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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: Trusts must encourage junior doctors to report long working hours, GMC says Abi Rimmer. 356:doi 10.1136/bmj.j1312

Your correspondent's article on junior doctor hours (BMJ 2017;356:j1312) does a dis-service to patients and to medicine in general, by missing the underlying reasons for the problem of medical fatigue. As a trainee in the 1970s, I and my contemporaries regularly worked 102 hour shifts. We were 'happily tired' at the end of the session yet still went on partying. These hours, which did us or patients no harm at all, gave us huge experience.

Today's junior doctors are 'unhappily tired' because they recognise either consciously or unconsciously having spent more than 50% of their working time doing paperwork, complying with increasingly onerous box-ticking over countless rules, regulations, protocols and guidelines, and also shoring up a health service whose bosses have starved the NHS of staff due to lamentable manpower planning or cost-cutting. Exactly the same problems are responsible for the poor morale in general practice and the nursing profession.

If we as a profession put specific focus on junior doctor hours, then the main culprits for turning clinical workers into glorified clerks will continue to avoid blame. These include hospital administrations, CCGs and most particularly the GMC. It is ironic indeed that its this organisation which is billed in your article as "encouraging junior doctors to report long hours" when one has only to recall the overwhelming contribution they make, and the paperwork they spew out, to making clinicians' lives a misery. And it is only when our regulators realise their huge sins that clinical workers will regain some sense of ownership of their careers and work.

Competing interests: No competing interests

18 March 2017
Peter J Mahaffey
Consultant Surgeon
Bedford
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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

Poolman, et al. [1] inappropriately extrapolate recent findings reported for LIPUS and fresh fracture healing [2] to include other fracture types, in particular nonunions. However, there is extensive evidence demonstrating the therapeutic and economic benefits associated with LIPUS treatment of delayed unions and established, debilitating nonunions [3-5]. Based on such evidence, the healthcare institute NICE in the UK has approved the use of LIPUS specifically for treating chronic nonunions [6]. Neither the “Rapid Recommendation” [1] nor the linked systematic review article [2] provide any rationale to countermand such guidance; patients and physicians should therefore not be denied access to this important treatment option for nonunion healing.

The “Rapid Recommendation” [1], which, as disclaimed, is “not a validated clinical decision aid”, is based principally on results of the TRUST trial on surgically treated acute (fresh) tibia fractures. Data from TRUST are included in the linked review [2], and comprise greater than one-third of the total number of included patients across the studies analyzed. Studies on fresh fractures predominate (although these are conflated with some nonunion, distraction osteogenesis, stress fracture, and osteotomy studies), such that the results for fresh fractures constitute the findings reported from the meta-analysis. The analysis is thus heavily skewed toward the results of the TRUST fresh fracture trial, and as such is further confounded due to the low overall rate of patient adherence to treatment in that trial (average 43% compliance) [7].

As the leading LIPUS device in the market, EXOGEN (Bioventus LLC, Durham, NC, USA) has been available since 1994, and numerous regulatory agencies including the FDA, Health Canada, BSi, TGA, Medsafe, UAE Ministry of Health, and SFDA have granted their approval based on review of the clinical evidence. In addition, Bioventus continues to seek additional clinical data for the effect of LIPUS on the treatment of acute fractures. EXOGEN has been used to treat more than 1 million patients worldwide, with complaints for lack of efficacy averaging less than 1%. Denying the use of LIPUS to patients who stand to benefit from this therapy is unjustified.

References
1. Poolman RW, Agoritsas T, Siemieniuk RAC, et al. Low intensity pulsed ultrasound (LIPUS) for bone healing: a clinical practice guideline. BMJ 2017;356:j576.
2. Schandelmaier S, Kaushal A, Lytvyn L, et al. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ 2017;356:j656.
3. Zura R, Della Rocca GJ, Mehta S, et al. Treatment of chronic (>1 year) fracture nonunion: Heal rate in a cohort of 767 patients treated with low intensity pulsed ultrasound (LIPUS). Injury 2015;46(10):2036-2041.
4. Rutten S, van den Bekerom MPJ, Sierevelt IN, Nolte PA. Enhancement of bone healing by low intensity pulsed ultrasound. A systematic review. JBJS Reviews 2016;4(3)e6.
5. Mehta S, Long K, DeKoven M, Smith E, Steen RG. Low intensity pulsed ultrasound (LIPUS) can decrease the economic burden of fracture nonunion. J Med Econ 2015;18(7):542-549.
6. National Institute for Health and Clinical Excellence. Interventional procedure overview of low-intensity pulsed ultrasound to promote fracture healing. https://www.nice.org.uk/guidance/mtg12/chapter/1-Recommendations
7. Pounder NM, Phillips M, Rueger J, Heeckt P. A matter of TRUST: An issue of compliance. BMJ 2016;355:i5351

