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Rapid Responses |
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EDITORIALS:
Boxing and the risk of chronic brain injury
- McCrory (4 October 2007)
[Full text]
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BMA needs evidence based policy
- Andrew J Ashworth
(6 October 2007)
 Read every Rapid Response to this article
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RESEARCH:
Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial
- Mason et al. (4 October 2007)
[Abstract]
[Full text]
[PDF]
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Older people who fall are more likely to fall again
- Philippa A Logan, et al.
(11 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Amateur boxing and risk of chronic traumatic brain injury: systematic review of observational studies
- Loosemore et al. (4 October 2007)
[Abstract]
[Full text]
[PDF]
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Amateur boxing
- Simon M. Kemp
(12 October 2007)
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How did you get that black eye?
- Dawn A Sim
(10 October 2007)
- Read every Rapid Response to this article
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VIEWS & REVIEWS:
Why the culture of medicine has to change
- Hayward (13 October 2007)
[Full text]
[PDF]
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Re: Change yes......but incrementally!
- Sam Lewis
(13 October 2007)
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Change yes......but incrementally!
- peter j mahaffey
(13 October 2007)
- Read every Rapid Response to this article
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PRACTICE:
An unusual cause of jaundice
- Owen et al. (13 October 2007)
[Full text]
[PDF]
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A Manifestation of Gilbert's Syndrome?
- Ossie F Uzoigwe
(13 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Preventing childhood obesity: two year follow-up results from the Christchurch obesity prevention programme in schools (CHOPPS)
- James et al. (13 October 2007)
[Abstract]
[Full text]
[PDF]
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Too early to ditch the fizz campaign
- J. Lennert Veerman, et al.
(11 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Comparison of hospital episode statistics and central cardiac audit database in public reporting of congenital heart surgery mortality
- Westaby et al. (13 October 2007)
[Abstract]
[Full text]
[PDF]
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Public reporting of Outcomes in Surgery: Time to reflect on Bristol?
- Ashok I Handa
(11 October 2007)
- Read every Rapid Response to this article
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FEATURE:
From small things
- Reynolds (13 October 2007)
[Full text]
[PDF]
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Chemical toxicity and mitochondria
- Heikki Savolainen
(12 October 2007)
- Read every Rapid Response to this article
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NEWS:
Mother asks surgeons to perform hysterectomy on daughter with cerebral palsy
- Dyer (13 October 2007)
[Full text]
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Hysterectomy/Sterilisation
- Vaidyanathan Gowri
(12 October 2007)
- Read every Rapid Response to this article
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NEWS:
Tooke inquiry calls for major overhaul of specialist training
- Eaton (13 October 2007)
[Full text]
[PDF]
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Post-CCT "Specialist" !
- Stuart H McClelland
(13 October 2007)
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Re: Tooke report
- D B Double
(12 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Modernising Medical Careers laid bare
- Delamothe (13 October 2007)
[Full text]
[PDF]
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ST Depression or ST Elevation?
- Chika Uzoigwe, et al.
(12 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Screening for abdominal aortic aneurysm
- Greenhalgh and Powell (13 October 2007)
[Full text]
[PDF]
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Screening for abdominal aortic aneurysm
- Hisato Takagi, et al.
(13 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Participation in mammography screening
- Schwartz and Woloshin (13 October 2007)
[Full text]
[PDF]
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False positives don´t result in overdiagnosis
- Christian Weymayr
(13 October 2007)
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And Women Over 70, over 80?
- Joseph More
(12 October 2007)
- Read every Rapid Response to this article
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EDITOR'S CHOICE:
The way of the world
- Delamothe (13 October 2007)
[Full text]
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What doctors should tell their patients about CAM
- Roger A Fisken
(12 October 2007)
- Read every Rapid Response to this article
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VIEWS & REVIEWS:
Fluoride: a whiter than white reputation?
- Griffiths (6 October 2007)
[Full text]
[PDF]
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Fluoride: a whiter than white reputation?
- John Graham
(8 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review
- Pewsner et al. (6 October 2007)
[Abstract]
[Full text]
[PDF]
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Left ventricular hypertrophy and QT dispersion in hypertensive patients
- Antoni Sisó Almirall, et al.
(11 October 2007)
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Correction to response posted on October 07 by Vanezis and Bhopal
- Andrew Peter Vanezis, et al.
(10 October 2007)
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Ethnic variations in the ECG
- Andrew P Vanezis, et al.
(7 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials
- van Sluijs et al. (6 October 2007)
[Abstract]
[Full text]
[PDF]
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Promoting active life styles in our children
- Ediriweera Desapriya, et al.
(10 October 2007)
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Physical activity in childhood and adolescence
- Joav Merrick, et al.
