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All rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Why we should avoid handover hostility Andrew Al-Rais. 356:doi 10.1136/bmj.j1272

Congratulations to Dr Al-Rais for speaking up, and to those readers who have supported his comments.
We daily lament the state of our struggling, underfunded NHS, and listen in disbelief as politicians deny, in terms often flippant or antagonistic, that the problems are largely of their making.
And how do we often behave to each other ?
With incivility and abuse that might be judged “ unparliamentary language “ by the Speaker of the House of Commons.
Should we be surprised ? Unfortunately not.
Well hidden, at least from the eyes of busy, senior colleagues, in the Careers Section of the BMJ, have been a number of recent reports concerning the extent and the potential dangers of rude and offensive exchanges between doctors. (1, 2)
Many of the doctors concerned may be BMA members, which should ignite the BMJ’s attempts to highlight and discuss this serious problem.
Is it likely the BMJ will confront the problem ?
Experience suggests the BMJ will not do so. (3)

1 Tom Moberly, BMJ Careers, 23rd Sept 2015
http://careers.bmj.com/careers/advice/Editor’s_Choice%3A_The_importance_of_being_civil

2 Abi Rimmer, BMJ Careers, 4th Jan 2016
http://careers.bmj.com/careers/advice/A_third_of_doctors_experience_rude...

3 http://www.bmj.com/content/351/bmj.h5624/rr-6

Competing interests: The writer has been labelled bogus, a naked quack, etc. etc, by numerous professors and senior colleagues in these columns. With mentors like these, little wonder if their staff copy bad habits. ( I am appraised annually, and was revalidated in 2015.)

28 March 2017
Noel Thomas
retd/part time GP
Bron-y-Garn, Maesteg, Wales CF34 9AL
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Re: All emergency departments must have GP led triage by October Gareth Iacobucci. 356:doi 10.1136/bmj.j1270

The NHS in England will receive an extra £100m in 2017-18 to invest in triage by GPs and other measures to ease the flow of patients into hospital emergency departments. The spending was justified by the Chancellor of the Exchequer with claims that “onsite GP triage in A&E departments can have a significant and positive impact on A&E waiting times”.(1)

Such claims appear at odds with recent systematic reviews that conclude the evidence base for using primary care services in emergency departments is weak and based on poor quality studies.(2-4) Overall attendances may even paradoxically increase due to provider-induced demand.(4) Attendance of sicker patients with more complex conditions may be part of the reason for rising pressure on emergency departments,(5,6) which would not be addressed by this initiative. Recruitment for this additional GP workforce would also be challenging.

Recognising the paucity of evidence on this pertinent issue, last year the NIHR Health Services and Delivery Research programme commissioned research to evaluate different models of care using GPs in (or alongside) emergency departments. As one of two commissioned studies, we are currently in the early phases of an evaluation of the effectiveness, safety, patient experience and system implications of such ‘GP-ED’ models, aiming to address the key policy questions of where or how the greatest value can be delivered.(7) As part of this early work we will send a national survey to all principal (‘type 1’) emergency departments in England and Wales to improve understanding of the GP-ED models already in place, the extent to which they achieve their aims, and to learn about the successes and consequences of different model types. We encourage all emergency departments to participate in this survey, to help improve understanding and to assist us in the selection of exemplars for case study sites to evaluate in more detail in the next phase of the study.

We understand the scale, complexity and urgency of the challenge of improving emergency department care, but it is vital that such critical policy decisions are rooted in evidence of benefits, safety and patient experience, and an understanding of wider system implications. We need to avoid the development of services which are then subsequently difficult to withdraw, but for which there is no good evidence of effectiveness.(8)

1. All emergency departments must have GP led triage by October BMJ 2017;356:j1270
http://www.bmj.com/content/356/bmj.j1270
2.Turner J, et al. What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review https://www.ncbi.nlm.nih.gov/books/NBK327599/
3.Khangura JK, et al. Primary care professionals providing non‐urgent care in hospital emergency departments. The Cochrane Library. 2012.
4. Ramlakhan, S, et al. Primary care services located within EDs: a review of effectiveness. Emer Med J 2016;0:1-9
5. Sicker patients the main reason for A&E winter pressures. The King’s Fund, UK. 2017 https://www.kingsfund.org.uk/press/press-releases/sicker-patients-main-r...
6. What’s going on in A&E? The key questions answered. The King’s Fund, UK. 2017 https://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-e...
7. Edwards et al. Evaluating effectiveness, safety, patient experience and system implications of different models of using GPs in or alongside Emergency Departments. NIHR HS&DR 15/145/04 https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/1514504/#/
8. McDonnell A, Wilson R, Goodacre S. Evaluating and implementing new services BMJ 2006;332(7533):109.

