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Richard Smith

Richard Smith: Using data to improve care and reduce waste in health systems

30 Sep, 14 | by BMJ

richard_smith_2014Annual expenditure on healthcare in the United States is currently $2.8 trillion, and about a third of it is wasted, says the Institute of Medicine. The sum wasted is about five times the GDP of Bangladesh, a country of 160 million people. This is waste on a spectacular scale, and reducing it while improving the quality of care is the main aim of the information technology developed by Optum, the services part of the UnitedHealth Group, said Richard Migliori, a former transplant surgeon and chief medical officer of the UnitedHealth Group. I don’t come to tell you what to do, said Migliori speaking last week to the Cambridge Health Network, but I hope to at least elicit your sympathy. more…

Richard Smith: Patients harmed by misdiagnosed preferences

25 Sep, 14 | by BMJ

richard_smith_2014Linda is 58 and has been diagnosed with breast cancer. She would have preferred not to have surgery but was convinced by her surgeon that it would be the best option. After her operation, the hospital contacted her to apologise as she had not had breast cancer. She’d been misdiagnosed. An inquiry, legal action, and compensation followed.

Susan is 78 and has also had breast cancer. She too did not want surgery but was told that it was the best treatment. Six weeks after her operation, she met a friend of the same age who had also had breast cancer. She had been treated with hormone therapy, having been told that she would probably die of something else before her breast cancer. Susan felt profound regret, but no action followed.

These two women have both been damaged by the health system, said Al Mulley, director of the Dartmouth Centre for Health Care Delivery Science, at a meeting at the Health Foundation last week. And, he said, misdiagnosis of preferences is everywhere. For example, three quarters of surgeons think that losing a breast is the main anxiety of women with breast cancer, but only 7% of women rank that as their main anxiety. more…

Richard Smith: Is it time to stop using the word poverty in Britain?

19 Sep, 14 | by BMJ

richard_smith_2014Is poverty yet another word that is so misunderstood we should stop using it—at least in Britain? John Lanchester, a friend of mine, argued so in the Observer. Can he possibly be right?

Lanchester doesn’t seem to be arguing that we should stop using the word poverty when we mean “absolute poverty.” When the Millennium Development Goals were set absolute poverty was defined as having to live on an income of less than $1 a day, but subsequently it was raised to $1.25. In 1980 half the world’s population lived below that line, now it’s a fifth—1.2 billion people. Few people, if anybody, would dispute that having to live on such an income is to live in poverty. Using this measure, Asia might be expected to eradicate poverty by 2030, but the Asian Development Bank has just argued that the rate should be $1.51, meaning that nearly 60% of the population of Bangladesh—a country I visit regularly—is living in poverty. more…

Richard Smith: Is global health too medicalised?

16 Sep, 14 | by BMJ

richard_smith_2014When I teach young doctors in Amsterdam about responding to NCD (non-communicable disease) in low and middle income countries, I ask them how they would allocate 100 units of resource. I give them four buckets.

One bucket is for treating people with established disease: patients with heart attacks, strokes, cancer, and chronic obstructive pulmonary disease. The second bucket is for treating metabolic risk factors, such as hypertension, hyperlipidemia, and raised blood glucose. The third bucket is for acting on the four risk factors—tobacco use, poor diet, physical inactivity, and the harmful use of alcohol—recognising that many of the interventions will be political, actions like raising the price of tobacco. The fourth bucket is for working on social determinants, such as poverty, housing, globalisation, and urbanisation. I ask the doctors not only how they will distribute their resources, but what they will do with the resources. more…

Richard Smith: Simon Stevens, chief executive of NHS England, live

12 Sep, 14 | by BMJ

richard_smith_2014When Simon Stevens, chief executive of NHS England, was buying his Sunday papers a few weeks ago he encountered an elderly woman complaining that her newspaper didn’t contain the television section. It did, as the newsagent pointed out to her before asking her, “Would you like me to walk you home?” Stevens was struck that this was a “dementia friendly community” in action. He followed the story by emphasising that the traditional “factory model of health and social care” will not solve society’s problems, including the rise in dementia. Without a redesign of health and social care services, the NHS will not be sustainable. “We don’t exclusively own the problem or the solution,” he said. more…