(5 October 2007)
- Read every Rapid Response to this article
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ANALYSIS:
Adding fluoride to water supplies
- Cheng et al. (6 October 2007)
[Full text]
[PDF]
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Fluoridation and aluminium
- Christopher Exley
(13 October 2007)
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A question of the common good
- C Albert Yeung
(12 October 2007)
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Water fluoridation and bladder cancer
- Raymond J Lowry
(10 October 2007)
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By all means, fluoridate. I’ll just refuse to drink it. - Oct 2007
- Phillip J Colquitt
(10 October 2007)
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It's time for a moratorium on fluoridation
- Barry A Groves
(10 October 2007)
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Adding fluoride to water supplies
- Dr Barry Cockcroft
(9 October 2007)
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Ethics of water fluoridation
- John F Beal
(7 October 2007)
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Dental benefits of water fluoridation
- Michael A Lennon
(5 October 2007)
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Medication with intent – the case against water fluoridation.
- Douglas W Cross
(5 October 2007)
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Adding fluoride to water supplies
- Colwyn M Jones
(5 October 2007)
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Fluoride Consumption – Much Higher than We Are Told
- Peter J Mansfield, et al.
(5 October 2007)
- Read every Rapid Response to this article
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OBSERVATIONS:
An age old problem
- Richards (6 October 2007)
[Full text]
[PDF]
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Self Management :An age old solution to an age old problem
- Arun K Chopra
(13 October 2007)
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Right to die?
- Peter Bruggen
(12 October 2007)
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Apologies to Tomji Tanabe
- Tessa J Richards
(8 October 2007)
- Read every Rapid Response to this article
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FEATURE:
Should general practitioners resume 24 hour responsibility for their patients? No
- Herbert (6 October 2007)
[Full text]
[PDF]
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Needs and Wants
- Andrew P Moltu, et al.
(6 October 2007)
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The Elephant in the (waiting) room
- Duncan M Williams, et al.
(6 October 2007)
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GP out of hours
- Julian C Law
(5 October 2007)
- Read every Rapid Response to this article
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FEATURE:
Should general practitioners resume 24 hour responsibility for their patients? Yes
- Jones (6 October 2007)
[Full text]
[PDF]
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Not either or...
- Steven Ford
(13 October 2007)
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GP Land
- Dr. Raja Baber Sheraz
(13 October 2007)
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In support of the GP Co-op
- john m caine
(12 October 2007)
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24hour responsibility
- ravinder Norman
(11 October 2007)
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depends on format
- Duran Kandhai
(11 October 2007)
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24 hours
- Gregory M Read
(11 October 2007)
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Not keen!
- Rosemary B Martin
(11 October 2007)
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The Good Old Days
- David Howard
(10 October 2007)
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gp 24hr resposibility
- tariq m hama
(10 October 2007)
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in the long run - giving up out of hours has been a bad thing
- edmund willis
(10 October 2007)
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In reply to Mr Wintertton above...
- David P Jones
(9 October 2007)
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yes responsibility is for doctors to bear
- robert derek wintertton
(8 October 2007)
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OOH, General Practice and Sanity
- David P Jones
(8 October 2007)
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Family Physicians
- Milind A Patil
(8 October 2007)
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No need for extended hours
- chris jenkins
(7 October 2007)
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TORONTO: After Hours medicine.
- Alexander FRANKLIN
(7 October 2007)
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Should general practitioners resume 24 hour responsibility for their patients? Yes
- Imran Arfeen
(6 October 2007)
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FINGS AINT WHAT THEY USED TO BE..
- Graeme Mackenzie
(6 October 2007)
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Whos falt is this anyway and why make it any worse than it already is ?