Competing interests: Dr Harrison is an employee of Bioventus and Dr Heeckt is a consultant for Bioventus

18 March 2017
ANDREW J HARRISON
Director of Research
Dr Peter Heeckt MD PhD
Bioventus
4721 Emperor Blvd, Suite 100, Durham NC, 27703
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Re: Spondyloarthritis: diagnosis and management: summary of NICE guidance Katherine McAllister, Nicola Goodson, Louise Warburton, Gabriel Rogers. 356:doi 10.1136/bmj.j839

I just would like to make a comment regarding the sentence 'Healthcare professionals in non-specialist settings fail to recognise signs and symptoms of spondyloarthritis'. I would appreciate if the BMJ editorial staff stopped publishing any more articles with these words or similar in them. As a generalist, I am tired of being told that as a non-specialist we often do not make the correct diagnosis. I would counter by saying many specialists in fields other than the one in question can also fail to recognise signs and symptoms. As doctors, we are all trying to do the best for our patients. Please can we be positive about each other, specialist and non specialist. I would like to see encouragement in review articles rather than remarks which can be taken the wrong way. In the present climate, encouragement and hope that we can learn and improve is what is needed.

Competing interests: No competing interests

18 March 2017
Jenny Ballantyne
General Practitioner
Grimsby
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Re: Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study Yusuke Tsugawa, Anupam B Jena, E John Orav, Ashish K Jha. 356:doi 10.1136/bmj.j273

Tsugawa et al. argue that the current standards for selecting international medical graduates to practice in the United States of America are sufficiently rigorous. One of the key study findings supporting this conclusion is that older Medicare patients treated by international graduates had a lower mortality rate compared to those treated by United States graduates (11.2% vs 11.6%, adjusted odds ratio 0.95, 95% confidence interval [0.93, 0.96], p < 0.001, n = 1,215,490 patients). The authors touch on the “at most modest clinical significance” of this finding in the discussion. However, in the abstract and “what this study adds” section, the authors instead reaffirm their claim that patients cared for by international graduates had lower mortality rates than those by US graduates. While such a statement is technically correct, I argue this conclusion inadvertently confuses statistical significance for clinical significance and is potentially misleading.

With a sample size over 1 million patients, almost any observed differences in the study will be statistically significant. For example, a mortality rate difference of just 0.1% will likely be statistically significant and the corresponding p-value will likely be <0.001, again simply because of the sample size of the study. In fact, if the authors computed mortality rates for the other variables in their logistic regression model (male vs female physicians holding all other variables constant, older vs younger physicians holding all other variables constant, etc…), I suspect all these differences will be statistically significant too. Would the authors then report that patients from one gender of physicians have a higher mortality rate than those from the other?

To better appreciate the significance of the observed difference in mortality rates presented in the paper, a supplementary table should be provided showing calculated mortality rates between the other variables in the logistic regression model (physician sex, physician age, etc…). Variables with the largest difference in mortality rates should be prioritized. If the difference in mortality rates is highest between international and US graduates, that would provide evidence justifying the authors’ claim. However, if a handful of other variables have a similar or higher difference, that would cast additional doubt on the authors’ claim.

I agree with the fundamental conclusion of the article in that the current standards for selecting international medical graduates to practice in the United States of America are sufficiently rigorous. International medical graduates play a vital role in providing much needed healthcare services to millions of Americans, and I believe they will be increasingly important in the years to come. However, it is not necessary to claim that international graduate patients have a lower mortality rate to support this argument. Given the potentially controversial nature of such a claim, additional results should be made available so the results provided in the paper can be better interpreted.

