At your next conference ask where the patients are

时间：2016-09-22

发布：Fiona Godlee, editor in chief

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It may not feel like it just now, but what we have is doctor centred care. Perhaps also institution, manager, and nurse centred care. What we don’t yet have is patient centred care, despite this being obviously what healthcare should be. But things are slowly shifting in the right direction, and The BMJ aims to help keep up the momentum.

An editorial last week summarised where we’ve got to with The BMJ’s patient partnership strategy (doi:10.1136/bmj.i4550), and there’s good progress to report. We now have patients as peer reviewers of research articles and contributing to education articles; we require authors to state how patients were involved in their research or in creating an article; and we are publishing a rich array of patients’ commentaries.

These efforts mirror progress elsewhere, with patients increasingly involved in designing and implementing clinical care and research. But some parts of the healthcare ecosystem have proved more resistant to change. It’s now 25 years since the International Aids Conference first included patients in its discussions, but as Larry Chu and colleagues point out (doi:10.1136/bmj.i3883), involvement of patients in medical conferences remains the exception rather than the norm. Done well, it widens the focus of presentations, encourages more patient relevant outcomes in research, and prompts improvement in the design and delivery of care, they say. Above all, it changes the culture of a conference. Although the drive has come from patients, the medical community has much to gain.

So, what does doing it well look like, and how can organisers overcome the barriers to patient involvement? With five years’ experience of running a large academic medical conference in which patients play a central part, Chu and colleagues are well placed to advise. It’s not enough, though essential, to have patients on the steering and programme committees from the start, they say. Organisers need also to encourage patients to attend, comment, and speak. This means making sure that patient delegates are properly looked after and supported so they can contribute on an equal footing to other participants. This is not window dressing and must not be tokenistic. Crucially, it brings patients “closer to the conversations driving the future of healthcare.”

As for The BMJ, we are proud to be the first medical journal to have earned the Patients Included stamp of approval (https://patientsincluded.org; http://bit.ly/patient-partnership), but we know there is more to do. Our patient panel meets this week to grade our work so far and tell us what it wants us to do next.

Footnotes

BMJ Blogs Amy Price: The evidence informed patient (http://blogs.bmj.com/bmj/2016/09/14/amy-price-the-evidence-informed-patient); Neil Betteridge: Effective involvement of patients at medical meetings (http://blogs.bmj.com/bmj/2016/09/14/effective-involvement-of-patients-medical-meetings-a-case-study); Dan Smyth: Patient involvement in the European Respiratory Society Congress 2015-16 (http://blogs.bmj.com/bmj/2016/09/14/patient-involvement-in-the-european-respiratory-society-congress)

BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i5123 (Published 22 September 2016)
Cite this as: BMJ 2016;354:i5123

Statins: we need an independent review

时间：2016-09-15

发布：Fiona Godlee, editor in chief

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Statins are back in the news. A review published in the Lancet last week, covered in our news story (doi:10.1136/bmj.i4893), presents what its authors clearly consider to be a definitive account of the evidence on statins that should, they say, bring an end to a dangerous debate.

Not everyone agrees. Though the benefits of statins for secondary prevention or in people at high risk of cardiovascular disease are undisputed, proposals to offer them to large numbers of people at lower risk remain controversial, much to the frustration of the statin trialists who authored the Lancet review. Commenting in The BMJ this week, Harlan Krumholz agrees on the strong case for the overall benefits of statins, but he wants more acknowledgment of the trials’ limitations (doi:10.1136/bmj.i4963). These include the lack of good evidence in elderly people, the variation in how adverse event data were collected, and the ageing of the trials themselves.

In a BMJ blog Richard Lehman says that adverse effects are much more common than the trials suggest (blogs.bmj.com/bmj). “Muscle pain and fatigability are not a figment of misattribution and public misinformation,” he says. “They are too prevalent and recurrent in people who desperately want to stay on statins. Rather than discount a widely observed phenomenon, we should ask why there is such a mismatch with reporting in the trials.” Could this mismatch be due to exclusion of people who experienced side effects during “run-in periods” before randomisation?