- Alex G. Robertson
(5 October 2007)
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General practitioners still do provide out-of-hours care
- Robert L. Morley
(5 October 2007)
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Out of hours GPs are well qualified , good doctors
- Caroline A Mitchell
(5 October 2007)
- Read every Rapid Response to this article
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FEATURE:
Industry funded patient information and the slippery slope to New Zealand
- Toop and Mangin (6 October 2007)
[Full text]
[PDF]
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Anecdotal instance of positive effects of drug advertising
- Charles L. Rogerson
(13 October 2007)
- Read every Rapid Response to this article
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NEWS:
Australian efforts to tackle abuse of Aboriginal children raise alarm
- Sweet (6 October 2007)
[Full text]
[PDF]
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NT Aboriginal health care
- Deane Dight
(7 October 2007)
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Address basic care for Aboriginal people
- DAVID G SAMUEL
(5 October 2007)
- Read every Rapid Response to this article
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NEWS:
UK does well on giving information to patients but poorly on access to new treatments
- Watson (6 October 2007)
[Full text]
[PDF]
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Bismark v. Beveridge
- Iain S Fraser
(11 October 2007)
- Read every Rapid Response to this article
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NEWS:
Africans die in pain because of fears of opiate addiction
- Logie and Leng (6 October 2007)
[Full text]
[PDF]
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Opiates for pain in dying patients and in those with sickle cell disease
- Felix ID Konotey-Ahulu
(11 October 2007)
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The fear of Opiate addiction – not unique to Africa
- Jecko Thachil
(8 October 2007)
- Read every Rapid Response to this article
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LETTERS:
A cheap soundbite
- Magos et al. (6 October 2007)
[Full text]
[PDF]
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Cold hands warm heart
- Karen J Hebert
(12 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Reform of the coroner system and death certification
- Luce (6 October 2007)
[Full text]
[PDF]
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Unintended consequences
- Laurie R Davis
(12 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Mental health in disaster settings
- Jones et al. (6 October 2007)
[Full text]
[PDF]
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Community psychiatry - a building approach
- Pandey Vibha
(1 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Encouraging children and adolescents to be more active
- Giles-Corti and Salmon (6 October 2007)
[Full text]
[PDF]
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Working harder together to tackle obesity
- Shalini Pooransingh
(12 October 2007)
- Read every Rapid Response to this article
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EDITOR'S CHOICE:
Tooth and nail
- Godlee (6 October 2007)
[Full text]
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Fluoridation - Bad To The Bone
- Maureen C. Jones
(9 October 2007)
- Read every Rapid Response to this article
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OBITUARIES:
Bjørn Ibsen
- Richmond (29 September 2007)
[Full text]
[PDF]
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Obituary Notice re Bjørn Ibsen
- Ronald V Trubuhovich
(10 October 2007)
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Dunce's hat
- Caroline Richmond
(3 October 2007)
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Bjorn Ibsen: Founding father of intensive care
- Roger H. Armour
(1 October 2007)
- Read every Rapid Response to this article
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VIEWS & REVIEWS:
The alcohol industry: taking on the public health critics
- Farrell (29 September 2007)
[Full text]
[PDF]
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Health cost of alcohol unregulated market
- Ronaldo R Laranjeira
(2 October 2007)
- Read every Rapid Response to this article
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VIEWS & REVIEWS:
Ethicist on the ward round
- Sokol (29 September 2007)
[Full text]
[PDF]
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Ethicist on the ward round?
- Cathriona Russell, et al.
(3 October 2007)
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Recognising the ethical problem
- Jonathan Howell
(3 October 2007)
- Read every Rapid Response to this article
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PRACTICE:
Care of healthy women and their babies during childbirth: summary of NICE guidance
- Kenyon et al. (29 September 2007)
[Full text]
[PDF]
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Unnecessary controversy
- Rishu Tandon
(5 October 2007)
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Prevention: a practical approach
- Vibha Pandey
(3 October 2007)
- Read every Rapid Response to this article
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FILLERS:
Relative risk
- Hanna (29 September 2007)
[Full text]
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An ethical problem
- Mounir (Munir) E Nassar, M.D., FACP
(7 October 2007)
- Read every Rapid Response to this article
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CLINICAL REVIEW:
Managing anovulatory infertility and polycystic ovary syndrome
- Balen and Rutherford (29 September 2007)
[Full text]
[PDF]
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Management of anovulatory infertility and polycystic ovary syndrome should include diagnosis and treatment of essential nutrient deficiencies.
- Ellen C G Grant
(1 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Effectiveness and safety of chest pain assessment to prevent emergency admissions: ESCAPE cluster randomised trial
- Goodacre et al. (29 September 2007)
[Abstract]
[Full text]
[PDF]
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Acute chest pain units. What's in a name?
- S Richard Underwood
(1 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Preventive strategies for group B streptococcal and other bacterial infections in early infancy: cost effectiveness and value of information analyses
- Colbourn et al. (29 September 2007)
[Abstract]
[Full text]
[PDF]
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The Dangers of Misinterpretation of Economic Analysis
- Jude N Chukwuma, et al.
(30 September 2007)
- Read every Rapid Response to this article
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ANALYSIS:
Use of process measures to monitor the quality of clinical practice
- Lilford et al. (29 September 2007)
[Full text]
[PDF]
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Outcomes Remain The Gold Standard
- Robert Matz
(3 October 2007)
- Read every Rapid Response to this article
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OBSERVATIONS:
Wham, bam, thank you CAM
- Kamerow (29 September 2007)
[Full text]
[PDF]
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The most important work I do.
- Dr Edmond V O`Flaherty
(6 October 2007)
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It's good to talk
- Susan E Farwell
(3 October 2007)
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What to do about CAM
- David Colquhoun
(2 October 2007)
- Read every Rapid Response to this article
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FEATURE:
Is there enough evidence to judge midwife led units safe? Yes
- Page (29 September 2007)
[Full text]
[PDF]
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Ongoing research on planned place of birth and safety
- David M Puddicombe, et al.
