Pediatric Advanced Life Support

Pediatric Advanced Life Sup... by on Scribd

Second victim

Elsewhere in this week’s journal, Melissa Clarkson and colleagues make a strong case for abandoning the term “second victim” when it refers to doctors involved in medical error (doi:10.1136/bmj.l1233), as they find that it promotes a mindset that is incompatible with patient safety and accountability. They say that many physicians are also uncomfortable with the term.

“There is a seductiveness to labelling yourself as a victim,” argue the authors. “Victims bear no responsibility for causing the injurious event and no accountability for addressing it . . . We know who the actual victims of medical errors are because we arranged their funerals and buried them.”

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

16. Tagung der Rhein-Main-AG Minimal Invasive Chirurgie

16. Tagung der Rhein-Main-A... by on Scribd

Zusatzbezeichnung Notfallmedizin

Do Hospitals Still Make Sense? The Case for Decentralization of Health Care

From their humble origins as charitable almshouses for the poor and destitute who could not afford to receive care at home, hospitals have evolved into large, profitable, expensive, technology-laden institutions at the epicenter of the health care universe. Almost every community has at least one general centralized hospital, and most have more than one — with those that don’t being considered “underserved” or “frontier” communities, and with the hospitals in such communities sometimes receiving the designation of “critical access.” But health care is changing. The exponential growth of digital and virtual health, the deployment of advanced technology deeper into the community, and the movement of higher-acuity care into the outpatient environment create opportunities to shift from a large, centralized health care system to a smaller, faster, more cost-effective one in which health care is more accessible, more affordable, more personal, and closer to home.
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Disentangling ourselves from “Big Formula”

Fiona Godlee, The BMJ

Despite decades of effort to curb the promotion of infant formula, sales are flourishing and breastfeeding is in decline, especially in the UK. Earlier this year we heard about the resurgent influence of “Big Formula,” with industry lobbying and funding for medical education harming babies and mothers around the world (doi:10.1136/bmj.k3577). This week we investigate one small but influential corner of the multibillion pound formula industry: the promotion of specialist formula for treating cow’s milk protein allergy (CMPA).

Chris van Tulleken finds a worrying range of deeply embedded relationships between formula manufacturers and doctors, dietitians, and professional bodies (doi:10.1136/bmj.k5056). The bones of the story are familiar. International guidelines are funded by the industry and written by experts who have their own industry ties. These guidelines, widely promoted to clinicians and the public through industry funded charities and educational meetings, promote the idea that non-IgE mediated CMPA causes a range of common non-specific symptoms, including colic, reflux, loose stool, and skin rash. Mothers are advised to exclude cow’s milk from their diet, which makes breastfeeding harder to maintain. Those who abandon exclusive breastfeeding are advised to use specialist formula. In contrast to IgE allergy, there is no diagnostic test for non-IgE CMPA, making it especially vulnerable to industry exploitation.

The tactics are clearly working. Between 2006 and 2016 in England numbers of prescriptions for specialist formula rose by nearly 500% to more than 600 000 a year, and the NHS now spends over £60m (€67m; $76m) a year, an increase of nearly 700% in the past decade. Some infants do have CMPA, but van Tulleken finds no evidence of such a huge hike in prevalence that would justify this surge in prescribing.

The story has all the hallmarks of overdiagnosis fuelled by commercial interests. To tackle this we will need experts who are free from financial conflicts to decide on tighter diagnostic criteria, draw up independent clinical practice guidelines, and deliver unbiased medical education. We also need clinicians and professional bodies to disentangle themselves from industry and to give their unconflicted support to breastfeeding.

The BMJ and its sister journals accept advertising for specialist breastmilk substitutes. The advertisements must be legal and honest and meet advertising standards, and we expect all claims of health benefit to be supported by published peer reviewed research. Last year the BMJ company received £200 000 for advertisements for breastmilk substitutes.

In light of van Tulleken’s investigation and our own growing concerns about the effect of aggressive promotion of breastmilk substitutes on rates of breastfeeding around the world, we are reviewing our policies on accepting advertising for these products. We welcome your thoughts on the issue and will report back in the new year.

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

The growing problem of diabetes

Fiona Godlee, The BMJ

Type 2 diabetes affects nearly 10% of the world’s adults, and rates are rising rapidly, especially in low and middle income countries.1 In the UK it affects about four million adults (6% of the population), and if nothing changes this will grow to about five million by 2025.2 And new figures released this week by Diabetes UK show that in England and Wales nearly 7000 people under age 25 now have type 2 diabetes (doi:10.1136/bmj.k4929).

With such numbers, diabetes in one form or another now makes up a substantial part of any doctor’s day (doi:10.1136/bmj.k4723). So what can you do for your diabetic patients? Firstly, don’t call them that, says Judith Hendley (doi:10.1136/bmj.k3119). She wants to be identified as a person first and not as a diabetic patient, a label that reduces her “to someone with diabetes and nothing else.”

Secondly, consider your use of language generally. Hendley suggests avoiding questions such as “Are you well controlled?” She says, “This feels like a question about my behaviour and how ‘good’ I have been.” Better to ask open questions that don’t judge or make assumptions, for example: are you having any difficulties with your blood sugar at the moment, and what is most important to you right now? Such reframing may sound trivial, but, says Hendley, it “could make a big difference to how the people in front of you see themselves and their condition—and how they see you.”