Richard Smith: “Psoriasis is my health”

5 Sep, 14 | by BMJ

richard_smith_2014To most doctors psoriasis is a disease to be fought, contained, and even cured, but is this far too narrow a view? John Updike, one of the greatest writers in English of the past century, had psoriasis for almost all his life, and he writes in Self-Consciousness: “Psoriasis is my health. Its suppression constitutes a poisoning of the system, of my personal ecology,” and “psoriasis is normal, and its suppression abnormal.” How can doctors who study disease and a patient who sees deep inside himself have such different views? The patient comes first, and so it is the doctors who must learn. more…

Richard Smith: Why scientists should be held to a higher standard of honesty than the average person

2 Sep, 14 | by BMJ

richard_smith_2014Although it may seem harsh, I believe that scientists should be held to a higher standard of honesty than the average person. The consequence is that they will be punished more severely for dishonesty—for example, by being banned from research for life.

The main reason for this is that science depends wholly on trust. If, for example, The BMJ receives a paper describing a trial in 200 patients, the editors don’t ask to see pictures, signatures, records, and consent forms from the 200 patients. They trust that there were 200 patients in the study, and that the researchers did what they said they did and reported the outcomes honestly. Ideally, the researchers will also recognise the limitations of their studies, although often they don’t, but at least if everything is reported honestly then the editors and readers can see the limitations for themselves. more…

Richard Smith: I hate going to the doctor

4 Aug, 14 | by BMJ

richard_smith_2014I hate going to the doctor. Don’t you? My statement is unsurprising as I’m a man and a doctor (of sorts), two groups who are known to dislike going to the doctor.

Like most Londoners, I don’t have a doctor. I belong to a practice, but take pot luck on whom I see. Last time it was a locum who was mainly interested in global health; he did some general practice to provide some income. Neither he nor I were much interested in the consultation.

So far I’ve averaged a consultation rate of about once every five years. I wouldn’t dream of going to the doctor with a cough, a cold, a fever, or most aches and pains. Something has to persist for a while before I contemplate going, and even then I usually don’t—because I don’t expect much value from the consultation. The doctor usually says: “It might be this, or it might be that. Or it could be something else altogether. We might run some tests.” more…

Richard Smith: “All problems are ultimately linguistic problems”

31 Jul, 14 | by BMJ

richard_smith2“All problems are ultimately linguistic problems,” says Muir Gray, once NHS chief knowledge officer, misquoting the philosopher Ludwig Wittgenstein. But I don’t think that he misquoted him badly, and that Wittgenstein did say something along those lines.

I thought of Muir and Wittgenstein, a powerful couple, as I read a piece in the Guardian about whether there is such a thing as “just terrorism.” My immediate response was that if it’s possible to have a “just war,” then “just terrorism” must also be possible. But don’t terrorists kill civilians? Can that be just? But then in war these days more civilians than soldiers are killed. Oh dear, this is difficult. more…

Richard Smith: Misunderstanding conflict of interest

18 Jul, 14 | by BMJ

richard_smith2In Britain we have had a row over whether a judge, Elizabeth Butler Sloss, should chair an inquiry into child abuse. Everybody agrees that she has the necessary skills and unquestionable integrity, but she has a conflict of interest: her long dead brother was in the government and may have been involved in covering up child abuse. The case has exposed deep misunderstanding on the nature of conflict of interest.

The country is in the grip of a moral panic over historical cases of child sexual abuse, with well known entertainers going to prison for abuses they committed 50 years ago. Every day we hear rumours of which “national treasure” (a British cliché) will be next. So the government had to react quickly to the possibility that politicians themselves had covered up abuses. In the rush to appoint a chair to the inquiry, the government probably overlooked Butler Sloss’s conflict of interest, and so she was appointed. more…

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