of the risks and benefits of new treatments is to be commended, some of these changes may have dis-incentivised research amongst “non-academic” clinicians and created an increasing a rift between academic experts and practitioners working at the coalface. more…

Katherine McKenzie: Supporting human rights, one patient at a time

13 Dec, 16 | by BMJ

katherine_mckenzie

I saw the first asylum seeker around ten years ago in my clinic. He came from a country with an autocratic president against whom he had peacefully protested. The government would not accept dissent from its citizens and they arrested, detained, and tortured him. He was released, but he was told that he would be killed for any future real or perceived opposition. He fled to the United States for safety, and eventually presented to my office for a medical forensic exam to document the scars of his torture. more…

Nick Fahy: Can real inter-sectoral working address deep-seated inequalities?

12 Dec, 16 | by BMJ

nick_fahy2Many doctors will have had the frustration of dealing with health problems that are actually the result of much more deep-seated social inequalities, some with their roots going all the way back to education and childhood. But how do we avoid just putting plasters on these underlying problems? How do we address these wider issues affecting health?

This was the focus of a two-day high-level conference last week in Paris, convened by the World Health Organization’s Regional Office for Europe. The WHO’s European strategy for health already goes in this direction, by aiming to improve not just health but “well-being,” which immediately brings in a much wider set of factors like employment and communities. But it’s all very well for us health people to show the need for action by others. It’s much more difficult to get other ministries and departments to actually do something. more…

Helen Wood: End of life care and intracranial haemorrhage

8 Dec, 16 | by BMJ

eolcAs a care of the elderly registrar currently working in a district general hospital, I am very familiar with the following story, and it is likely to be recognised by others who take part in the on-call medical take, as well as those who work in accident and emergency, neurosurgery, and palliative medicine.

It is midnight and the stroke thrombolysis bleep goes off. You get there as quickly as possible and meet an 83 year old man, previously independent, who has been brought to the emergency department with a Glasgow coma scale (GCS) score of 9/15 and dense right sided weakness. more…

Nick Hopkinson: Air quality—what’s the point of warnings?

8 Dec, 16 | by BMJ

nick_hopkinson

The Thames is wreathed in smog—the Mayor of London, Sadiq Khan, issues an air quality alert and announces a new system of air quality warnings. There will be road-side dot matrix message signs on the busiest main roads into London, with instructions to switch engines off when stationary to reduce emissions. Air quality messages will be displayed on countdown signs at bus stops and river pier signs across the city as well as electronic update signs in the entrances of all 270 London Underground stations. Down the line from the studio the breakfast TV interviewer asks “what’s the point of the warnings, what can anyone do?” We have no choice but to breathe the air that’s there, so on the face of it this is not an unreasonable question. In fact there are three important constituencies these warnings are addressed to. more…

Sarah Radcliffe: A future NHS that meets the needs of people living with HIV

7 Dec, 16 | by BMJ

sarah_radcliffeWhat does it mean to describe HIV as a long-term condition (LTC)? It has become common terminology in policy and media discussions, but the use of this phrase within NHS commissioning can still make some people living with HIV and some specialist clinicians uneasy.

The unease stems mainly from the concern that calling HIV a LTC may imply it is less serious or a less complex condition now that treatment is available. But many long-term conditions are serious and can cause serious illness in the absence of treatment. HIV will not for the vast majority of people require hospital admission, but it continues to be a complex condition that will need specialist clinical input into the foreseeable future. There are of course specificities around HIV, not least that it remains a stigmatised condition. The impact of stigma, however, is a consideration for how the NHS should meet the LTC support needs of people living with HIV—not a reason against framing HIV in these terms. more…

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