(4 October 2007)
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5 year survey in Isles of Scilly
- Toby Dalton
(4 October 2007)
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Midwifery down the drain
- Anne Savage
(4 October 2007)
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Are midwife-led maternity units safe?
- Dr Mike Bull
(3 October 2007)
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No
- Ian A L Treharne
(3 October 2007)
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Author's Response
- Lesley Page
(3 October 2007)
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midwifery led-units: choice and safety
- Fatima A Husain, et al.
(3 October 2007)
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Risk to babies with home delivery and midwife led units
- Philip Murray
(3 October 2007)
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Midwife led unit’s needs more evidence prior to independent practice
- Chelliah R Selvasekar
(2 October 2007)
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'From cradle to grave'
- Anna E Livingstone
(2 October 2007)
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Places of birth- Satisfaction or Safety?
- Bode Williams
(2 October 2007)
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Place of Birth
- Melvyn F Docker
(2 October 2007)
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NO, midwifery-led care is a risky business.
- Olakunle Fajemirokun-Odudeyi
(1 October 2007)
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Damaged babies
- Lydia M Stevens
(30 September 2007)
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Safety and Quality of care really matter
- Sally K Tracy
(30 September 2007)
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Single measure of safety
- A Sajayan
(30 September 2007)
- Read every Rapid Response to this article
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NEWS:
Advice to pregnant women to avoid eating peanuts should be withdrawn, says Lords committee
- Kmietowicz (29 September 2007)
[Full text]
[PDF]
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At last: some common sense
- Stuart H McClelland
(1 October 2007)
- Read every Rapid Response to this article
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NEWS:
Doctors rank myocardial infarction as most "prestigious" disease and fibromyalgia as least
- Dobson (29 September 2007)
[Full text]
[PDF]
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Doctors rank myocardial infarction as most "prestigious" disease and fibromyalgia as least
- Maureen Norton
(1 October 2007)
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How "prestigious" do the public view disease
- Martin Whitehead
(30 September 2007)
- Read every Rapid Response to this article
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LETTERS:
Uniquely disadvantaged
- Livesey (29 September 2007)
[Full text]
[PDF]
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Double-edge swords: challenges faced by ill physicians
- Robert L. Klitzman
(1 October 2007)
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Advantages and disadvantages perhaps culturally based.
- Andre des Etages
(30 September 2007)
- Read every Rapid Response to this article
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LETTERS:
Profound ethical issues were smoothed over
- Blumsohn (29 September 2007)
[Full text]
[PDF]
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Re: Conflicts of Interest
- Aubrey Blumsohn
(1 October 2007)
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Conflicts of Interest
- David R Coghill
(30 September 2007)
- Read every Rapid Response to this article
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LETTERS:
Capitalism is a force for good
- Charlton (29 September 2007)
[Full text]
[PDF]
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Achieving health equity with more liberty, wealth, and ethics.
- Anonymous Cuban professional
(5 October 2007)
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Population and Poverty: Malawi
- James G Danaher
(2 October 2007)
- Read every Rapid Response to this article
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LETTERS:
None so blind
- Wake (29 September 2007)
[Full text]
[PDF]
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None so blind...looking for the evidence
- Rowland L Cottingham
(10 October 2007)
- Read every Rapid Response to this article
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LETTERS:
Summary of responses
- Twisselmann (29 September 2007)
[Full text]
[PDF]
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Performance related pay
- Peter S L Barling
(5 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Physician assisted death in vulnerable populations
- Quill (29 September 2007)
[Full text]
[PDF]
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Mentally ill given short shrift
- Madelyn H. Hicks
(10 October 2007)
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Concerns not dispelled
- Desmond O'Neill
(3 October 2007)
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Don't be fooled into accepting doctor-assisted dying
- Stephen MW Hutchison
(1 October 2007)
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There is more to vulnerability
- Andrew Thorns
(1 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
The Declaration of Helsinki
- Goodyear et al. (29 September 2007)
[Full text]
[PDF]
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Re: The Delaration of Helsinki is DEAD
- udo schuklenk
(8 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Risk of cancer and the oral contraceptive pill
- Meirik and Farley (29 September 2007)
[Full text]
[PDF]
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Pituitary adenomas are not cancers
- Richard Quinton, et al.
