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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: Five minutes with . . . Suzy Jordache Tom Moberly. 357:doi 10.1136/bmj.j2371

Perhaps the title gives a clue to one of the underlying problems. Clinical life has become so 'rammed' that we rarely spend more than five minutes doing anything not subject to guidelines and protocols. In reality '5 minutes with ... Suzie Jordache' for many clinicians is probably much less than that. Interesting and important certainly, but complex, incompletely understood and too demanding of thinking time. A task without a target, an unaffordable luxury, but tomorrow's care sacrificed for lack of time to ponder.

Competing interests: No competing interests

25 May 2017
Arjun Ardeshana
CT1 anaesthesia
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
L8 7XP
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Re: Non-inferiority trials Philip Sedgwick. 342:doi 10.1136/bmj.d3253

Dr. Sedgwick writes in the text of this endgame, as follows:

"Which one of the following statements best describes the null hypothesis for the statistical test of the comparison of pristinamycin with penicillin in the primary end point?.........c) In the population, the cure rate for penicillin is greater than for pristinamycin by 10% or more d) In the population, the cure rate for pristinamycin was no more than 10% below that for penicillin............"

He goes on writing, further............

"Answer c is the best description. ......... The sample size was calculated so that the trial would show that pristinamycin was not inferior to penicillin in efficacy if the cure rate for pristinamycin was no more than 10% below that for penicillin. The difference of 10%, called the non-inferiority margin, was based on clinical judgment. If the cure rate for pristinamycin was lower than that for penicillin by a difference larger than the non-inferiority margin, then pristinamycin would not be considered clinically equivalent to penicillin in efficacy......."

So, in effect, it is answer d which is the best description and not c, which has been erroneously written.

Competing interests: No competing interests

25 May 2017
Neeru Gupta
Scientist F
Jugal Kishore and Neeta Kumar.
Indian Council of Medical Research
Ansari Nagar, New Delhi-110029.
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Re: Health research priorities and gaps in South Asia Sunil De Alwis, Lalit Dandona, et al. 357:doi 10.1136/bmj.j1510

There is no denial that quality and quantity of published medical literature from India is poor. Most of the scientific literature emanates from national level or regional medical institutes, and medical colleges located in metropolitan cities. Besides the lack of infrastructure or funding for conducting such research, the main reason for the lack of medical research and consequent publication is a dilapidated bent of research oriented mind. A careful analysis of published literature would reveal that the main source of these publications is thesis work done by residents during their postgraduate study. The extra mural research is little in quantity.

Although a number of central agencies like ICMR are offering funds, the expertise to design a study and research project is virtually non-existent in medical colleges located in peripheral cities. There is an urgent need to familiarise medical teachers and postgraduate students with research methodologies and designing projects that can result in funding for research. The non-availability of current scientific journals both in print and electronic forms is yet another reason. The libraries of these medical colleges need funds to provide access to both paid and unpaid contents. The cost of publishing in open-access sources is very high (even by Indian standards) and is a barrier in submitting publications to these journals.

There is a need to expand the ICMR through setting up of regional centers located in state capitals to stimulate research at the cutting edge.

Competing interests: No competing interests

24 May 2017
Dinesh Sharma
Retired Medical Teacher
Amritsar-143001 India
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

This seemingly simple observational study, based presumably on a huge sample size, generates too many questions to count and too few answers to be useful: it does however appear to be important. As physicians over time move inexorably from one age category to the next, replication of the study at intervals, to see if the observed effect on mortality (& perhaps other outcomes) persisted, would be very interesting. As patients face the prospect of doctors having to work more and more years we need to understand these findings.

