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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: 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

Dear Sir,

This is an interesting article comparing mortality based on physician's age, however, there are several flaws in the study.
I have worked as a hospitalist and I am familiar with the work flow of the hospitalist as well as intensivist.

1. In comparison to the UK system (in no way do I want to derecognize the contributions of hospitalists), hospitalists depend mainly on subspecialists for most of the problems. Role of hospitalist many times is reduced to "following the recommendatios" only. When hospitalist is identified as primary biller, likely there are two options. Either they did not use a subspecialist or patient was not too complex. In other words, if a patient dies from GI bleed, you have to blame the GI specialist, not the hospitalist.

2. Most deaths in hospital happen in intensive care units in the USA. Those who die on the wards (floor) are either deemed to be at the end of life or DNR. There is no mention of intensive care in this study. Invariably, an intensivist will be involved in the care at the time of death.

3. There is no exclusion of withdrawal of care as well because that will increase the mortality of a physician.

4. Study was also limited to those older than 65 and cannot be generalized to all age population.

This study is poorly designed and seems to malign the age of the physician as part of outcome.

Competing interests: No competing interests

21 May 2017
ramakant sharma
intensivist
Chandler AZ
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Re: Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative Sita M A Bierma-Zeinstra, Madhu Mazumdar, et al. 356:doi 10.1136/bmj.j1131

I offer a patient's perspective upon your study conclusions:

Personal PMX: I had my first knee operations at age 10 secondary to sports injuries. In addition to a total of 4 menisectomies, I further underwent several other knee surgical procedures, also secondary to sports injuries. By age 59, the quality of my life had become significantly degraded as a consequence of severe knee osteoarthritis and sequelae, including contractures, limitations in all ranges of motion, significant pain even when sedentary, and decreasing functional capabilities in such matters as walking, negotiating elevation differences, exercising, doing work around the house, and, the inevitable difficulties maintaining a positive outlook on life. In October, 2004, I underwent bilateral total knee arthroplasties (TKA), some 4 1/2 months after multiple right rotator cuff repair procedure.

Post-Op Experience: I was able to attain completely normal flexion and extension after 8 of 12 scheduled physical therapy sessions, was able to walk a mile without difficulty of any sort after 6 weeks and swam "my mile" on December 7, 2004, some 6 weeks after surgery. Frankly, I have never had occasion to look back and I remain absolutely delighted with the restoration of function for things I hadn't been able to do for 20 years and never thought I would ever be able to do again. I have been and remain completely pain free, hike whenever and wherever I want to go, have no trouble with scaling ladders, re-roofing the house or doing any of the other things a 72 year-old guy scares his wife with when he undertakes such things. My surgeon receives a letter from me every 5 years advising that I am still the happiest camper on the planet, and, will receive another such letter in a few months when my knees "become teenagers".

Thoughts And Observations:

Reading your study and reflecting upon my own experiences with TKA, interactions with other TKA patients, and, reflections upon such matters as TKA patient selection, patient motivation and the like, I conclude that your study misses the boat through excessive focus on statistics and failing to appreciate the limits of ameliorative treatments and modalities and the significance of "the vital intangibles".

For example, I agree and salute that the best physical therapy may delay some forms of deterioration in "knee health" and resultant loss of function. But, physical therapy tends to be no more than a delaying strategy as no amount of physical therapy will necessarily bring temporary stability or stop the progress of the by definition progressive nature of the degenerative osteoarthritic processes.

I also don't think you have adequately considered and factored in critical difference in patient cohorts as relates to efficacy of TKA. How many of your study patients could be properly characterized, regardless of age, as being in some category of obese, lead primarily sedentary lives and are thereby least likely to either fully engage in or sustain post-operative rehabilitation activities? I suggest that there is probably a stark difference in post-operative assessment of improvement in quality of life between such patients and those who regularly hit the gym or are otherwise much more physically active.

Still a further major intangible is patient attitude. I am sure I am not alone in approaching this major event in life from the perspective that I refuse to accept anything less than an optimum outcome if I can have any meaningful say in the matter. And, since every TKA patient is really in charge of his/her own recovery, of course I can have a meaningful say in the matter.

So, I agree that there are some patients for whom TKA is not an advisable procedure. But, the tenor of your study is overly discouraging in it conclusions/recommendations. For properly selected/motivated patients, TKA has been and remains a "godsend".

Now, let's please revisit this subject in 4-5 years as stem cell and other therapies revolutionize medicine.