Competing interests: NIHR HS&DR 15/145/04 Commissioned Study: GPs in EDs - Evaluating effectiveness, safety, patient experience and system implications of different models of using GPs in or alongside Emergency Departments.

28 March 2017
Alison Cooper
Clinical Research Fellow and GP
Rebecca Sherlock, Andrew Carson-Stevens, Helen Snooks, Adrian Edwards
Cardiff University
5th Floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS
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Re: Low intensity pulsed ultrasound (LIPUS) for bone healing: a clinical practice guideline Inger B Schipper, Brent Mollon, Maureen Smith, Alexandra Albin, et al. 356:doi 10.1136/bmj.j576

Dear Editor,

We understand our rapid recommendation represents a major disappointment for Bioventus, a manufacturer of low intensity pulse ultrasound (LIPUS) devices that invested vast amounts of money introducing devices to the market including speaker fees and travel reimbursement for authors of the cited publications.
As recently outlined in our letter to the editor - responding to similar criticism from M. Farrar - we disagree that there is extensive evidence that LIPUS is effective in non-unions (http://www.bmj.com/content/356/bmj.j1483). The three available RCTs are small and have serious limitations ( http://www.bmj.com/content/356/bmj.j656). None of these trials nor the two mentioned retrospective studies sponsored by Bioventus evaluated endpoints important to our patient panel members.
The argument that LIPUS is used in millions of cases does not bear on its effectiveness. Rather, this is an example of bringing a medical device to the market without trustworthy evidence - but with successful marketing - and reflects the shortcomings of the processes responsible for ensuring device effectiveness prior to dissemination. (http://www.bmj.com/content/349/bmj.g5133.long , http://www.bmj.com/content/353/bmj.i3323.long)

Rudolf W. Poolman, orthopedic surgeon, Thomas Agoritsas, assistant professor; Reed A C Siemieniuk, methodologist; Gordon H Guyatt, distinguished professor; Stefan Schandelmaier, methodologist; Per O Vandvik, associate professor.

Competing interests: No competing interests

28 March 2017
Rudolf W. Poolman
Consultant Orthopedic Surgeon
Thomas Agoritsas, assistant professor; Reed A C Siemieniuk, methodologist; Gordon H Guyatt, distinguished professor; Stefan Schandelmaier, methodologist; Per O Vandvik, associate professor
OLVG
Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
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Re: Should research ethics committees police reporting bias? Simon E Kolstoe, Daniel R Shanahan, Janet Wisely. 356:doi 10.1136/bmj.j1501

Looking at the historical record of IRB/REB functioning and performance, one is drawn to the conclusion that location within the research organization creates an inherent conflict of interest wherein the best interests of research participants lose out to the competing interests of researchers, the research organization, and the sources of research funding, be they governmental or non-governmental (1).

Intervening to protect against inadvertent and premeditated biased reporting of research findings costs money and is easily dismissed as infeasible by an enterprise that depends largely on volunteers. So, even though the IRB/REB is theoretically responsible for monitoring and controlling the behaviors of researchers whose research has received approval as “ethical,” the allocation of the resources needed to achieve that part of the IRB/REB mission seems unlikely.

There is a crisis of confidence in the biomedical research enterprise coming from increasing public knowledge that (a) 85 percent of all research funding is a waste (2) and (b) that a commensurately large proportion of reported research findings cannot be replicated (3).

The budgets of NIH and other federal funding agencies in the US are no longer sacrosanct. Some factions point to these agencies and their operating personnel as part of the federal government swamp that must be drained in order to deregulate American society.

Deregulation and budget cutbacks argue against increased IRB/REB funding to enhance protections against inadvertent and premeditated biased reporting of research findings. If anything, one can expect increased competition for reduced amounts of available funding to induce more rather than less biased reporting by biomedical researchers.