As for the factors behind the global diabetes epidemic, there’s always more to learn. Analysis of data from two large cohorts of nurses confirms the key role of unhealthy lifestyles (doi:10.1136/bmj.k4641). A systematic review looks specifically at the effect of fructose on glycaemic control and concludes that this depends on the source of fructose and how much extra energy it provides (doi:10.1136/bmj.k4644). Sweetened drinks and some other foods that add excess “nutrient poor” energy were most likely to adversely affect glycaemic control.

Weight loss is essential for management of diabetes and can lead to remission, but once achieved it can be hard to maintain. In what may be a ground breaking randomised trial, Cara Ebbeling and colleagues found that energy expenditure was higher when people ate a low carbohydrate diet during weight loss maintenance (doi:10.1136/bmj.k4583). People randomised to a high carbohydrate diet had higher concentrations of the hormone ghrelin, which is thought to reduce energy expenditure.

Ultimately the burden of diabetes is unsustainable. While patients and health professionals manage as best they can, the real and urgent solutions rest with our governments.

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

What we must learn from mesh

Fiona Godlee, The BMJ

What can we learn from the shameful story of vaginal mesh? That thousands of women have been irreversibly harmed; that implants were approved on the flimsiest of evidence; that surgeons weren’t adequately trained and patients weren’t properly informed; that the dash for mesh, fuelled by its manufacturers, stopped the development of alternatives; that surgeons failed to set up mesh registries that would have identified complications sooner; and that the National Institute for Health and Clinical Excellence and the UK regulators let them off the hook (doi:10.1136/bmj.k4137, doi:10.1136/bmj.k4164). As our editorial says (doi:10.1136/bmj.k4231), unless mandatory national registries are now established another mesh tragedy is inevitable.

The mesh story tells us something else: the extent to which surgeons, researchers, and professional bodies are entangled with the device manufacturers. This is nothing new. Indeed discussion of it will be as tediously familiar to most readers of The BMJ as it is to us editors. But we make no apology for raising it again. Why? Because of the evidence that researchers’ conclusions and clinicians’ decisions are influenced in favour of their sponsors’ products. If this were not the case, why would manufacturers spend the money? GlaxoSmithKline has just confirmed the usefulness of paid opinion leaders by reinstating payments to clinicians who speak and write about its products (doi:10.1136/bmj.k4157).

So I have two questions. First, should clinicians and researchers take money from industry? My answer is no. We don’t allow judges or journalists to take money from the people they are judging or reporting on. Doctors should be equally independent in their advice to patients. This is why, uniquely among the major medical journals, The BMJ ensures that the authors of clinical education articles and editorials are free from relevant financial interests (doi:10.1136/bmj.g7197). As for industry sponsored research, we welcome the call by Paula Rochon and colleagues for journals to ensure that academic authors retain full control of the process (doi:10.1136/bmj.k4224).

Second, given that doctors and researchers do take money from the industry, should the details be readily available to patients and the public? My answer is yes. Jonathan Gornall found this wasn’t the case with mesh (doi:10.1136/bmj.k4164), despite NHS guidance on declaration of financial interests. NHS trusts are catching up with their responsibilities, but slowly. The Association of the British Pharmaceutical Industry’s database is voluntary and therefore ultimately ineffectual. The device industry’s equivalent body, the Association of British HealthTech Industries, has refused to take even this baby step. The GMC has been asked to establish a register of doctors’ interests (doi:10.1136/bmj.h396) but shows no signs of doing so.

In the US the Sunshine Act hasn’t solved the problem (doi:10.1136/bmj.k4151) but it has put doctors on notice (http://bit.ly/2C94j6G). Other countries should follow this lead.

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

Improving the working environment for safe surgical care

Improving the working environment for safe surgical care by Prof Dr Dr Ernst Hanisch on Scribd

Building Trust by Learning to Listen

If I had to focus in on one or two things, I would highlight two. And the first is the L for listen. Mehr

Trusting Healthcare Providers and Institutions: Key Findings

Research shows that open lines of communication create trust, and vice versa, and that trusting relationships are key to better healthcare outcomes. One study, for example, has shown that poor communication among the staff in a pediatric hospital influenced their trust levels and how they cared for patients. In another study, clinicians who worked in an intensive care unit were trained in how to conduct a family meeting, specifically in empathetic listening. Family members who met with these clinicians had less depression and post-traumatic stress after their loved one had died.
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Cultivating Great Teams: What Health Care Can Learn from Google

How Teams Excel

We’ve learned that there are five key dynamics that set successful teams apart from other teams at Google:

1. Psychological safety: Can team members take risks by sharing ideas and suggestions without feeling insecure or embarrassed? Do team members feel supported, or do they feel as if other team members try to undermine them deliberately?
2. Dependability: Can each team member count on the others to perform their job tasks effectively? When team members ask one another for something to be done, will it be? Can they depend on fellow teammates when they need help?
3. Structure & clarity: Are roles, responsibilities, and individual accountability on the team clear?
4. Meaning of work: Is the team working toward a goal that is personally important for each member? Does work give team members a sense of personal and professional fulfillment?
5. Impact of work: Does the team fundamentally believe that the work they’re doing matters? Do they feel their work matters for a higher-order goal?

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Topmediziner 2016

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  Die Validität von Routinedaten by Prof Dr Dr Ernst Hanisch

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Practical Improvement Science in Health Care

Wie erreichen wir eine Verbesserung

Public reporting of surgeon outcomes

Public Reporting of Surgeon Outcomes by Prof Dr Dr Ernst Hanisch

Siddharta Mukherjee’s three laws of medicine

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AOK - Zur wissenschaftlichen Wertigkeit der Lebensbäumchen

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