Michael L. Price

Competing interests: No competing interests

21 May 2017
Michael L Price
Attorney
None
None
PO Box 16752, Tucson, Arizona 85732-6752
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Re: A snoring child Jared Gursanscky, Marnee Boston, Tawakir Kamani. 357:doi 10.1136/bmj.j2124

I was very interested in this article, but was somewhat surprised to see 'intranasal montelukast' recommended as a remedy. I suspect this is a typographical or editing error.... surely you mean ORAL montelukast and/or intranasal steroids [ presumably as drops or spray ] ?

Please could you explain, thank you.

Dr M P Mayfield

Competing interests: No competing interests

21 May 2017
Dr M P Mayfield
General Practitioner
Harrogate
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Re: George Meachim George Bentley, Susan Meachim. 357:doi 10.1136/bmj.j1656

He was a true gentleman. I miss him.

Competing interests: No competing interests

21 May 2017
Mark E McConnell
Physician
2621 Van Loon Rd
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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

Michael J. Hope Cawdery points out that critical thinking is not explicitly taught or assessed in most education programmes for health professionals. I would go further and suggest that it is actively discouraged in today’s doctors - who often seem to have very little idea about why a particular treatment or, indeed, the human body works.

Competing interests: No competing interests

21 May 2017
Peter Balfour
Addiction psychiatrist
-
-
6 Oaken Street, Ashton-u-Lyne, Lancs OL7 9NS
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Re: Five minutes with . . . Suzy Jordache Tom Moberly. 357:doi 10.1136/bmj.j2371

Congratulations an excellent piece that raises a huge topic
As a 50 something GP with the benefit of being a trainer and GP appraiser you recognise a burning issue which seems to me universal to my peers and which my support networks have help me identify and manage
The reality is that many of us are adapting to this by developing portfolio careers that focus on what we enjoy and often taking us away from our core clinical work.
However in doing so the broader system loses the benefit of the experience and knowledge that was fundamental to providing balanced medical opinion
To ignore this and allow my generation to leave the NHS prematurely for the multiple reasons will in the medium term be bad for patients and weaken the profession permanently
It is simply unfair to expect our more junior colleagues to argue against the forces that do not understand our job when they are burdened with the challenges of career development and the more intense work life balance issues of younger families. As exemplified by the Junior doctors recent and ongoing dispute. Which was a proxy for the changes that the NHS senior mangers wish to impose on us all
Finding an effective voice for my generation is essential before we leave from burnout. Or the methods we choose to avoid burnout
If we fail to do so the question I ask myself is - who will look after me in the way I expect when I am old and frail?
When I do not like who I get then the collective regret will resurface

Competing interests: No competing interests

21 May 2017
Lyndon Wagman
GP
Lane End Medical Group , Edgware , Middx
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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

Undoubtedly, “Dutch euthanasia practice is considered to be careful, safe, verifiable, and transparent” [1]; but the world is larger. In many other places, conflicts of interest would prevail over integrity [2].
1. van Wijngaarden E, Ab Klink A. Assisted dying for healthy older people: a step too far? BMJ 2017;357:j2298
2. https://www.researchgate.net/publication/317036805_Scientific_misconduct...

Competing interests: No competing interests

21 May 2017
Sergei Jargin
medical reviewer
Clementovski per 6-82
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Re: Effective cybersecurity is fundamental to patient safety Guy Martin, James Kinross, Chris Hankin. 357:doi 10.1136/bmj.j2375

The recent WannaCry ransomeware attack certainly caused patient harm, with deferred operations in Secondary Care, and delayed access and likely prescription errors in Primary Care.

The well documented gaping holes in NHS IT security which allowed it represent a failure to guard sufficiently against a known risk to patients. As such, the whole episode could be viewed as requiring a response and apology to all patients collectively under the NHS statutory Duty of Candour. The questions now are: firstly, who needs to own up and make that apology, and secondly, who specifically is responsible for what actions to make future attacks less likely?

Competing interests: No competing interests

20 May 2017
Adam R Douglas
GP
51 Graythwaite, Chetser le Street, County Durham, DH22UH.
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Re: Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland Abigail R A Aiken, Irena Digol, James Trussell, Rebecca Gomperts. 357:doi 10.1136/bmj.j2011

