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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: Decriminalisation of abortion Clare Dyer. 356:doi 10.1136/bmj.j1485

Professor Bewley is correct to ask for clearer terminology in the BMJ, an improvement that will cause other readers to rejoice . Perhaps Professor Bewley is ideally suited to judge what is “contradictory, obsolete, ambiguous and misleading” in your journal ?

After she and a few professorial colleagues labelled me and my homeopath colleagues as “bogus “ and practising “ naked quackery” (1) in your pages, I pointed out to her that such terminology made us unsuitable to be registered with the GMC, and that she had a clear professional duty to report us to the GMC, or to our employers. (2) None of us have been struck off the Register, so we must assume that, for charitable reasons, or a lack of evidence, she chose not to fulfil her professional duty to report us.

Readers may wonder if this historical allusion is relevant today, when we are surrounded by examples of double standards and hypocrisy in public and professional life.
We should acknowledge that the BMJ has lately reminded us, how destructive and dangerous, to ourselves and to patient care, is the tendency of medical professionals to be rude and dismissive to colleagues. (3, 4)

Public discussion about homeopathy in the UK is notable for the misinformed views,or ignorance of most people. They are influenced by a tiny minority of equally ignorant but denigratory people, with disproportionate media influence, who cannot abide anything that conflicts with their world view.

Homeopaths every day see people who can be always comforted, often relieved, and sometimes cured, when conventional medications have failed, or cause problems. Homeopathy is relatively inexpensive, and very safe. There are multitudes of adults and children out there who could benefit, and who deserve to be educated, and able to make an informed choice. They fail to do so partly because the nature of public and media debate has been distorted and debased by the misleading terminology so disliked by Professor Bewley. Perhaps she has moved on since she and her colleagues used similar terminology ?

1 http://www.bmj.com/content/343/bmj.d5960?sso=

2 http://www.bmj.com/rapid-response/2011/11/03/rethe-clinical-evidence-spe...

3 http://careers.bmj.com/careers/advice/Editor’s_Choice%3A_The_importance_of_being_civil

4 http://careers.bmj.com/careers/advice/A_third_of_doctors_experience_rude...

Competing interests: NHS and peripatetic homeopath, no private practice.

19 April 2017
Noel Thomas
retd/ part time GP
Bron y Garn, Maesteg, Wales CF34 9AL
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Re: Is this trial misreported? Truth seeking in the burgeoning age of trial transparency Peter Doshi. 355:doi 10.1136/bmj.i5543

Authors or editors deciding to omit clinically unimportant findings for a given trial seems a bit short sighted, not only for the reasons mentioned above. If an outcome isn't clinically important in one study, that doesn't mean it isn't clinically relevant across studies, or perhaps, when a slightly different clinical question is asked in a meta-analysis. For example, summary data for harms may be sufficient for a trial publication, however, when data across trials/studies are synthesized, such as in meta-analysis, raw or individual data on harms may become more meaningful. In today's digital age the issue of journal space is a moot point, so why not simply insist that all outcomes/results be reported/posted, even if in a supplement? What harm would that do to a journal or author?

Competing interests: No competing interests

19 April 2017
Larissa Shamseer
PhD Candidate
University of Ottawa
501 Smyth Rd, Ottawa, K1H8L6
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Re: Five minutes with . . . Michael Keighley Anne Gulland. 356:doi 10.1136/bmj.j1419

Dear Editor,
The above article contends that anal incontinence in women is due to vaginal delivery (VD). Implied in this statement is that caesarean delivery (CD) would prevent that disability. Two points argue against this. The first is that population based studies show that nearly as many men have anal incontinence as women, and of course many women never have vaginal deliveries, making the number of men relative to women having had VD even closer [1]. More importantly there is a Cochrane review assessing the efficacy of CD in preventing anal incontinence. The odds ratio was 0.98, 95% confidence intervals, 0.79-1.21, i.e. the risk was virtually identical whether the woman had a VD or CD [2].

CD is the most commonly performed operation on this planet. It may cause serious problems for mother and baby. Rates vary from 9% to 70% in different populations. Though there is no doubt that CD can be life saving for the baby, before health benefits for CD are claimed for the mother, the efficacy of CD needs to be more rigorously assessed and compared to its risks.

This is because the analyses above were obtained from observational epidemiology, mostly large population based cohort studies. The data would be much stronger if obtained from randomized trials of average risk pregnancies, and none exist for this question. Other randomized trials of CD vs. VD do exist, demonstrating that this can be done. For such a massive intervention, these are long overdue.

I agree with Prof. Keighley that the results of sphincter surgery for VD related anal incontinence are for the most part disappointing. I think this is due principally because the cause of post partum anal incontinence is still poorly understood.

Sincerely,

Richard Nelson
University of Illinois School of Public Health, Chicago

1 Nelson RL. Epidemiology of fecal incontinence. Gastroenterology. 2004
Jan;126(1 Suppl 1):S3-7. Review. PubMed PMID: 14978632.

2 Nelson RL, Furner SE, Westercamp M, Farquhar C. Cesarean delivery for the
prevention of anal incontinence. Cochrane Database Syst Rev. 2010 Feb
17;(2):CD006756. doi: 10.1002/14651858.CD006756.pub2. Review. PubMed PMID:
20166087.

Competing interests: No competing interests

19 April 2017
Richard L Nelson
Colorectal surgeon
University of Illinois School of Public Health, Epidemiology / Biometry Division
1603 West Taylor, Room 956, Chicago, Illinois 60612, USA
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Re: Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study Joshua D Stein, Rory M Marks, John Z Ayanian, Brahmajee K Nallamothu, et al. 357:doi 10.1136/bmj.j1415

Dr Seidler says that violent coughing might lead to vertebral fractures.
In my working life I did see rib fractures resulting from coughing. I can understand the mechanism.
Vertebral fractures are mentioned as resulting from coughing ( in osteoporotic patients).
However, I never saw such fractures. May I request Dr Seidler and other experienced physicians and orthopaedic surgeons to be kind enough to tell me the mechanism involved? I shake my head in perplexity. Raised intrathoracic pressure, raised venous pressure. How do these cause vertebral collapse? There is no top down compression.
Thank you

Competing interests: No competing interests

19 April 2017
JK Anand
Retired doctor
Free spirit
3 Wayford Close, Peterborough
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Re: Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study Joshua D Stein, Rory M Marks, John Z Ayanian, Brahmajee K Nallamothu, et al. 357:doi 10.1136/bmj.j1415

A very interesting study that mght lead to reduction in inappropriate use of a potent class of medications for self limited medical conditions. However as the authors noted, the presence of the underlying illnesses themselves could be indicative of, or risk factors for, the variables being measured. A control group consisting of patients with similar illnesses not treated with corticosteroids would hsve been more informative. The small absolute difference could easily be attributed to the underlying illnesses. In addtion to the examples cited by the authors, decreased mobility from back conditions might increase the risk of DVT. Violent coughing with repiratory illnesses might lead to vertebral fractures.

Competing interests: No competing interests

19 April 2017
Donald L Seidler
Medical Doctor
Charleston,WV
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Re: Alban Avelino John Barros D’Sa Sonia H Barros D’Sa, Ian J Barros D’Sa. 350:doi 10.1136/bmj.h2485

Alban and I were studying at West Ham. He went on to Bristol to study Medicine while I went to Durham (Newcastle) for Architecture.

Alban was the 'big brother', a devout Catholic with ethics and morals deeply held and was a natural mentor for many of his colleagues. I had the honor to be his closer friend, the privilege of befriending his two brothers while in London.

We lost touch as life took us on different paths until in retirement in USA, I took time to trace old friends, to find Alban in Coventry. Unfortunately, e-mail security deprived a successful direct contact and, alas, to learn of his passing !!