Arguably, researcher survival coupled with the dynamics of getting published (4) will not be deterred by the likely weak and pro forma efforts of an ethics-oversight enterprise that is already challenged by lack of resources and inherent conflicts of interest.

References

1. Lemmens T, Freedman B. Ethics for sale? Conflict of interest and commercial research review boards. The Milbank Quarterly 2000; 78(4): 547-584. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751172/pdf/milq_185.pdf

2. Chalmers I, Glasziou P. Avoidable waste in the production and reporting of research evidence. The Lancet 2009; 374 (9683): 86-89. DOI: http://dx.doi.org/10.1016/S0140-6736(09)60329-9.
http://thelancet.com/journals/lancet/article/PIIS0140-6736(09)60329-9/fulltext.

3. Munafò MR, Nosek BA, Bishop DVM, Button KS, Chambers CD, Percie du Sert N, Simonsohn U, Wagenmakers E-J, Ware JJ, Ioannidis JPA. A manifesto for reproducible science. Nature Human Behaviour 1, Number: 0021 (2017). doi:10.1038/s41562-016-0021.

4. Rodrigues V. Publication and reporting biases and how they impact publication of research. Edtage Insights, Oct 29, 2013. http://www.editage.com/insights/publication-and-reporting-biases-and-how....

Competing interests: No competing interests

28 March 2017
John H Noble Jr
Emeritus Professor
State University of New York at Buffalo
508 Rio Grande Loop, Georgetown, Texas, USA
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Re: Industry links with patient organisations Jeremy Taylor, Simon Denegri. 356:doi 10.1136/bmj.j1251

Taylor and Denegri (1) argue that pharmaceutical industry support of patient organisations can be beneficial provided certain safeguards are in place, notably transparency and patient involvement in allocation of funds.

In making these recommendations, however, the authors ignore three key problems. First, it is now well established that gift recipients experience an unconscious obligation to reciprocate, which may manifest as alignment with benefactor interests. Just as recipients of an unsolicited, even unwanted gift, for example from a religious group, are inclined to donate money in return (2), patient groups funded by industry display attitudes favourable to donors (3).

Second, Taylor and Denegri put much emphasis on the value of transparency, maintaining that disclosure of financial relationships serves to “robustly” manage conflicts of interest. Much evidence now points to the naivety of this view and the fact that disclosure, while necessary, is not sufficient and can, perversely, exacerbate bias (4).

Third, limiting financial support, for example to 5% of total income as National Voices does, is thought to minimise the risk of influence by industry (1). It is now clear, however, that even small gifts can influence attitudes and behaviour (5); drug companies are delighted to see medical students and doctors using pens with their company logo.

Finally, the argument encouraging engagement and ‘appropriate’ financial ties between patient organisations and industry (1) must be challenged. The problem is not overt corruption by industry, but that the unconscious bias resulting from financial sponsorship of patient groups threatens their integrity and reputation. Patients are justifiably sceptical about doctors’ financial links to industry (6); the same scepticism and prudence should apply to their own organisations.

1. Taylor J, Denegri S. Industry links with patient organisations. BMJ 2017;356:j1251.
2. Cialdini RB. Influence: Science and practice. 4th ed. Boston: Allyn & Bacon; 2001.
3. Peredhudoff SK, Alves TL. The patient & consumer voice and pharmaceutical industry sponsorship. Amsterdam: Health Action International (HAI) Europe; 2011. http://haieurope.org/wp-content/uploads/2011/02/31-Jan-2011-HAI-EUROPE-R....
4. Cain DM, Loewenstein G, Moore DA. The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest. J Legal Studies 2005;34:1-25.
5. Grande D, Frosch DL, Perkins AW, Kahn BE. Effect of exposure to small pharmaceutical promotional items on treatment preferences. Arch Intern Med 2009;169:887-93.
6. Menkes DB. Industry sponsorship—what do patients think? BMJ 2016;355:i6010.

Competing interests: No competing interests

27 March 2017
David B Menkes
academic psychiatrist
Joel Lexchin
University of Auckland
Waikato Clinical Campus, Hamilton 3240, New Zealand
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Re: Rosamund Snow David Payne. 346:doi 10.1136/bmj.j850

The staff and Board of Trustees of the International Society for Medical Publication Professionals (ISMPP) are very saddened by the passing of Rosamund Snow. As a patient living with Type 1 diabetes, Rosamund courageously extended her patient experiences by serving as The BMJ’s patient editor and as a researcher at Oxford University focused on patients’ involvement in medical education.