Competing interests: No competing interests

18 March 2017
Daniel Li
Medical Student
The Ohio State University College of Medicine
370 W 9th Ave, Columbus, OH 43210
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Re: Voluntary family planning to minimise and mitigate climate change John Guillebaud. 353:doi 10.1136/bmj.i2102

The Sydney Morning has put out today, message from the President of Turkey, to Turks residing in Europe.
http://smh.com.au/world/begin-baby-boom-across-europe-recep-erdogan-tell...
Prof Guillebaud and those of his way of thinking might care to chew over the message.

Competing interests: No competing interests

18 March 2017
JK Anand
Retired doctor
Free spirit
Peterborough
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Re: A suspected viral rash in pregnancy Jack Carruthers, Alison Holmes, Azeem Majeed. 356:doi 10.1136/bmj.j512

The authors thank Dr Mannion for his response to our article. We are grateful to him for pointing out the error in the table stating that VZIG could be given intravenously. The manufacturers state that VZIG should be given intramuscularly. This is best practice.

In its current form, the table is derived from the Royal College of Obstetrics and Gynaecology (RCOG) 'Green Top' guideline on varicella in pregnancy. This guidance states that 'in an observational study of 212 seronegative women who received an appropriate dose of VZIG, either intramuscular or intravenous, within 10 days of significant exposure to chickenpox, half of the women developed either a normal or an attenuated form of chickenpox and a further 5% had a subclinical infection' (Green Top Guideline No. 13, 'Chickenpox in Pregnancy', online at: www.rcog.org.uk/globalassets/documents/guidelines/gtg13.pdf). The guidelines do not otherwise specify the route of administration of VZIG. We would draw our readers' attention to Dr Mannion's advice in light of these different directions from the RCOG.

Competing interests: No competing interests

18 March 2017
Jack E Carruthers
Honorary Clinical Research Fellow
Azeem Majeed, Alison Holmes
Department of Primary Care and Public Health, Imperial College London
Reynolds Building, St Dunstan's Road, London, W6 6RP
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Re: David Oliver: Why shouldn’t nurses be graduates? David Oliver. 356:doi 10.1136/bmj.j863

Following Dr Copeman's response

I didn't really intend my column or the responses below the line to become a doctrinal debate about research methodologies and the weight and validity of different approaches.

However, I have cited in the original column a pragmatic study carried out with some rigour by a reputable research team with a strong track record in their field.

Attempting a cohort study would, as Dr Copeman doubtless realises, be subject to all manner of confounding variables and would also take years to arrive at a conclusion. And even if the results showed somehow that non-graduate nurses were just as capable, safe and effective as graduates, it wouldnt make any difference to the proposition of my column - namely, that there is nothing wrong with nurses having degrees and that it's ludicrous to claim that uniquely among healthcare professions, nurses are somehow damaged by university education nor that nursing requires a knowledge base and research underpinnings as surely as do professions allied to medicine.

Now, where I do agree is that if we want to do all we can to attract people into healthcare professions, and to retain them, it is important to do all we can to facilitate wider routes of entry and encourage a more diverse base of applicants for training and to allow some people to accumulate their qualifications via a "skills escalator".

In addition, the UK government's decision to cut nursing bursaries and repeatedly to suppress evidence based safe staffing guidance, to go through with Brexit and to impose pay freezes on NHS professions over a number of years and to underfund the NHS has led to major crises of morale in the nursing workforce and worsened workforce gaps. None of that has anything to do with degrees.

David

Competing interests: No competing interests

18 March 2017
David Oliver
consultant physician
NHS
Berkshire
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Re: GP training in mental health needs urgent reform Elizabeth England, Vicki Nash, Kamila Hawthorne. 356:doi 10.1136/bmj.j1311

"We now accept that people’s mental and physical health are intertwined, while GPs support more patients to manage complex, comorbid conditions. Consequently, GPs are required to become experts in areas outside healthcare such as housing, relationships, family, and employment, and they must be well supported to take on such roles, including social prescribing."

(1) This takes something objectively true - that patients are becoming more complex - and uses it to give weight to something which isn't - that this means GPs must become expert in lots of other non-medical things. By way of illustration, can anyone explain exactly why patients having more comorbidities means I need to "learn" to give them career advice?