(3 October 2007)
- Read every Rapid Response to this article
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VIEWS & REVIEWS:
MTAS or a tale of evidence heedless medicine
- Nachev (22 September 2007)
[Full text]
[PDF]
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Selection methodology: more fiction than fact, and a worrying future
- A Thomson
(12 October 2007)
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Unsatisfactory response by Ms Patterson
- Peter von Kaehne
(12 October 2007)
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No defence
- ben dean
(11 October 2007)
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Evidence heedless medicine
- John Sanderson
(11 October 2007)
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Re: Selection methodology; fact, fiction and the future
- Alison L Gill
(11 October 2007)
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Re: Selection methodology; fact, fiction and the future
- Matthew J Daniels
(11 October 2007)
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Re: MTAS or a tale of evidence heedless medicine
- Alison S Carr
(11 October 2007)
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More light less heat
- Frank R Smith
(11 October 2007)
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Selection methodology; fact, fiction and the future
- Fiona Patterson
(4 October 2007)
- Read every Rapid Response to this article
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PRACTICE:
Ramadan fasting and diabetes
- Sheikh and Wallia (22 September 2007)
[Full text]
[PDF]
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Post prandial hyperglycemia
- Ali K Kamona
(5 October 2007)
- Read every Rapid Response to this article
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PRACTICE:
Do all fractures need full immobilisation?
- Glasziou (22 September 2007)
[Full text]
[PDF]
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Appropriate, no universal, referal please
- Paul P Glasziou
(11 October 2007)
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The use of Evidence Based Medicine in clinical practice
- Emma Stapleton
(8 October 2007)
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evidence
- ben dean
(8 October 2007)
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The case for specialist treatment
- Margaret M McQueen
(3 October 2007)
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Expertise and evidence must learn to work together
- Paul Glasziou
(1 October 2007)
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dumbing down?
- ben dean
(30 September 2007)
- Read every Rapid Response to this article
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RESEARCH:
Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study
- Rona et al. (22 September 2007)
[Abstract]
[Full text]
[PDF]
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Mental health consequences of overstretch – what about hospital emergency departments?
- Martin Wiese
(7 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Child-parent screening for familial hypercholesterolaemia: screening strategy based on a meta-analysis
- Wald et al. (22 September 2007)
[Abstract]
[Full text]
[PDF]
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Screening for familial hypercholesterolemia
- Peter J. Lansberg, et al.
(5 October 2007)
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Familial hypercholesterolaemia: time for further action, not further debate
- Ian Hamilton-Craig
(5 October 2007)
- Read every Rapid Response to this article
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ANALYSIS:
Medical immigration: the elephant in the room
- Winyard (22 September 2007)
[Full text]
[PDF]
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some overseas medical schools are inferior
- edmund willis
(10 October 2007)
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Re: We got to find an amicable solution
- Jay Ilangaratne
(2 October 2007)
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Competition is good for patients
- Martin Zinkler
(2 October 2007)
- Read every Rapid Response to this article
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EDITOR'S CHOICE:
Training our doctors
- Godlee (22 September 2007)
[Full text]
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Training and careers of French doctors
- herve Maisonneuve, et al.
(5 October 2007)
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VIEWS & REVIEWS:
No patient is an island
- Sokol (15 September 2007)
[Full text]
[PDF]
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Response to Willett's cartoon
- Ron Pigott
(1 October 2007)
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PRACTICE:
A painful hip
- O'Connor (15 September 2007)
[Full text]
[PDF]
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Pain Hip Pitfalls
- Chika E Uzoigwe, et al.
(10 October 2007)
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OBSERVATIONS:
Alzheimer's Society replies to Iain Chalmers
- Hunt (15 September 2007)
[Full text]
[PDF]
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Alzheimer Society of Canada responds to Linda Furlini ‘Why I am no longer a member of the Alzheimer Society’
- Scott Dudgeon
(3 October 2007)
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EDITORIALS:
Dealing with scientific misconduct
- Bosch (15 September 2007)
[Full text]
[PDF]
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Re: Scientific misconduct occurs at all levels
- Alejandro A. Bevaqua
(1 October 2007)
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PRACTICE:
Using a combination inhaler (budesonide plus formoterol) as rescue therapy improves asthma control
- Barnes (8 September 2007)
[Full text]
[PDF]
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A SMART choice for primary care asthma therapy ?
- Brian J Lipworth, et al.
(13 October 2007)
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ANALYSIS:
Families of patients with premature coronary heart disease: an obvious but neglected target for primary prevention
- Chow et al. (8 September 2007)
[Full text]
[PDF]
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Targeting at risk families for cardiovascular primary prevention
- Martha J Wrigley, et al.
(7 October 2007)
- Read every Rapid Response to this article
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FEATURE:
The market in primary care
- Pollock et al. (8 September 2007)
[Full text]
[PDF]
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More questions than answers.
- Hendrik J Beerstecher
(8 October 2007)
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Market Forces Health Improvement
- Richard Alan Mendelsohn, et al.