ISMPP had the pleasure of working with Rosamund on an ISMPP U educational webinar this past November, and was heartened by her lovely presence and strength. Rosamund was a pioneer in patient advocacy, impacting medical research and journals. Her inspirational contributions and brilliant character will be greatly missed.

Competing interests: No competing interests

27 March 2017
Al Weigel
President and CEO
520 White Plains Road, Suite 500, Tarrytown, NY 10591, USA
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Re: Leading anaesthetist praises NHS response to Westminster attacks Anne Gulland. 356:doi 10.1136/bmj.j1515

Khalid Masood served several prison sentences [1] due to violent outbursts dictated by his obsessive lust for blood, "I want some blood, I want to kill someone".
While in prison, the first, the second, or the third time, visiting GPs Psychologists and Psychiatrists, should have detected these dangerous traits, and offered some designated form of therapeutic intervention, according to Mental Health Act, appointing a "Responsible Clinician", "aftercare", "Supervised Community Treatment", "Community Treatment Order", etc.
Fear for violation of Khalid Masood's freedom rights is illogical, since he was already secluded, repeatedly.
Such therapeutic acts are free in the NHS, and yes, in Greece as well.
Concluding, this was a mentally unstable patient for decades, that was failed by the NHS.
Reference
[1] http://www.independent.co.uk/news/uk/home-news/khalid-masood-adrian-elms...

Competing interests: No competing interests

27 March 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynecology
Thessaloniki, Greece
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Re: Promises, promises Elizabeth Loder. 356:doi 10.1136/bmj.j1446

I agree with BMA Chairman Mark Porter stating many of these measures are sticking plaster measures. I personally do not feel that confining trainees to the UK for five years or repaying their educational costs is constructive. It will end with the trainee resenting their employer even more than many do now and plotting their escape after this five year end period to another country that will welcome them with incentives / open arms.

What is not calculated is already how much a trainee gives to train in this country. The moving house continually year after year (for up to 13 years for some of us), the score of compulsory courses we must pay for that are not covered by our meager study leave budget and finally the membership exams.

Being a Doctor is an incredible occupation, but make no mistake measures like this one continue to erode at the thread that holds this occupation above others in the highest regard and soon I suspect people will simply just choose other degrees for training.

Competing interests: No competing interests

27 March 2017
Kirk Bowling
ST8 Surgical trainee
Derriford Hospital
Derriford Road, Plymouth
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Re: Cost effective but unaffordable: an emerging challenge for health systems Benedict Rumbold, Albert Weale, James Wilson, Annette Rid, et al. 356:doi 10.1136/bmj.j1402

Fairness in implementation would be the critical aspect of this policy.

As long as NICE implements their "imperfect" proposal in a fair manner, many people might come around to supporting it.

A condition/disease (eg breast cancer) which has significantly more lobbying power should be treated in the same manner as a condition which has less lobbying power (eg ovarian cancer).

Competing interests: No competing interests

27 March 2017
S Sundar
Consultant Oncologist
Nottingham University Hospital NHS trust
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Re: Leading anaesthetist praises NHS response to Westminster attacks Anne Gulland. 356:doi 10.1136/bmj.j1515

I find it extraordinary that Saripanidis (rapid response, 27 March) felt apt to criticise Dr Helgi Johannsson for complimenting relevant NHS staff for their handling of casualties. Further, based on a report in a broadsheet, Saripandis makes the bold assertion that “proper NHS management would have implemented efficient therapeutic interventions years before”; perhaps, Saripandis could explain, whether or not, he is suggesting that all people with violent and dissocial personality traits or dissocial personality disorder should be treated by the NHS to prevent any catastrophic outcomes including most extreme acts of terrorism. It may be that in Greece, all people with violent and dissocial personality traits including potential terrorists are receiving free ‘efficient therapeutic interventions’ under their healthcare system. Finally, I wonder whether Saripandis is aware of the criteria for detention and treatment under the Mental Health Act 1983(as amended).

Competing interests: No competing interests

27 March 2017
Jay Ilangaratne
Founder
www.medical-journals.com
East Yorkshire
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