At a more fundamental level, who should decide when such questions are too dangerous to ask? Certainly not those who have a vested interest in the debate being shut down. Rory Collins, head of the Cholesterol Treatment Trialists’ (CTT) Collaboration, continues to call for the retraction of two BMJ articles that disputed the use of statins in low risk people (doi:10.1136/bmj.f6123; doi:10.1136/bmj.f6340). His call comes despite an independent expert panel set up by The BMJ and, subsequently, the Committee on Publication Ethics (COPE) concluding that The BMJ had acted appropriately in its handling of the papers. This week we publish documents (http://static.www.bmj.com/sites/default/files/copedocuments.pdf) that serve to correct Richard Horton’s comments in the Lancet (doi:10.1016/S0140-6736(16)31583-5), in which he wrongly stated that COPE had “declined to act” on Collins’s concerns. (See also my rapid response www.bmj.com/content/351/bmj.h3908/rr-8.)

Independent third party scrutiny of the statins trial data remains an essential next step if this increasingly bitter and unproductive dispute is to be resolved. I have now written to England’s chief medical officer, Sally Davies, asking her to call for and fund an independent review of the evidence on statins. As Krumholz concludes, sharing the individual patient level data from the statins trials would send “a strong message that no single person or group should have exclusive access to data” that are so important for public health.

Footnotes

For more of The BMJ’s content relating to the statins debate go to bmj.com/campaign/statins-open-data.

BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4992 (Published 15 September 2016)
Cite this as: BMJ 2016;354:i4992

No room for sexism

时间：2016-09-01

发布：Fiona Godlee, editor in chief

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It is perhaps no great surprise that two traditionally macho cultures—Australia and surgery—combine to harbour sexist attitudes. But the extent of the harassment of Australia’s female surgeons, and the impunity with which senior surgeons meted out the abuse, has only recently been fully acknowledged. That it has is thanks to the courage of one woman in speaking out. Vascular surgeon Gabrielle McMullin’s description of an entrenched culture of sexual harassment caused a media storm last year, followed by a flood of corroborative stories from female surgeons who had experienced persistent sexual advances and innuendo, gender slights, and comments on their appearance, with predictable effects on their careers and emotional health.

Luckily, as Amy Coopes reports (doi:10.1136/bmj.i4210), it also brought about a concerted response from the Royal Australasian College of Surgeons, including an unreserved apology from its president. A college inquiry unearthed a toxic culture of fear and reprisal. Too many surgeons had been silent bystanders as well as perpetrators, he said. The college’s new education and awareness campaign—“Let’s operate with respect”—includes mandatory training on discrimination, bullying, and sexual harassment. McMullin wants further action, including black boxes to record what is said and done in operating theatres.

What of the UK? GMC data indicate that bullying happens but is less prevalent than in Australia, a fact that Scarlett McNally attributes (doi:10.1136/bmj.i4682) to longstanding training programmes and a willingness to challenge inappropriate behaviour. Still, there is room for improvement. McNally highlights the challenge of avoiding “unconscious bias”—the natural tendency to form assumptions about another person, which can lead to sexism, racism, and even “heightism.” And she reminds us that bullying and abuse put patients as well as staff at risk. Studies repeatedly show that rigidly enforced hierarchies and poor interpersonal relations impair patients’ safety and deliver poorer experiences of care. And organisations with women in leadership positions have been found to perform better (https://www.theguardian.com/business/2015/sep/29/companies-with-women-on-the-board-perform-better-report-finds).

Any talk of sexism in UK medicine may seem odd while we bask in an unprecedented era of female leadership. At least six of the medical royal colleges (including physicians, surgeons, and general practitioners) have women at the helm, and we currently have women in the roles of chief medical officer and (ahem) editor in chief of The BMJ. But women are still vastly under-represented in senior academic positions and NHS trust boards. In a BMJ Blog Miriam Fine-Goulden says that if we are to correct this we need to hold men and women to the same standards in their personal and professional lives (http://blogs.bmj.com/bmj/2016/08/15/miriam-fine-goulden-how-we-talk-about-women-leaders). She asks us to reflect on how we talk about our colleagues: “Would I say this if that person was a member of the opposite sex?”

BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4720 (Published 01 September 2016)
Cite this as: BMJ 2016;354:i4720