(3 October 2007)
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NEWS:
Agency warns about dosing error for amphotericin after patients with cancer die
- Hawkes (8 September 2007)
[Full text]
[PDF]
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Correction: Amphotericin product names
- Frances MacIntosh
(8 October 2007)
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LETTERS:
Author's reply
- Watson (8 September 2007)
[Full text]
[PDF]
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Re: NICE guidelines on childhood UTI
- J Valmai Cook
(1 October 2007)
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PRACTICE:
Ehlers-Danlos syndrome
- Gawthrop et al. (1 September 2007)
[Full text]
[PDF]
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Question re possible association with Attention Deficit Hyperactivity Disorder
- Bruce W Urquhart
(5 October 2007)
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FILLERS:
A depressed gorilla
- Pop (1 September 2007)
[Full text]
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Neglect of Psyhosocial Interventions in a Depressed Gorilla
- Dave W H Baillie
(3 October 2007)
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RESEARCH:
Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial
- Foster et al. (1 September 2007)
[Abstract]
[Full text]
[PDF]
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Clearly suboptimal acupuncture
- Andrew Hoe
(1 October 2007)
- Read every Rapid Response to this article
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LETTERS:
Time to get our acts together
- Reid and Menon (1 September 2007)
[Full text]
[PDF]
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There is a need for greater awareness of and training on the Mental Capacity Act (MCA) 2005 within the National Health Service (NHS).
- Jude N Chukwuma, et al.
(5 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Chronic fatigue syndrome or myalgic encephalomyelitis
- White et al. (1 September 2007)
[Full text]
[PDF]
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Miscommunications and Misunderstandings
- Douglas T Fraser
(5 October 2007)
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ME as an inclusion of CFS
- Les O SIMPSON
(3 October 2007)
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PSYCHIATRISTS SAY: CBT for ME does NOT work
- Tessa Vinicius
(2 October 2007)
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Actometers or pedometers should be used in rehabilitation studies in the field to check whether the interventions are actually leading to (substantial) increases in activity levels
- Tom Kindlon
(30 September 2007)
- Read every Rapid Response to this article
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CLINICAL REVIEW:
Acute respiratory distress syndrome
- Leaver and Evans (25 August 2007)
[Full text]
[PDF]
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Should we use low tidal volume in all our ARDS patients?
- Eduardo M Svoren, et al.
(12 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial
- Montini et al. (25 August 2007)
[Abstract]
[Full text]
[PDF]
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Response to Montini Article
- Alejandro Hoberman, et al.
(12 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial
- Mant et al. (25 August 2007)
[Abstract]
[Full text]
[PDF]
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Response from both Hospital and GP angles
- Ashish B Patel
(10 October 2007)
- Read every Rapid Response to this article
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FEATURE:
Hyperactivity in children: the Gillberg affair
- Gornall (25 August 2007)
[Full text]
[PDF]
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Assessment for the Swedish Research Council
- Denny H Vågerö
(12 October 2007)
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Industry of Death?
- Vanna Beckman
(12 October 2007)
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Apology for a slur required
- Steven P R Rose
(3 October 2007)
- Read every Rapid Response to this article
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EDITOR'S CHOICE:
Nice feedback
- Godlee (25 August 2007)
[Full text]
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Searching a PDF
- Pawan Randev
(1 October 2007)
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RESEARCH:
Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations
- Canani et al. (18 August 2007)
[Abstract]
[Full text]
[PDF]
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Probiotics for treatment of acute diarrhoea in children
- María G. Joyanes
(6 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression
- Burns et al. (18 August 2007)
[Abstract]
[Full text]
[PDF]
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Assertive Community Treatment: The South East CMHT, Barnet, Experience
- Azad A Cadinouche, et al.
(8 October 2007)
- Read every Rapid Response to this article
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ANALYSIS:
Potential of electronic personal health records
- Pagliari et al. (18 August 2007)
[Full text]
[PDF]
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Prespectives on Personal Health Record
- Rahul Shetty, et al.
(6 October 2007)
- Read every Rapid Response to this article
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ANALYSIS:
Preventive health care in elderly people needs rethinking
- Mangin et al. (11 August 2007)
[Full text]
[PDF]
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Essential geriatric care
- Tamilmani A J
(1 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Body mass index cut offs to define thinness in children and adolescents: international survey
- Cole et al. (28 July 2007)
[Abstract]
[Full text]
[PDF]
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Re: Thinness,BMI and Body Size
- Tim J Cole
(6 October 2007)
- Read every Rapid Response to this article
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FEATURE:
Should we consider a boycott of Israeli academic institutions? No
- Baum (21 July 2007)
[Full text]
[PDF]
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Professor Baum still not answering and handing over to IMA
- Christopher J Burns-Cox, et al.