(2) Reference 3, "supporting" the idea that GPs should do this, is an NHS England webpage about "valuing mental health" https://www.england.nhs.uk/mental-health/parity/ - it's laden with jargon like "parity of esteem" and meaningless management-waffle about how they "focus effort and resources on improving clinical services and health outcomes", as if anyone *doesn't*! More to the point, this isn't a reference - it's an NHS England website. It no more supports the argument than my saying "banks are great" and posting a link to Barclays' website as a reference.

(3) The whole article is particularly ironic given that NHS England have just siphoned £800m in part from the mental health budget to fund shortfalls elsewhere http://www.bmj.com/content/356/bmj.j1382 This doesn't demonstrate much 'valuing' of mental health, and they do say that actions speak louder than words.

(4) 'Social prescribing' is at best GPs taking up the slack caused by the shortfalls of the Citizen's Advice service, and at worst dumbing down highly-trained medical professionals to giving people leaflets on boilers and dampproofing. Perhaps the sort of people who give up clinical medicine to do NHS England roles prefer this to what they trained to do?

The editorial to my mind argues for taking medical professionals and frittering away their training in the art of medicine in favour of handing out leaflets. The idea that this should be part of GP training I cannot oppose strongly enough.

Competing interests: No competing interests

18 March 2017
Nicholas M Grundy
GP
London
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Re: GP training in mental health needs urgent reform Elizabeth England, Vicki Nash, Kamila Hawthorne. 356:doi 10.1136/bmj.j1311

Whilst I agree that General Practice with the broadest of all specialty curricula and the shortest of all specialties' training needs more time, this article contains a non-sequitur that subtly undermines my specialty.

The authors write:

"Around 90% of people with mental health problems are supported in primary care, and GPs also deal with the physical health needs of people with severe mental illness. Despite this, under half of GPs have received mental health training."

If 90% percent of mental health problems are supported in primary care, then any GP who has been well trained in UK NHS general practice placements will have had training in mental health.

By stating that "under half of GPs have received mental health training" the authors disregard the excellent training that GP specialty trainees receive in GP settings, the fantastic efforts of our learners and educators and the process that signs off coverage of the GP curriculum. We should be proud of the contextual training that is delivered in general practice settings which is widely recognised as high quality and is highly rated by learners.

I challenge the authors to look at e-portfolio entries relating to demonstration of mental health competences and see the number of learning events that occur in general practice placements.

Indeed, a more pertinent question might be how psychiatry specialists get contextual exposure to the 90% of mental health problems that are supported in General Practice.

General Practice as a specialty is often denigrated. ( http://pb.rcpsych.org/content/early/2016/02/09/pb.bp.115.053140 )

It is surely possible to argue for longer training for general practitioners without bashing the experience of our general practitioners or bashing general practice training?

Competing interests: No competing interests

18 March 2017
Mark J Purvis
GP Director
Health Education England
Keighley
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Re: Resuscitation policy should focus on the patient, not the decision Zoë Fritz, Anne-Marie Slowther, Gavin D Perkins. 356:doi 10.1136/bmj.j813

It is apparent, that when discussing ReSPECT contributors are all coming from different places, and bringing different perspectives and priorities. It doesn't help that sometimes we use different words to mean the same thing, and sometimes we use the same words to mean different things. So at times, it isn't even clear that both sides of a conversation, are discussing the same issue – even if they believe they are discussing the same issue.

Alex Ruck Keene, a barrister, writes (ref 1) about proxy decision-makers when I write about welfare attorneys: and if we are writing about England, we mean the same thing. Alex writes 'There is an argument that a decision that a proxy seeks to make which is starkly contrary to any reasonable formulation of the best interests of the patient cannot be said to be a relevant decision for purposes of s.6(6).' and then effectively argues that such an 'obviously perverse' decision (my phrase) can be ignored by clinicians, without an appeal for a court ruling being in progress. Alex adds that he would expect recourse to a COP ruling in such a situation, however. Well, ReSPECT is supposed to apply to 'emergency situations' which happen within a patient's own home, when the clinician is a 999 paramedic – if the treatment would be CPR, and the welfare attorney forbids CPR, does Alex believe that 'recourse to the COP' is possible ? In any event, section 6(7) is clear: it says that life-sustaining treatment, against the expressed decision of the welfare attorney, can be applied while a decision is being sought from a court.

I have just been chastised by Claud Regnard (ref 2) for apparently not correctly quoting an article which said 'professionals should “Avoid over-emphasising brutality”' - it seems I wrote 'professionals should ‘avoid emphasising’ the nature of CPR' in my comment. On page 20 of the latest version of the 'Joint CPR Guidance' (ref 3) we can read ' If the welfare attorney makes that decision, it is a binding decision that clinicians must respect, unless … the clinician has good reason to believe that the decision made by the welfare attorney was not made on the basis of the patient’s best interests'. To me that guidance's 'good reason to believe' is nothing like as strong a 'starkly contrary to any reasonable formulation of'.

Claud also tells me that 'Far from being an anachronism, ReSPECT is about restoring the individual to the center of the decision-making process'. Kate Masters, a relative, in her piece (ref 4 – and now helpfully open-access [at last!]) the crucial words 'But my mum had made her decision: she didn’t want the form'.

If ReSPECT and the clinical establishment really did want to 'restore the patient to the centre of decision-making', then the need for Advance Decisions to be created and then respected by 999 paramedics would be stressed. That would address the problem faced by Beverly Tempest (ref 5), of how can she successfully forbid attempted CPR, if she is 'healthy' but does suffer a cardiopulmonary arrest while she is at home. But instead (see the PDF which can be downloaded from ref 6) senior clinicians such as Claud Regnard [I quote from one of his 'Deciding Right' pieces] have been telling junior clinicians something different – it is hard to compress this because of the word 'validity' so I will reproduce from my PDF:

FROM 'DECIDING RIGHT'

Emergency treatment must proceed unless
- they have already died, as indicated by the presence of post-mortem
changes such as rigor mortis;
- it is clear that treatment cannot succeed;
- a valid DNACPR document is available at the bedside;
- an ADRT or court order exists and there is time to check its validity and
applicability;
- there is a personal welfare (health and welfare) LPA with authority to
make life-sustaining decisions and there is time to check the validity and applicability of the order.

MY COMMENT

Why does the wording above, not say either:

- a valid DNACPR document is available at the bedside and there is time to check
its validity and applicability;
- an ADRT or court order exists and there is time to check its validity and
applicability;
- there is a personal welfare (health and welfare) LPA with authority to
make life-sustaining decisions and there is time to check the validity and
applicability of the order.

OR

- a valid DNACPR document is available at the bedside;
- an ADRT or court order is available at the bedside;
- there is a personal welfare (health and welfare) LPA with authority to
make life-sustaining decisions is present.

From my 'family carer perspective' I want decisions expressed by the patient to be respected: 'the system' seems to instead want decisions 'recorded/validated by the GP' to be followed. I see no fundamental difference between my terminally-diagnosed father explaining his decision to me when no clinician is present, or my father explaining his decision to a clinician when I am not present: it is his decision, he has told someone, so we should all be following his decision.

And there is absolutely no 'respect for logic' (refs 7 and 8), in the idea that 'reading a ReSPECT form' equips a 999 paramedic to understand the situation as well as the family carer who called 999 understands it – and as best-interests decision-making is founded on understanding the situation, why are 999 paramedics not told 'inform the family carer of the clinical situation – then ask the family carer if he feels sure about what would be in the patient's best-interests – then if the family carer answers 'I'm sure he would want you to do …' you [the paramedic] should do what the family carer tells you to do'.

Ref 1 http://www.mentalcapacitylawandpolicy.org.uk/respect-a-new-approach-to-a...

Ref 2 http://www.mentalcapacitylawandpolicy.org.uk/respect-a-new-approach-to-a...

Ref 3 https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/

Ref 4 http://www.bmj.com/content/356/bmj.j1084

Ref 5 http://www.bmj.com/content/356/bmj.j1216/rr-1

Ref 6 http://nmcforum.ning.com/discussions/some-professional-beliefs-amount-to...

Ref 7 http://www.bmj.com/content/356/bmj.j1143/rr

Ref 8 http://www.bmj.com/content/355/bmj.i5705/rr-15

Competing interests: No competing interests

18 March 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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