Don't just soldier on—read this

时间：2015-12-28

发布：Fiona Godlee, Editor in Chief, The BMJ

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We recently learnt that health professionals, among others, do work that is the least replaceable by computers and robots (doi:10.1136/bmj.h6250). This is something Jeremy Hunt may be pondering with regret as talks continue on the junior doctors’ and consultant contracts. It may also partly explain why doctors don’t take sick leave when they’re ill.

Data show that doctors are much less likely than other healthcare workers to take time off sick. As Kathy Oxtoby reports, this could be because doctors are less prone to being ill, but it seems more likely that they feel the need to soldier on regardless (doi:10.1136/bmj.h6719). This sounds admirable—not wanting to let colleagues and patients down when everyone is under pressure. But there are other, less noble, motives that drive doctors to cover up illness: fear that taking time off will damage their career or reduce their standing among peers.

Believing that you’re irreplaceable, or wanting to hide an illness from your colleagues, can damage longer term health and career, as well as putting patients at risk, Marika Davies explains (http://careers.bmj.com/careers/advice/Medicolegal_aspects_of_working_while_unwell). Clare Gerada adds that not only competence but also compassion can be lost when doctors feel unable to take time off (doi:10.1136/bmj.h6720). “If doctors have stopped enjoying contact with patients, or if they are drinking too much or self medicating, they should think about whether they might need to get help,” she says.

Articles elsewhere in The BMJ should help to refresh jaded palates, reminding us why medicine remains so endlessly fascinating. Per Aspenberg reveals how close he came to coauthoring a fake paper (doi:10.1136/bmj.h6605). Flattered to be invited to join an academic working group, he found out the truth when he saw his name on an industry funded position paper. Ben Adams asks whether the current model of authorship is broken (doi:10.1136/bmj.h6560)—should we instead have film-style credits with everyone who participated, including patients, named at the end of each research paper?

And then there is Lyme disease. In an Editorial from an impressive line-up of experts from nearly all corners of the globe, Liesbeth Borgermans and colleagues explain that this unusual multisystem disease is on the rise, possibly due to climate change (doi:10.1136/bmj.h6520). As we learn more about how the spirochaetes evade immune defences and survive antibiotic challenge, the medical community is forced out of its comfort zone, they say. With the story of H Pylori still fresh in our minds, we cannot afford to ignore findings that contradict our current beliefs about disease.

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6695 (Published 10 December 2015)
Cite this as: BMJ 2015;351:h6695

Research is the future: get involved

时间：2015-12-10

发布：Fiona Godlee, Editor in Chief, The BMJ

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Research and journalism can work together to achieve better outcomes for patients. In 2013 The BMJ published a feature on the fashionable practice of sentinel node biopsy in people with malignant melanoma (doi:10.1136/bmj.e8645). The journalist Ingrid Torjesen reported that follow-up data from a key clinical trial had not been published. Her article prompted a commentary in the British Journal of Dermatology raising doubts about the benefits of sentinel node biopsy (doi:10.1111/bjd.12487). When the long awaited data were eventually published in the New England Journal of Medicine last year (doi:10.1056/NEJMoa1310460), specialty journals ran further critical comment.

Now an editorial in The BMJ confirms the view that sentinel node biopsy confers no survival advantage except perhaps in a small minority of patients (doi:10.1136/bmj.h5940). “Any apparent benefit in disease-free survival is clearly a result of trial design and mislabelling of patients,” say Michael Bigby and Catalin Popescu.

Clinical research, properly done and fully and openly reported, is essential to improving the care of patients. Karl Claxton and colleagues (doi:10.1136/bmj.h5987) explain how meta-analysis can help us decide whether more research is needed and when to implement existing research. And we also ask whether, as the UK’s National Institute of Health Research believes, clinicians’ involvement in research is as important as treating patients (doi:10.1136/bmj.h6329). This may seem impossible, given the increasing pressure of patient care. But, as Anne Gulland reports, the institute’s clinical research networks are there to support UK clinicians, and the institute is using its funding power to actively promote women researchers.

