Misdirected care in a misdirected world

时间：2017-09-14

发布：Kamran Abbasi，executive editor，The BMJ

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Hurricanes and floods tell a story of planetary pain and distress. Many of us love our planet but don’t fully understand it. Our solutions are misdirected, ignoring what matters to the planet. Our interests come first. The same applies to patients. Many of us love our patients but struggle to understand their motivations. Our solutions are misdirected.

Victoria Wright has a facial disfigurement. Born with cherubism, she looked like any other girl until the age of 4. Then, her jaw grew bigger, her eyes began to protrude, and the bridge of her nose flattened. Now in her 30s, Wright continues to refuse surgery to reduce her lower jaw. Her disfigurement, she says, “is entwined with my sense of identity.” Yet, when she sees doctors for unrelated problems they sometimes focus on her jaw and tell her that they know excellent surgeons. The question she’d prefer to be asked, and isn’t, is whether there is anything else doctors could do to support her (doi:10.1136/bmj.j4068).

A focus on treating a clinical problem can obscure what matters to a patient. A chronic disease might feel like a life sentence—type 2 diabetes is a perfect example—but should we consider people differently once it is in remission? Louise McCombie and colleagues suggest that celebrating success of remission is a powerful motivator for people with type 2 diabetes to maintain weight loss (doi:10.1136/bmj.j4030). Changing diagnostic coding to reflect remission is likely to deliver better clinical outcomes and reduced healthcare costs.

What happens, though, when diagnosis is controlled by patients? Google is working with the US National Alliance on Mental Illness to offer an online screening test (PHQ-9) to anybody searching for terms such as “Am I depressed?” The alliance’s Ken Duckworth believes that using a standard diagnostic test helps patients seek support and that overtreatment is unlikely, as therapy will still be prescribed by a clinician (doi:10.1136/bmj.j4144). Simon Gilbody, in reply, worries that the case for screening is dubious and that Google’s scheme will largely pick up transient psychological distress.

In an accompanying commentary that epitomises this week’s subtle theme of misdirected care, the patient David Gilbert observes that Google’s offer of a diagnostic test is merely a transfer of paternalistic care to the digital world (doi:10.1136/bmj.j4207). The power of online tools, he argues, will be realised only once service users are equal partners in policy, planning, and delivery of health services.

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4256 (Published 14 September 2017)
Cite this as: BMJ 2017;358:j4256

Lessons for life

时间：2017-08-31

发布：Elizabeth Loder, head of research

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As children around the world trudge back to school, it’s worth considering the connection between education and health. Better educated people have a lower risk of myocardial infarction, stroke, and even certain kinds of cancer. Is education the cause of these better outcomes, or is it just a marker of people who are destined to be healthier for other reasons?

Tillmann and colleagues (doi:10.1136/bmj.j3542) used mendelian randomisation to see whether people with genetic variants associated with longer education have a lower risk of coronary heart disease. And they do: 3.6 years’ extra education was associated with a roughly one third lower risk. The researchers say that these findings “suggest that low education is a cause of coronary heart disease.”

Editorialists Richards and Evans (doi:10.1136/bmj.j3849) find this evidence convincing. They remind us how the technique of mendelian randomisation works: genes linked to longer time in education are distributed randomly at birth. Analysing people on the basis of their genetic make-up helps separate the health effects of education from those of affluence, intelligence, or the many other advantages that track closely with years of schooling.

In this study, the benefit conferred by extra education was “comparable to the effect of short term statin use for primary prevention of coronary heart disease.” Furthermore, the results are in line with other research including natural experiments. The evidence for compulsory education as a public health intervention is growing stronger.

Meanwhile, one lesson we can’t seem to learn is that more medical technology isn’t always a good thing. Quinonez and colleagues (doi:10.1136/bmj.j3850) review the increased use of pulse oximetry to assess children with bronchiolitis. Oximetry is associated with a large increase in hospital admissions but no improvement in mortality. The authors suggest that overdiagnosis of hypoxaemia could be reduced by using this technology more judiciously, lowering the oxygen level that triggers medical intervention, and intermittent instead of continuous monitoring in some settings.

Jeremy Hunt is a politician, not a scientist, but that did not keep him from picking a fight with Stephen Hawking about hospital staffing. Some remedial lessons about cherry picking evidence may be in order for Hunt: Rachel Clarke (doi:10.1136/bmj.j3972) views his Twitter spat with Hawking as “deadly serious” rather than silly. Selective use of evidence in the service of ideology undermines science, she says, and, “in an era of fake news . . . facts are all we have.”

Finally, Margaret McCartney (doi:10.1136/bmj.j3955) declares that “General practice is based on a lie—a lie that we can do this safely and well in 10 minutes.” Double that time would be needed for “acceptably safe” practice; even more if patients are to be fully involved in their care.

“No one goes into medicine for an easy life. But I’m haunted by a feeling of persistent failure,” writes McCartney. Doctors know that no amount of education or skill can make up for a lack of time or resources. It’s a lesson policy makers would do well to learn, too.

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4039 (Published 31 August 2017)
Cite this as: BMJ 2017;358:j4039

Ahead of their time

时间：2017-08-17

发布：Sophie Cook, UK research editor

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The arrival of a newborn is usually a time of excitement and happiness, accompanied by a healthy degree of trepidation about what lies ahead. But for parents or carers of preterm babies feelings of fear and anxiety may predominate.

In England and Wales around one in 13 babies is born preterm and one in 250 extremely preterm (before 28 weeks). In 2015 this amounted to 53 209 preterm and 3014 extremely preterm babies (Office for National Statistics http://bit.ly/2vFagTL). Neonatal medicine has achieved big improvements in mortality over the past few decades, but developmental morbidity remains a concern. For parents, discussions about developmental uncertainty begin early. These conversations weigh heavily, paving the way for anxious anticipation of every milestone and a tendency to benchmark your child against others.

The best information about developmental risk comes from robust cohort studies, such as EPICure (doi:10.1136/bmj.e7961), which report key clinical and developmental outcomes. But these have tended to look only at the extremes of preterm birth, limiting their relevance to babies born very and moderately preterm (27-34 weeks), who make up the majority of early deliveries. This week in The BMJ a study by Véronique Pierrat and colleagues looks at the changing patterns of morbidity in babies born in France in 1997 and 2011 at 22-34 weeks gestation, followed up at 2 years of age (doi:10.1136/bmj.j3448).

For children born at 22-31 weeks’ gestation, those 14 years between the two groups brought improvements in overall survival and in survival without severe or moderate disability. A statistically significant decrease in cerebral palsy was also noted in the 24-31 and 32-34 weeks’ gestation groups. This is encouraging. But developmental delay remained common, even in babies born moderately preterm. Socioeconomic status and being small for gestational age were the main factors associated with lower developmental scores. The authors say these factors should be considered when planning follow-up.

How then should we follow up children and young people who are born prematurely? Our NICE guideline summary (doi:10.1136/bmj.j3514) offers an approach, and we have added a handy infographic to help you navigate the recommendations for the different risk groups. Important take-home messages are to acknowledge the strain imposed by the situation, consider the individual needs of the family, and encourage parents to report concerns early, because behind every preterm baby is a family faced with a childhood of uncertainty.

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3900 (Published 17 August 2017)
Cite this as: BMJ 2017;358:j3900