(12 October 2007)
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Professor Baum, as a Doctor: please treat the cause not the symptom
- Mamdouh EL-Adl
(12 October 2007)
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The threatened academic boycott of Israel and the accusation that the Israel Medical association (IMA) is complicit in the torture of prisoners.
- Michael Baum
(4 October 2007)
- Read every Rapid Response to this article
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FEATURE:
Should we consider a boycott of Israeli academic institutions? Yes
- Hickey (21 July 2007)
[Full text]
[PDF]
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Go and see the truth for yourself. I did.
- Asad Khan
(7 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Depression in adolescents
- Hazell (21 July 2007)
[Full text]
[PDF]
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Invega advertising
- Selwyn Learner
(1 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Implementing the NHS information technology programme: qualitative study of progress in acute trusts
- Hendy et al. (30 June 2007)
[Abstract]
[Full text]
[PDF]
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Unexpected benefit of Choose and Book
- Paul E Shannon
(11 October 2007)
- Read every Rapid Response to this article
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CLINICAL REVIEW:
Diagnosis and treatment of sciatica
- Koes et al. (23 June 2007)
[Full text]
[PDF]
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Treatment of Sciatica
- Charles S Galasko
(8 October 2007)
- Read every Rapid Response to this article
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ANALYSIS:
Selection for specialist training: what can we learn from other countries?
- Jefferis (23 June 2007)
[Full text]
[PDF]
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Selection for specialist Training- A fair approach
- Vaibhav Tyagi, et al.
(1 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
Diabetic ketoacidosis
- Dhatariya (23 June 2007)
[Full text]
[PDF]
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Would Normal Saline be licensed today?
- Nicholas Levy, et al.
(11 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Interventions to promote walking: systematic review
- Ogilvie et al. (9 June 2007)
[Abstract]
[Full text]
[PDF]
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Inactivity in Secondary Care Doctors
- Amy L Chue, et al.
(10 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database
- Jones et al. (19 May 2007)
[Abstract]
[Full text]
[PDF]
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Alarm symptoms in primary care: Further evidence
- Knut A Holtedahl
(1 October 2007)
- Read every Rapid Response to this article
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ANALYSIS:
Functional foods: the case for closer evaluation
- de Jong et al. (19 May 2007)
[Full text]
[PDF]
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Functional Foods: Already a feature of every-day practice
- Ian R Wallace
(3 October 2007)
- Read every Rapid Response to this article
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VIEWS & REVIEWS:
Addiction in America: in search of a fix
- Veltman (31 March 2007)
[Full text]
[PDF]
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Addiction: Imaginary Gains and Real Losses
- Hugh Mann
(3 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Effects of antithyroid drugs on radioiodine treatment: systematic review and meta-analysis of randomised controlled trials
- Walter et al. (10 March 2007)
[Abstract]
[Full text]
[PDF]
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Importance of calculation of absorbed dose in radioiodine treatment in patients pre-treated with antithyroid drugs
- Gertrud Berg
(12 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial
- Hay et al. (11 November 2006)
[Abstract]
[Full text]
[PDF]
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Re: Rotational Field Quantum Magnetic Resonance
- Sukhbindar S Sibia
(6 October 2007)
- Read every Rapid Response to this article
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REVIEWS:
Why are so many people dying on Everest?
- Sutherland (26 August 2006)
[Full text]
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Damned if you treat, damned if you don’t.
- Sean T Hudson
(3 October 2007)
- Read every Rapid Response to this article
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ANALYSIS AND COMMENT:
Do enforced bicycle helmet laws improve public health?
- (25 March 2006)
[Full text]
[PDF]
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What about motorcycle helmets?
- Marcel Girodian
(3 October 2007)
- Read every Rapid Response to this article
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ON THE CASE:
The case of the disappearing teaspoons: longitudinal cohort study of the displacement of teaspoons in an Australian research institute
- Lim et al. (24 December 2005)
[Abstract]
[Full text]
[PDF]
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Practical solution
- Jennifer A Stillman, et al.
(6 October 2007)
- Read every Rapid Response to this article
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NEWS ROUNDUP:
GMC drops charges against paediatrician in Climbie case
- Dyer (18 September 2004)
[Full text]
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Mellor's dilemma
- Jonathan Gornall
(8 October 2007)
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Kawasaki Disease - Misdiagnosed.
- Michael D Innis
(2 October 2007)
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Re: Or was she raygunned?
- Penny Mellor
(2 October 2007)
-
Kawasaki Disease and Victoria Climbie
- Nellie T Adjaye
(1 October 2007)
- Read every Rapid Response to this article
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EDITORIALS:
What's a good doctor, and how can you make one?