More than three million NHS patients took part in research over the past five years. Bravo. Now let’s make sure that patients are properly involved, not just as participants but in trial conception, design, and conduct and the analysis, reporting, and dissemination of results. You may have noticed the new “patient involvement” box in The BMJ’s research articles. Sadly, all too often the text reads something like, “No patients were involved in setting the research question or the outcome measures; nor were they involved in the design and implementation of the study. There are no plans to involve patients in the dissemination of results.” We hope that the shock of such statements will stimulate change. Examples of good patient involvement will also help: see the multicentre randomised trial on stepped care for depression and anxiety (doi:10.1136/bmj.h6127).

Our plan is to shine a light on the current state of affairs and then gradually raise the bar. Working with other journals, research funders, and ethics committees, we hope that at some time in the future only research in which patients have been fully involved will be considered acceptable.

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6525 (Published 03 December 2015)
Cite this as: BMJ 2015;351:h6525

More sinning than sinned against

时间：2015-11-27

发布：Fiona Godlee, Editor in Chief, The BMJ

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Among the statistical sins of England’s health secretary, Jeremy Hunt, summarised and rebutted this week by David Craven (doi:10.1136/bmj.h6358), we might soon have to include an assertion by Hunt that patients will die if junior doctors strike. But an Analysis article this week indicates otherwise. David Metcalfe and colleagues have taken a systematic look at studies reporting mortality data from doctors strikes’ around the world (doi:10.1136/bmj.h6231). Of the six studies from developed countries, none showed an increase in mortality. Indeed, in two cases mortality fell during strikes. The authors conclude that, given this evidence, and provided that emergency care is available, doctors’ strikes do not put the safety of patients at risk.
This is reassuring, as are assurances from the BMA and the General Medical Council that (and who could doubt it) doctors will respond in the event of a major incident (doi:10.1136/bmj.h6322). But a strike is still something most doctors would greatly prefer to avoid. “We don’t want to strike,” writes Roshana Medhian in BMJ Careers, “but for the good of our patients, colleagues, and the NHS we may have to” (http://careers.bmj.com/careers/advice/Junior_doctors%E2%80%99_winter_of_discontent%3A_public_needs_to_know_why_striking_is_necessary).

Our editorialist David Hunter recognises this wider context to the current dispute (doi:10.1136/bmj.h6317). Beyond the juniors’ concerns about longer hours and less pay sits an established and growing erosion of trust between NHS staff and politicians. The current funding crisis, only slightly abated by the latest spending announcements (doi:10.1136/bmj.h6356), has hit while NHS staff are still struggling with the consequences of the coalition’s unnecessary, expensive, and damaging Health and Social Care Act. The act and the increasingly unrealistic demands for efficiency fuel fears that the government’s real agenda is to dismantle the NHS.

Whether Hunt wants a strike is hard to tell. He certainly seems to have set his face against the profession, repeatedly portraying doctors as the only obstacle to his dream of a fully functional seven day service. A paper this week will add fuel to his fire, but I and David Craven advise caution. The study confirms a “weekend effect” in obstetrics, with a slight but statistically significant increased risk of death in babies born at weekends (doi:10.1136/bmj.h5774). But, as with The BMJ’s recent paper on the weekend effect in hospitals (doi:10.1136/bmj.h4596), this study does not attribute excess deaths to lower staffing at weekends. Only one outcome was associated with the level of consultant staffing. And no data were available to assess other crucial resourcing, such as numbers of midwives on duty.

With consultants and GPs standing by their junior colleagues, Margaret McCartney writes that Hunt’s biggest success as health secretary has been “to unite the medical profession—against him” (doi:10.1136/bmj.h6279). Rather than misusing yet more statistics, Hunt should take this brief opportunity to regain the profession’s goodwill, by seeking independent arbitration and averting the strike.

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6369 (Published 26 November 2015)
Cite this as: BMJ 2015;351:h6369