Competing interests: No competing interests

24 May 2017
Ben Lane
clinical fellow in anaesthesia
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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Re: Assisted dying for healthy older people: a step too far? Els van Wijngaarden, Ab Klink, Carlo Leget, Anne-Mei The. 357:doi 10.1136/bmj.j2298

Here are some principles I have put together regarding the care of severely ill patients:

1. Never give words of reassurance.
2. The challenge is not just allowing, but enabling the patient to articulate his feelings.
3. Often the patient has strong feelings about his relatives: probe, discuss, but don’t correct or contradict or give suggestions.
4. The pain of the present will usually be coloured, shaped, influenced by pains in the past. And this means that
5. The patient may wish to reminisce, recount, revisit the past – this is not a denial of the present, but a “trip down memory lane” before it is too late for this.
6. Good mood, even jokes, are not to be treated as a denial, but an invitation for a warm, close few minutes – proof that the illness has not decimated all personal qualities.

AND THE CARER?

1. The carer must be seen as equally in need of comfort/support.
2. He/she also experiences pain, but will usually feel “not entitled” to it.
3. Important to investigate what is the carer’s interpretation of the patient’s condition and, above all, what he/she anticipates is the prognosis.
4. Most carers will feel guilty for not giving sufficient support or, even, for being a factor in the patient’s condition and/or present state. Again, reassurance should not be given. Putting it in a formula “he knows he is not guilty, but he feels guilty.” Therefore, questions must be put forward, allowing the carer to recognize how complex and contradictory are his feelings.

Dr A H Brafman, MRCPsych.

Competing interests: No competing interests

24 May 2017
Abraham H. Brafman
Psychoanalyst
London
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Re: Margaret McCartney: Our politicians are wilfully failing the NHS Margaret McCartney. 357:doi 10.1136/bmj.j2474

Our politicians are wilfully failing the NHS

Certainly the politicians have failed the NHS but the NHS itself has failed both patients and the nation in several ways.

This brought to light by a recent article in the BMJ entitled “Italy recognises patient safety as a fundamental right” http://www.bmj.com/content/357/bmj.j2277?utm_medium=email&utm_campaign_n...

1) This failure of the NHS to implement an effective safety policy to minimize “medical error” is costing £millions if not £billions in reparation costs and legal costs. This could be substantially reduced.

2) The failure to update diagnostic techniques in diseases because “the methods defined 40-50 years ago are considered adequate” is another area where substantial savings could be made. In this regard I am thinking of Type 2 diabetes(TD2). We are always told that early diagnosis is essential to improve the possibility of full recovery yet in practice the current protocol and guidelines continues to rely on methods that are based on hyperglycaemia and HbA1c. Dr JR Kraft (The Diabetes Epidemic and You) has shown on the basis very solid research that early diagnosis should be based on hyperinsulinaemia which predates the appearance of hyperglycaemia and thus provides a greater probability of full recovery.

In turn this would result in considerable financial savings. The current system simply ensures that patients will inevitably end up by having to use insulin as one expert recently claimed. Furthermore if insulin resistance is involved, this addition of insulin to an already hyperinsulinaemic condition, which in itself is damaging to the patient.

All this because fasting blood insulin levels are not measured. While back in the ‘60s and ‘70s when only RIA tests were available with all the legal requirements involved with radio isotopes I can understand hospitals reluctance to become involved with such methodology. Additionally at that time when an apparently suitable methodology was available it seems reasonable.

However science moves on with the development of the ELISA test; kits can be obtained. Thus, the possibility of a much earlier diagnosis of TD2 is possible with a better chance of full recovery (providing that the Ancel Keys contribution is put to rest) with substantial savings in pharmaceutical costs and a minimization of the problems associated with hyperinsulinaemia (such a CVD and cognitive problems such as Type 3 diabetes (aka Alzheimer’s). As commercial medical laboratories can measure insulin blood levels for a mere £39, the NHS, as a non-profit organization could probably do the test for £20 or less.

3) This example raises the issue of what other areas are similarly affected by failure to progress. As a patient one is sometimes left with the impression that Big Pharma’s need for sales and the status of its KOLs is more important than patients’ health. I am reminded of the initial response of the experts to Dr Barry Marshall’s discovery of Helicobacter pylori as a major cause of GI ulcers.

