Making uncertainty workBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j815 (Published 16 February 2017) Cite this as: BMJ 2017;356:j815
Vitamin D supplementation is always on the shortlist of clinical topics guaranteed to spark interest and debate. The term “supplement” might conjure up thoughts of an added extra—something beneficial or enhancing—but vitamins are treatments with potential harms and benefits. The plethora of evidence requires careful navigation before embarking on therapy. Bolland and colleagues recently explained the uncertainty surrounding Vitamin D supplementation, concluding that it should not be used in adults to prevent non-musculoskeletal disease (doi:10.1136/bmj.i6201).
This week, however, a systematic review and meta analysis of 25 trials of vitamin D supplementation by Martineau and colleagues finds that treatment is associated with a reduced risk of acute respiratory infection among all participants (adjusted odds ratio 0.88 (95% confidence interval 0.81 to 0.96) (doi:10.1136/bmj.i6583).
Reduction in acute respiratory infections seems an important outcome for those considering treatment, but, in an accompanying editorial, Bolland and Avenell argue against a change in practice (doi:10.1136/bmj.j456). Despite this impressive meta-analysis, doubts remain about the magnitude of the effect at population level. They suggest that we wait for larger trials of vitamin D supplementation, which are expected to report on the effect on respiratory infections in the next few years.
Trials may be the answer to this particular question, but Crum and colleagues caution that “medical diagnoses and treatments are never isolated from patient mindsets and social contexts” and that, despite the many benefits of randomised trials, they may obscure the “psychological and social elements underlying placebo effects in active treatment” (doi:10.1136/bmj.j674). The psychological and social forces of healing have potential benefits, even though they receive much less attention than drugs and devices. Although it’s refreshing to read new ways to tackle the rising complexity of non-communicable diseases, we first need to “open our own minds to that possibility,” they say.
Understanding a patient’s mindset is best achieved in an environment of established trust and rapport. This is something we should fight to preserve in UK general practice, argues Margaret McCartney (doi:10.1136/bmj.j736). She says, “If we ensure that long term relationships are the default priority, we’ll be closer to getting back to the joy we all need in our working lives.” This will not only help us to appreciate a patient’s mindset but also to encourage open discussion where clinical uncertainty exists.