On a tour of WHO headquarters, in Geneva, I wandered past a vast cellar of shrink wrapped unused and unread guidelines. It occurred to me that, given around 7% of clinical “facts” become outdated each year, these guidelines were rapidly passing, or already past, their “use by” date [1]. While glossy journals, 500 page systematic reviews, and grand guidelines are all worthy, clinical impact only occurs when someone reads, digests, and acts on the information. more…

When the Beatles claimed that they “don’t care too much for money, money can’t buy me love,” they did not provide scientific references. While we might hope that statements of fact or causation in popular songs are based on a systematic review of the controlled trials, my guess is that we are a long way from evidence-based pop songs (evening entertainment at Cochrane Colloquia excepted). But if money can’t buy love, maybe it could be better spent on clinical quality improvement? That certainly seems to be a strong current fashion, known as “financial incentives,” or its close cousin “Pay for Performance.” Mention these terms in medical company and there seems to be a polarized reaction. The camps might be characterised as either the “Albert Schweitzers” who believe that clinical work should be driven by an altruistic interest in the benefit for patients (with an adequate but unlinked remuneration), and the “Gordon Gekkos” (who said in the movie Wall Street: “Greed is right; greed works”) who believe that money drives all behaviour and is therefore the key to improving quality. more…

Innovation is currently fashionable. But new is not necessarily better [1]. Progress rests in sifting out the effective innovations. Edison clearly understood this process: when he developed the light bulb, he tried and discarded thousands of possible filaments. Without testing and recording each option, he may have gone on a random walk and left us in the dark. But persistence despite failures paid off. When a reporter asked him about his lack of success he replied: “Young man, why would I feel like a failure? And why would I ever give up? I now know definitively over 9,000 ways that an electric light bulb will not work. Success is almost in my grasp!” more…

Dear Santa,

This year, instead of presents I wondered if instead you might take some things away?

Maybe you could start with unnecessary tests, unhelpful diagnoses, and over treatment? These can be harmful to the individuals who receive them, but also results in patients with real medical needs having delayed or no services. If we could pare back to things with a demonstrable overall benefit, both groups would be better off.

I am not sure how long the Christmas wish list of an adult is allowed to be, but let me start with diagnoses—could we have a few less please? more…

Do you regularly read Chronobiology International? No, me neither. But that was the source journal for the article we read at a recent GP journal club I attended in Perth (Western Australia, not Scotland). It reported the 5.6 year follow up results of a 2,000 patient randomised trial that compared evening to morning dosing of antihypertensives[1]. That’s a clinically important question for GPs. The rather surprising result was that night time dosing led to a statistically significant halving of mortality. However the intermediate effects—of slightly lower daytime blood pressure and less nocturnal dipping—did not seem enough to explain the impact. The triallists were probably “lucky” and the reduction found was an overestimate. Nevertheless, given the lack of harms, we agreed it was reasonable to recommend evening dosing (and fitted in with how folk should take statins). more…

Disease labels have an aura of authority and permanence. But definitions can drift considerably over time changing who is and is not classified as “diseased.” For hypertension, Greene [1] has nicely documented the steady lowering of the threshold over the past five decades, but we have kept the same label and same attitudes. It might be more truthful to say “you have hypertension version 3.1,” or perhaps we should drop the term altogether? Up until the 1950s “hypertension” was used for symptomatic patients, but most now labelled as hypertensive are asymptomatic, and the threshold BP has dropped steadily. But in asymptomatic patients we are concerned with cardiovascular risk and blood pressure is only one of several risk factors.  Perhaps it is time to drop the individual risk factor arbitrary dichotomies (hypertension, hypercholesterolemia, obesity, and even diabetes), and focus on what patients are concerned about—cardiovascular risk. more…