- Hurwitz and Vass (28 September 2002)
[Full text]
[PDF]
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Re: its multifactorial
- Hammad Akram
(6 October 2007)
- Read every Rapid Response to this article
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NEWS:
Withdrawal from paroxetine can be severe, warns FDA
- Tonks (2 February 2002)
[Full text]
[PDF]
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Re: Paroxetine
- E Lynn Alexander, et al.
(7 October 2007)
- Read every Rapid Response to this article
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SOUNDINGS:
The value of life
- Farrell (12 September 1998)
[Full text]
[PDF]
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I believe in insulin
- Neil \ Kirk\, et al.
(30 September 2007)
- Read every Rapid Response to this article
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PAPERS:
Genetic influences on osteoarthritis in women: a twin study
- Spector et al. (13 April 1996)
[Abstract]
[Full text]
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Possible Incorrect Citation
- Madeline C Walsh
(3 October 2007)
- Read every Rapid Response to this article
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RESEARCH:
Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials
van Sluijs et al. (6 October 2007)
[Abstract]
[Full text]
[PDF]
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Effectiveness of interventions to promote physical activity in children and adolescents:...
Promoting active life styles in our children |
10 October 2007 |
|
|
Ediriweera Desapriya,
Research Associate
Department of Pediatrics, Centre for Community Child Health Research 4480 Oak Street V6H 3V4,
G.Scime,S.Subzwari and I. Pike
Send response to journal:
Re: Promoting active life styles in our children
|
We read with interest this week’s BMJ systematic review on physical
activity promotion interventions of children and youths (1) but the
review lack of deserves attention for several potentially important
physical activity behaviors. (2) Encouraging active transport is one way
to increase overall levels of physical activity. (2) Walking and cycling
are two forms of physical activity that meet the metabolic criteria for
achieving health benefits from exercise. (3)
Walking or cycling can be fitting more easily into everyday life and
life’s tasks than the addition of recreational exercise with its extra
time and cost commitments. Walking has the further benefit of being
available to most people regardless of income, location or age. (4)
Therefore walking is basic forms of transportation that are accessible to
virtually all humans in the world.
However, children's independent mobility is greatly influenced by
traffic and parents' real and perceived concerns about safety. (2) The
epidemic of childhood obesity has been attributed largely to sedentary
life styles. Therefore it is critical to identify the barriers and
potential effective strategies for surmounting the problems that hinder
walking and cycling. (5, 6) One recent study in US explored the question
why children don’t walk to school more often. Parents reported multiple
barriers that inhibit walking and biking to school as follows: long
distances (55%), traffic danger (40%), weather (24%), crime (18%), and
school policy (7%). Similarly, in UK a recent study shows that 85% of
parents were worried about traffic danger on the journey to school. (5)
Parents discouraging their children from walking and cycling to school
because they are worried about the dangers from traffic (7)
Cost-benefit analysis of using safe bike/pedestrian trails in
Lincoln, Nebraska, to reduce health care costs associated with inactivity
was conducted. The cost-benefit ratio was 2.94, which means that every $1
investment in trails for physical activity led to $2.94 in direct medical
benefit. Therefore, building trails is cost beneficial from a public
health perspective. (8)
Contemporary health promotion places considerable emphasis on
creating supportive environments (9). Consistent with this trend, there
have been calls for greater consideration of the physical environment in
physical activity research and practice (10).
REFERENCES:
(1) Van Sluijs E.M.F., McMinn A.M., Griffin S.J. Effectiveness of
interventions to promote physical activity in children and adolescents:
systematic review of controlled trials. BMJ 2007 doi:
10.1136/bmj.39320.843947.BE
(2). Giles-Corti, B., Salmon, J. Encouraging children and adolescents
to be more active. BMJ 2007; 335: 677-678
(3) Desapriya E, Pike I, Babul S., Health benefits of physical
activity. CMAJ. 2006; 26; 175(7):776
(4) Mason, C. Transport and health: en route to a healthier
Australia. Medical Journal of Australia 2000; 172:230-232
(5) Rowland D., DiGuiseppi C., Gross M., Afolabi E., Roberts I.
Randomized controlled trial of site specific advice on school travel
patterns. Arch Dis Child 2003; 88: 8-11
(6). Desapriya E.B., Pike I., Basic A., Subzwari S. Deterrent to
healthy lifestyles in our communities. Pediatrics. 2007;119(5):1040-2
(7) British Medical Association Board of Science and Education.
Injury prevention. London: BMA, 2001.
(8). Wang G, Macera CA, Scudder-Soucie B, Schmid T, Pratt M, Buchner
D. A cost-benefit analysis of physical activity using bike/pedestrian
trails. Health Promot Pract. 2005; 6(2):174-9.
(9). World Health Organization (WHO).The Ottawa Charter for health
promotion. Health Promotion International, 1986;1, 3–5.
(10). Sallis, J.F., Owen, N., 1990. Ecological models. In: Glanz,
K., