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Chris Ham: Statesmanship among medical leaders could help resolve the junior doctors’ dispute

18 Apr, 16 | by BMJ

Whatever the rights and wrongs of the standoff between the government and junior doctors, failure to reach agreement on a new contract is bad for patients and for staff. The all out strike planned for the end of the month will cause disruption and delay for patients, and add to the pressures on staff who cover for absent colleagues. It will also create dilemmas for junior doctors torn between loyalty to their peers and their primary—and strongly felt—duty to patients.

The dispute may also affect recruitment into medicine and the willingness of newly qualified doctors to practise in England. It will have an impact too on the discretionary effort of junior doctors who form the backbone of patient care throughout the NHS. more…

Paul Hodgkin: The dogs that don’t bark are the most difficult to hear

18 Apr, 16 | by BMJ

For at least the last 70 years patients have been regularly gathered in crowded outpatient clinics and left to sit in silence. Decade after decade, country after country, health systems around the world have ignored the massive potential for patients to learn from each other. Forget the rhetoric about listening and engaging patients. Just look at all those crowded outpatient waiting rooms—still silent, still full of the lonely crowds that medicine invariably seems to create whenever it brings patients together. A case of dogs not barking if ever there was. more…

Richard Lehman’s journal review—18 April 2016

18 Apr, 16 | by BMJ

richard_lehmanNEJM 14 April 2016 Vol 374

Fixing spinal stenosis
1413 Magnetic resonance imaging was like magic when it first appeared. Suddenly structures in the back that could only be guessed at on x-rays or even CT scans could be seen in lavish detail. It became clear that there was no such thing as a normal back: discs bulged here and degenerated there, narrowed nerve foramina abounded, and vertebrae showed slippage in many wanton and disturbing ways. For millions of patients with back pain, plausible explanations could be demonstrated on the screen and treated with expensive new operations and devices. Just to give a keynote lecture about one of these could earn an orthopaedic surgeon $1 million from a manufacturer less than 20 years ago. For lumbar spinal stenosis, simple decompression operations were rapidly overtaken in the US by combined procedures of decompression and fusion, which increased by a factor of 15 between 2002 and 2007. Two publicly funded trials in this week’s NEJM may mark the end of the party, surely one of the most extravagant even in the history of American medicine. From cool Sweden comes a trial in 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels. They were randomized to undergo either decompression surgery plus fusion surgery, or decompression surgery alone. The combined procedure cost more but did not result in better outcomes at two or five years’ follow-up. more…

Jeffrey Aronson: When I use a word . . . Mechanisms and evidence

15 Apr, 16 | by BMJ

jeffrey_aronsonTo recap: my definition of a pharmacological mechanism, slightly expanded from before, is “one or more entities and activities organised spatially and temporally to interact in such a way as to be associated, depending on the milieu, with a phenomenon or phenomena”. In what ways can pharmacological mechanisms, so defined, be used as evidence?

The Indo-European root UEID meant to look at or see, or something seen. And since seeing is believing, it also meant to know. The derived Latin verb videre meant to see, in various senses: to perceive with the eyes, to have vision, look at, notice, imagine, witness, meet, watch out, see to or provide, consider, and foresee; it also meant to ascertain by inquiry or consideration. more…

Vivekanand Jha: National dialysis programme in India—how to get it right

15 Apr, 16 | by BMJ

vivek_jhaWith the announcement of a National Dialysis Service, India is set to join the growing list of nations that provide free or highly subsidised treatment to patients with end-stage kidney failure.

Dialysis is expensive—it consumes 2–6% of the healthcare expenditure [1], even though end stage kidney disease (ESKD) patients account for only 0.1–0.2% of the total population. Any proposed service must therefore be cost efficient. The proposed service focuses on haemodialysis (HD), while neglecting other options such as kidney transplantation, and peritoneal dialysis (PD), which is cheaper to the healthcare system and can be done at home, hence it is the preferred treatment modality for state-funded dialysis programmes [2]. more…

Neville Goodman’s Metaphor Watch: Flashes, flies, and spanners

15 Apr, 16 | by BMJ

neville_goodmanKnowing the vicissitudes of medical research, I expected a fair number of flashes in the pan and flies in the ointment, but neither is a common metaphor in PubMed.

I had somehow thought that flash in the pan came from gold-mining: the miner, as he swilled water around his pan, being deceived by the flash of something that was not the sought-after gold. But it is nothing to do with mining; flash in the pan originated in the 18th century describing the firing of the priming in a flintlock musket, without the musket firing its ball. From that, it has come to mean an abortive effort or outburst, or something that promised much but gave little. Searching on flash and pan has just 21 results, but only 7 are to flash in the pan. Five are asking if a new phenomenon is the way to the future (e.g. metobonomics, a particular application of endoscopic stents, systems pharmacology), and one is deciding that off-pump coronary artery bypass grafting is here to stay. The remaining one has inverted the metaphor, describing the use of fluorescence to detect amyloid proteins. more…

The 7th Global Patients Congress: Patient engagement in innovation for health

14 Apr, 16 | by BMJ

Kawaldip SehmiSitting in the Edward Heath Room at the 7th Global Patients Congress at the Selsdon Park Hotel, Croydon, discussing universal health coverage (UHC) for all by 2030 (a target in the sustainable development goal for health), one is quickly reminded that if health is a political goal, then UHC is one of the ultimate political choices.

Listening to the debates, one can appreciate that the NHS needed the powerful personalities of Beveridge and Bevan to help the UK found the oldest system of UHC after great political and social upheavals in 1948.

The room, however, has ghosts. more…

Desmond O’Neill: HIP medicine

14 Apr, 16 | by BMJ

Des O Neill 2015In the last month I have had two wonderful musical experiences in Dublin, each causing me to reflect on one of the key challenges of medicine, that of getting to the core of what is troubling people who seek medical attention.

Each of the performances was from music ensembles who seek to perform music in a fashion that as closely as possible resembles what the composer would have heard at that the time. Tuning, instruments, and musical styles have changed over the years and what we now hear is substantially different from what listeners in the baroque and classical eras would have heard. more…

Tara Lamont: How was it for you? Reflections on patient experience research

14 Apr, 16 | by BMJ

Tara_Lamont_3“Expect to see blood in your semen.” This was the shouted afterthought from the clinician to a middle aged patient with prostate cancer across a crowded waiting room as he left the consultation. A room of strangers turned to look at him now thinking, as he pointed out wryly, about his sexual activity. Just a small thing. But one which affected this patient deeply. This was just one of the filmed patient experience stories which can be used as triggers for real change in staff behaviour and service delivery. more…

Kamal R Mahtani: Evidence based mentoring for “aspiring academics”

13 Apr, 16 | by BMJ

Kamal R MahtaniThere are times in our careers when we are not sure what to do next, whoever we are. We may lack experience or the confidence to decide what to do; or we may have made a decision and need a word of advice from someone more experienced, reassuring us that the idea was sensible. At such times, having a mentor to advise, guide, or simply assuage our uncertainties, can be the key to taking the next steps successfully and enhancing our professional development. more…

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