May Alban RIP after a noble life.

Competing interests: No competing interests

19 April 2017
Peter Kou
Architect
Riba
Riva Maryland 21140 USA
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Re: Standing up for science in the era of Trump Kamran Abbasi, et al. 356:doi 10.1136/bmj.j775

On Saturday 22 April 2017, groups of scientists will be assembling in many cities.

In London the March for Science will start off from the Science Museum in Exhibition Road (meeting at 11am) and move on across town to Parliament Square between 12 and 2pm. The rally near Parliament is expected to finish around 3.30pm.

Let's stand up for science this Saturday !

Competing interests: No competing interests

19 April 2017
Woody Caan
Scientist
Duxford, Cambridgeshire
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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

Gaps and priorities in health research for south Asia issues discussed by Soumya Swaminathan and colleagues brought out many important issues. The content summary along with our comments are given below:

1. Increasing burden of NCDs in South Asia represented still disproportionately for reporting of the related research area. More public health intervention research is the need of the hour.
2. Per capita number of papers listed increased in South Asia than the global average to an extent of 3.6-6.9 times from 2005 to 2015. This is an encouraging fact. The health related publications are 21.7% in Nepal, 23.3% in India and 30.0% in Sri Lanka respectively in South Asia (n=180).
3. Among South Asian countries, the per capita expenditure on health was highest for India with 0.12% of GDP. As a global reflection, a 76% health expenditure in India was also for industry. This may not contain any proportion for public health research component.
4. As medical aspects of health are over-emphasized, research on preventive and health promotion are scarce in South Asia. This is supported by evidence that only 5% of publications are from public health out of all health related publications. Basic research and quality clinical trials are needed to develop and test low cost kits/ markers that are beneficial to the developing world.
5. Boosting health in South Asia require adequate funding, research capacity building and research governance along with regional collaboration. Government and academic researchers could make health research a case of an investment for major public health good in thelong run. Then perhaps there will bepolitical interest for policies and strategies on health research. Presently, regional collaboration among South Asian countries are 2% only. But the region has similar socio-cultural environment and political dynamics, so successful experiences of health outcome in any part of the region could be shared with another to enhance health research collaborations.

Dr L. Satyanarayana, Scientist G
Dr Smita Asthana, Scientist D
Dr Surabhi Bhatia, research Student
ICMR-NICPR,
Noida -201301 (UP), India

Competing interests: No competing interests

19 April 2017
Labani Satyanarayana
Scientist
Smita Asthana, Surbhi Bhatia
ICMR-National Institute of Cancer Prevention and Research
I-7 sector 39, Noida
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Re: David Oliver: Choosing to be honest about patient choice David Oliver. 357:doi 10.1136/bmj.j1829

It is interesting that David Oliver has just drawn attention in his response, to the article about ‘shared decision-making’ by Dr Natalie Joseph-William et al. I noticed a connection when I came across both articles yesterday: I have submitted a response to the paper about SDM, and I would have referenced this paper by Dr Oliver if I had not decided to write a response which was almost devoid of references to other pieces.

Moving on to Dr Oliver’s paper:

‘Patients can have any choice they want, so long as it’s the cheaper, more convenient one we’d prefer them to make. Let’s stop pretending otherwise.’

That can be compared with my ‘similarly cynical’:

http://www.bmj.com/content/351/bmj.h4437/rr-63

It seems to me, that for some authors 'coercion' is being used to describe 'persuasion but in a direction I personally do not agree with'. That isn't very useful. Neither is only asking 'was the decision 'autonomous' ?' when [to the person raising the issue of autonomy] it 'seems to be the wrong decision'.

Competing interests: No competing interests

19 April 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: Implementing shared decision making in the NHS: lessons from the MAGIC programme David Tomson, Sheila Macphail, Carole Dodd, Kate Brain, et al. 357:doi 10.1136/bmj.j1744

I very much agree with the overall thrust of this paper, so my comments here should be taken as being ‘supportive’, but I would point out that

‘Clinicians’ long held commitment to doing what they perceive to be the best for their patients is a key barrier to attitudinal change. This is well intended, but fails to recognise that patients’ values, opinions, or preferences are important and might differ from their own.’

encompasses ‘a deep technical issue’ rather well. I write ‘technical’ because I am avoiding using ‘ethical’ or a similar term. I would not want my doctors to have a commitment to doing the worst for their patients – but while the second sentence is correct, it is also misleading in a ‘technical’ sense. Here, for ‘technical’ the word ‘legal’ can be substituted.

All of England’s ‘consent law’ is contained within the Mental Capacity Act: and ‘shared decision-making’ is an unhelpful term if the MCA is being described. The consent process if the patient is mentally capable, is correctly described as Supported Decision-Making: the clinician explains clinical options and outcomes, after which the patient accepts or refuses an offered intervention. As we can read on page 2 of the paper:

‘These [decision support tools] provide short (one to three pages) summaries of the treatment choices, the likely outcomes, and the factors that patients might consider when making their decision, including risk and benefit data.’

Challenge 3 raises the issue of whether or not patients actually want to make their own decisions, which I feel sure is a major issue: but, it is clear that English law is now firmly based on a requirement for Informed Consent, and it becomes ‘messy and problematic’ if patients are treated in the absence of genuine informed consent. Patients are not required to express a ‘preference’ at the conclusion of the process of informed consent: the patient is required to express the decision. Not to express ‘a good, or wise, decision’ but to express ‘an informed decision’ - which takes us back to the barrier of clinicians ‘doing what they perceive as the best for their patient’, when our law limits the clinical role to the provision of information.

Challenge 4 starts with ‘Clinicians and managers implementing shared decision making want to know what difference it makes to their patients and to clinical practice’ and that is also problematic for informed consent: the difference in outcomes, good or bad, is not the metric for informed consent. It will never be a satisfactory situation if our judges and law are examining whether consent was informed, while our clinicians [and perhaps patients] are more interested in comparing ‘outcomes’.

Challenge 5 develops the same theme - ‘For example, the Quality and Outcomes Framework rewards general practitioners for behaviours that are evidence based but not necessarily about what matters most to patients’ - and that is the foundation of informed consent: ‘what matters most to the individual patient’. What matters to the patient will often be ‘the best clinical outcome’, although this is not so true in end-of-life, which I write about, and it is not necessarily true in other situations.

So, in ‘Recommendations for implementation’, when I read the following, all I can say is ‘well, your shared decision-making is not an accurate description of our law’:

‘Shared decision making may not necessarily result in, or depend on, complete agreement between a clinician and a patient. Instead, it is about bringing both types of expertise together, and weighing up the available options in light of both of these perspectives; it makes it more likely that the final decision is informed by what the clinician knows (medical evidence, clinical experience) and by what the patient knows (what matters to them, the outcomes they are prepared to accept).’

There is no ‘melded mind’ involved in Informed Consent: it is not a combination of the clinician’s mind and the patient’s mind that ‘weighs up the available options’ - the patient’s mind weighs up the options, so it would be, to fit English law:

‘the final decision is informed by what the clinician knows (medical evidence, clinical experience) but made by the patient, who also considers what matters to him and which outcomes he prefers’

FOOTNOTE: the paper does not seem to address mentally-incapable patients. But the MCA does not describe ‘shared decision-making’ there, either: it describes ‘defensible decision-making’ (which requires consultation and information sharing) and it also describes whether decision-making authority exists or not (what typically exists, is a legal duty – not a legal authority).

It is problematic when ‘ethics’ and ‘law’ do not easily fit:

http://www.bmj.com/content/353/bmj.i2230/rr-7

Mike Stone Contact mhsatstokelib@yahoo.co.uk

Competing interests: No competing interests

19 April 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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