4) The failure of the NHS administration to improve its administrative own practices to a more patient friendly approach is vitally needed.

Thus in conclusion I do not think throwing money at the NHS is the way to go. Human nature being what it is, throwing money at a problem merely removes the imperative to improve and be fiscally aware.

Competing interests: No competing interests

24 May 2017
Michael J. Hope Cawdery
Retired veterinary researcher
None
Portadown
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Re: 60 seconds on . . . cancer Nigel Hawkes. 357:doi 10.1136/bmj.j2084

Letter to the BMJ regarding60 seconds on . . . cancer

"60 seconds on . . . cancer" would have been much better if it was 60 seconds longer: it has ignored the great epidemiological studies emanating from Montreal, Canada in which it was shown that traffic-related air pollution significantly increases the incidence of both breast (Postmenopausal Breast Cancer Is Associated with Exposure to Traffic-Related Air Pollution in Montreal, Canada: A Case–Control Study. Dan L. Crouse, Mark S. Goldberg, Nancy A. Ross, Hong Chen, and France Labrèche https://www.ncbi.nlm.nih.gov/pubmed/20923746) and prostate cancer (Traffic-related air pollution and prostate cancer risk: a case–control study in Montreal, Canada Marie-Élise Parent, Mark S Goldberg, Dan L Crouse,Nancy A Ross, Hong Chen, Marie-France Valois, Alexandre Liautaud https://www.ncbi.nlm.nih.gov/pubmed/23531743.

While learning that “two thirds of cancer causing mutations arise from copying errors when cells divide” is interesting, it would contribute much more if we were able to determine why such errors occur. The Montreal studies suggest that “Such errors are [not necessarily] unavoidable”, and that if society applied itself to further epidemiological studies, we might be able virtually to eliminate cancer.

Ken Ranney, M.D., FRCPC, FCAP, FCACB, Pathologist and Clinical Biochemist, retired.
Peterborough, Ontario, Canada
K9J 6H6

Competing interests: No competing interests

24 May 2017
E. Kenneth Ranney
Pathologist and Clinical Biochemist, retired
Peterborough, Ontario, Canada K9J 6H6
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Re: US government website for collecting adverse events after vaccination is inaccessible to most users Peter Doshi. 357:doi 10.1136/bmj.j2449

Peter Doshi's discovery of the VAERS website malfunction is an interesting example of our CDC's lack of real interest in discovering vaccine adverse effects. VAERS seems to be nothing more than window dressing, and a part of US authorities' systematic effort to reassure/deceive us about vaccine safety. There are other examples:

1. Over 284 US cases of acute flaccid myelitis have been reported since August, 2014. (CDC, Acute flaccid myelitis, 4/20/17) The CDC and other authorities seem to have avoided investigating the possibility that vaccinations and provocation paralysis are co-factors in the causation of this terrible disease. (Cunningham, unpublished manuscript, 1/8/17, and many personal communications since January 30, 2015)

2. The 20% increase in autism spectrum disorder among the offspring of women who received the flu shot during the first trimester of pregnancy was dismissed as "non-significant" after an odd statistical manipulation. (Zerbo et al, JAMA Pediatr, 11/28/16 online) Donzelli and colleagues asserted that the statistics were not appropriate and that the risk increase, which meant 4 extra ASD cases for every 1000 women vaccinated, should be taken seriously. (JAMA Pediatr, 4/24/17 online)

3. Doshi states that, "no more than 10% of adverse events" get reported to VAERS, but the situation is much worse. From 1990 to 2007 there were about 80,000 US cases of Kawasaki disease; during the same period just 56 US cases were reported to VAERS--0.07%. (Hua et al, Pediatr Inf Dis J 2009: 28:943-947) The cause of KD is unknown; it is rare, it is very serious, and it is prevalent among young and frequently vaccinated children. If any event deserves prompt reporting to VAERS it is Kawasaki disease, but this does not happen.

The randomized trials leading to vaccine licensure are typically too small to statistically validate the occurrence of rare but serious adverse events, so this is left to postmarketing surveillance ("pharmacovigilance"). However, conscientious postmarketing surveillance simply does not occur....Walter Spitzer was a distinguished professor of epidemiology at McGill University. He once dryly observed: "The best way to remain in the dark about vaccine safety is not to look for it. One way not to look, but pretend to be looking, is to study small samples." (Spitzer, 'Is MMR linked to autism?' Testimony before the Government Reform Committee, US House of Representatives, April 25, 2001)

Meanwhile, US vaccine authorities are trying to mandate every vaccine on the immunization schedule for every child, regardless of the frequency, severity, and transmissibility of the target diseases, and regardless of serious limitations in our knowledge of long-term safety and effectiveness for many of the newer vaccines. (AAP committees, Statement on vaccine exemptions, Pediatrics 2016; 138:e20162145.) Breathtaking!

Competing interests: No competing interests

24 May 2017
Allan S. Cunningham
Retired pediatrician
Cooperstown NY 13326, USA
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Re: Critical thinking in healthcare and education Sandy Oliver, Kevan Collins, Astrid Austvoll-Dahlgren, Tammy Hoffmann, et al. 357:doi 10.1136/bmj.j2234

Critical thinking is an essential cognitive skill for the individuals involved in various healthcare domains such as doctors, nurses, lab assistants, patients and so on, as is emphasized by the Authors. Recent evidence suggests that critical thinking is being perceived/evaluated as a domain-general construct and it is less distinguishable from that of general cognitive abilities [1].

People cannot think critically about topics for which they have little knowledge. Critical thinking should be viewed as a domain-specific construct that evolves as an individual acquires domain-specific knowledge [1]. For instance, most common people have no basis for prioritizing patients in the emergency department to be shifted to the only bed available in the intensive care unit. Medical professionals who could thinking critically in their own discipline would have difficulty thinking critically about problems in other fields. Therefore, ‘domain-general’ critical thinking training and evaluation could be non-specific and might not benefit the targeted domain i.e. medical profession.

Moreover, the literature does not demonstrate that it is possible to train universally effective critical thinking skills [1]. As medical teachers, we can start building up student’s critical thinking skill by contingent teaching-learning environment wherein one should encourage reasoning and analytics, problem solving abilities and welcome new ideas and opinions [2]. But at the same time, one should continue rather tapering the critical skills as one ascends towards a specialty, thereby targeting ‘domain-specific’ critical thinking.

For the benefit of healthcare, tools for training and evaluating ‘domain-specific’ critical thinking should be developed for each of the professional knowledge domains such as doctors, nurses, lab technicians and so on. As the Authors rightly pointed out, this humongous task can be accomplished only with cross border collaboration among cognitive neuroscientists, psychologists, medical education experts and medical professionals.

References
1. National Research Council. (2011). Assessing 21st Century Skills: Summary of a Workshop. J.A. Koenig, Rapporteur. Committee on the Assessment of 21st Century Skills. Board on Testing and Assessment, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.
2. Mafakheri Laleh M, Mohammadimehr M, Zargar Balaye Jame S. Designing a model for critical thinking development in AJA University of Medical Sciences. J Adv Med Educ Prof. 2016 Oct;4(4):179–87.

Competing interests: No competing interests

24 May 2017
Simran Kaur
Assistant Professor
Suriya Prakash Muthukrishnan, Ratna Sharma
All India Institute of Medical Sciences, New Delhi
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

The whole concept of this study is ageist and repugnant. You might as well design the next one based on the race of the physician.

Competing interests: No competing interests

24 May 2017
Gabriella Good
Geriatrician
University of New Mexico
6118 Edith Blvd NE, Unit 157, Albuquerque NM
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