Notes on three scandals

时间：2016-02-07

发布：Fiona Godlee, Editor in Chief, The BMJ

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Medicine has its fair share of scandals. This week The BMJ reports on three. First, cardiologists John Dean and Neil Sulke highlight what they see as the scandal of the short life of pacemaker batteries (doi:10.1136/bmj.i228). Over half of patients with pacemakers will need new batteries, they say, and many need several replacements. But there are no incentives to develop longer life devices. Increasing longevity would reduce profits for manufacturers, implanting physicians, and their institutions, they say. Meanwhile, patients risk infection and other complications of replacement, and money is wasted replacing batteries before they’ve expired.

The second scandal is a more deep seated one: medicine’s failure to act when members flout basic codes of probity and competence. In the extraordinary saga, doggedly pursued by Peter Wilmshurst for nearly 20 years, surgeon Anjan Kumar Banerjee was briefly awarded an MBE despite having been struck off for serious professional and research misconduct (doi:10.1136/bmj.h6952). He still retains fellowships from three royal colleges and a masters degree that was based on fraudulent data.

Uncovering a bizarre catalogue of failures, Wilmshurst finds rot in almost every pillar of the medical establishment: the universities, the GMC, the royal colleges, the medical honours system—all opaque to scrutiny and resistant to accountability. “When errors occur, the establishment would usually rather close ranks and silence whistleblowers than correct the error,” says Wilmshurst. We need, he says, to get rid of the existing “club culture” in British medicine and create instead a culture that values integrity and transparency.

In his linked editorial (doi:10.1136/bmj.i293), the former BMJ editor Richard Smith has understandably given up hope of change from within the profession. “Something is rotten in the state of British medicine and has been for a long time,” he says. What we need is “a statutory body with powers that can oversee research institutions, including universities.”

Our third scandal reflects an equally longstanding malaise, this time in drug development. Deborah Cohen has been on the trail of the evidence behind the new direct oral anticoagulants for three years. Her first report found hidden evidence of a therapeutic range for dabigatran, undermining claims that patients taking these new drugs don’t need regular blood checks (doi:10.1136/bmj.g4670). Further digging by Cohen has uncovered use of a faulty monitoring device in the only pivotal trial of rivaroxaban, casting serious doubt on findings that underpin use of what is now the world’s best selling new oral anticoagulant (doi:10.1136/bmj.i575). Efforts to allow independent analysis of the data have so far failed.

To paraphrase Smith’s conclusion, things will go wrong in medicine. The real scandal is in failing to act properly when they do.

BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i674 (Published 04 February 2016)
Cite this as: BMJ 2016;352:i674 

A champion for medicine’s humanity

时间：2016-01-29

发布：Fiona Godlee, Editor in Chief, The BMJ

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“Man’s inhumanity to man, Makes countless thousands mourn,” wrote Robert Burns in 1784. Evidence of that inhumanity is all around us, in reports from the world’s war zones, the refugee crisis in the Middle East and Europe, and closer to home wherever we are. This week, with the annual celebration of Burns’s birthday, we also celebrate your support for a charity whose volunteers provide healthcare to vulnerable people suffering the effects of inhumanity.

Doctors of the World is part of the global Médecins du Monde network, which runs more than 350 projects in more than 80 countries with more than 3000 volunteers. Over the past two months our Christmas charity appeal has been seeking your donations to support the work of Doctors of the World. We have heard how its volunteers and local salaried staff are helping Sierra Leone’s health system recover after the epidemic of Ebola virus disease (doi:10.1136/bmj.h6841). We have also heard how the charity helps doctors and nurses volunteering in the Middle East and Europe to provide healthcare for refugees fleeing Syria and Afghanistan (doi:10.1136/bmj.h6515). Despite the destruction of its clinic in Calais and ever present risks to its staff, Doctors of the World continues to run pop-up clinics for refugees stranded there in appalling conditions (doi:10.1136/bmj.i182). The charity’s ability to bring political and legal pressure has forced the French authorities to provide basic public health measures such as clean drinking water.

This week Richard Hurley brings things closer to The BMJ’s home town, reporting on the charity’s work in London (doi:10.1136/bmj.i502). As well as its permanent clinics in Bethnal Green and Hackney, Doctors of the World has identified a particularly vulnerable group, London’s foreign domestic workers. With their visas now tied to a single employer, isolated and fearful of deportation if they seek help, this mainly female group of about 16 000 workers is at high risk of physical and sexual abuse. The charity’s volunteers provide healthcare and advice, while fighting for wider recognition that it is everyone’s right to receive free primary care regardless of immigration status.

Doctors of the World needs more volunteer doctors and nurses, and it relies on private donations to continue its vital independent work. Readers of The BMJ have already generously donated over £25 000 (€33 000; $36 000). If you would like to donate, the details of how to do so are at the end of this week’s article (doi:10.1136/bmj.i502). Thank you to all who have donated money so far and to Doctors of the World for championing medicine’s enduring humanity.

BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i535 (Published 28 January 2016)
Cite this as: BMJ 2016;352:i535

Minding our words

时间：2016-01-22

发布：Kamran Abbasi, International Editor, The BMJ

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We must choose our words carefully. Take Jeremy Hunt, for example. England’s health secretary has earned a reputation for misrepresenting statistics on weekend mortality and exaggerating the effects of industrial action by doctors (doi:10.1136/bmj.h6358). Mindful of Hunt’s scare tactics about the effects of reduced staffing, you might be surprised to learn that the NHS did not collapse after the junior doctors’ strike on 12 January (doi:10.1136/bmj.i314).

As rational thinkers, we will withhold judgement on the effect of the strike on outcomes among patients, but as with previous one-off action any serious effect seems unlikely. In a scenario where the public reputation of junior doctors is untarnished, possibly enhanced, and patients are unaffected, the biggest blow—a “punch,” some said1—was landed on Hunt’s crusade against juniors.

Yet Hunt, who is suddenly “busting a gut” on behalf of patients, isn’t alone in being careless with words and phrases. Stella Duffy explains her decision to opt for mastectomy and reconstructive surgery after a diagnosis of ductal carcinoma in situ (doi:10.1136/bmj.h6786). Her reasons for reconstructive surgery were well considered. Less so the reaction from health professionals. Duffy was repeatedly told, by virtual strangers, that her reconstructed breast “looked good.” But her greater concern was how her reconstructed breast felt, how it was very different from what her breast felt like before, how it no longer felt like a breast, how nobody discussed this with her before her operation.

Simon Cocksedge, a Derbyshire GP, worries about words. He argues that describing patients as “heartsink” is derogatory and demeaning (doi:10.1136/bmj.h6542). The registrars at his practice and the multidisciplinary team are also opposed to its use. “How would you feel as the patient with that label?’ said one. They were worried about the mindset it instils in a practitioner. Better to be interested in a patient and the challenges they pose.

Meanwhile our columnist David Oliver, a geriatrician, turns his attention to doctors who protest that they didn’t “go into medicine to do social work” (doi:10.1136/bmj.i270). By social work they mean multidisciplinary rehabilitation and discharge planning for patients with complex comorbidities. This, he says, describes the job of geriatricians.

It is a job that requires dedication, skill, and judicious choice of words. All these attributes are also essential to win one of The BMJ Awards. Entries for this year are still open. For a chance to be recognised for your work visit thebmjawards.bmj.com/home.

BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i361 (Published 21 January 2016)
Cite this as: BMJ 2016;352:i361