It is vital that the outcomes of telemedicine abortions are made available. Clandestine practices can potentially be detrimental to health. Hence the seminal publication of Aiken et al. is to be welcomed(1). However a potentially important point is overlooked by the authors. The Women on Web organisation (WoW) counsel women against the need for anti-D immunoglobin to avert Rhesus D alloimmunisation. This is contrary to the position statements of the Institute of Obstetricians and Gynaecologists: Royal College of Physicians of Ireland(2), The UK Royal College of Obstetricians of Gynaecologists(3), The American College of Obstetrics and Gynecologists(4) and the Society of Obstetricians and Gynaecologists of Canada(5).
Further, certain practices of WoW do raise some concern. The telemedicine portal advises women, should they seek medical attention, to tell attending doctors that they have suffered a miscarriage rather than attempted a medical abortion (https://www.womenonweb.org/en/page/1683/in-collection/6902/what-if-you-h...). This raises specific issues in Ireland. The Institute of Obstetricians and Gynaecologists: Royal College of Physicians of Ireland guidelines expressly state that women who suffer a spontaneous abortion within 12 weeks' gestation do not require anti-D. However in all cases of medical abortion anti-D must be administered "as soon as possible" after the event(2). The advice given by WoW may place women and subsequent children at risk. Ireland has one of the highest prevalences of the Rhesus negative phenotype in the world at 15%(6,7). This makes the WoW guidance potentially particularly hazardous in this population. It may be premature to conclude that telemedicine abortions are safe in the short- or longterm.

(1)Aiken ARA, Digol I, Trussell J, Gomperts R. Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ. 2017 May 16;357:j2011

(2)https://rcpi-live-cdn.s3.amazonaws.com/wp-content/uploads/2016/05/10.-An...

(3)https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-...

(4)http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Commit...

(5) http://www.jogc.com/article/S1701-2163(16)00043-8/abstract?showall=true

(6) https://www.giveblood.ie/All_About_Blood/Blood_Group_Basics/

(7)Bhutani VK, Zipursky A, Blencowe H, Khanna R, Sgro M, Ebbesen F, Bell J, Mori R, Slusher TM, Fahmy N, Paul VK, Du L, Okolo AA, de Almeida MF, Olusanya BO, Kumar P, Cousens S, Lawn JE.Neonatal hyperbilirubinemia and Rhesus disease of the newborn: incidence and impairment estimates for 2010 at regional and global levels. Pediatr Res. 2013 Dec;74 Suppl 1:86-100. doi: 10.1038/pr.2013.208. web appendix www.nature.com/pr/journal/v74/n1s/extref/pr2013208x1.doc

Competing interests: No competing interests

20 May 2017
Jadeva Mehet
Doctor
Chika Edward Uzoigwe, Luis Carlos Sanchez Franco, Ignacio Gascon Conde, Adrian Sanchez Campoy
Alexandra Hospital, Redditch
Redditch, UK
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Re: If your patient doesn’t speak the same language as you . . . Anonymous. 357:doi 10.1136/bmj.j1511

It is important to note that whilst the vast majority of patients who do not speak the same language as the clinician who bring someone along to translate might prefer to speak through a trusted family member or friend, there are a small number where the accompanying person is not who they say they are, or does not have your patient’s best interests at heart.
Human trafficking is a vast but mostly hidden crime, and often in healthcare settings we miss an opportunity to help someone because we don’t speak to them on their own. In the United Kingdom, there are many thousands of men, women and children who are currently being exploited in conditions of modern slavery – in brothels, cannabis farms, construction sites, private homes and hand car washes, amongst many others (1). They may be a foreign national, or someone born in the UK. Trafficked people suffer from severe psychological and physical harm (2). Their traffickers control them in varied ways, including: debt bondage, coercion and lies, threats to the person or their family, violence, and cultivating a dependency on the trafficker for food, accommodation and other needs (1).
The PROTECT report (2) found that although trafficked people come into contact with health services (particularly maternity departments, A&E and GP surgeries) (2), many are being missed. Traffickers want to prevent their victims escaping their situation, so they are likely to come in with your patient and translate for them or remain in the room so that the trafficked person is too afraid to disclose (2). For these reasons, it is important that healthcare professionals receive more training about recognising the signs of human trafficking and when to insist on using an interpreter, which is by no means easy. If we can recognise the signs and know about the help that’s available through the Modern Slavery Helpline, healthcare services can play an important part in ending the crime of modern slavery.

1) National Crime Agency 2015, The Nature and Scale of Human Trafficking in 2014. Accessed 20/05/17. Available at: http://www.nationalcrimeagency.gov.uk/publications/656-nca-strategic-ass...
2) Oram et al 2015, Provider Responses Treatment and Care for Trafficked People. Department of Health Policy Research Programme. Accessed 20/05/17. Available at http://www.kcl.ac.uk/ioppn/depts/hspr/research/CEPH/wmh/assets/PROTECT-R...

Competing interests: No competing interests

20 May 2017
Toby Bonvoisin
Medical student
University of Sheffield
1 Townend Street, Sheffield, S10 1NJ
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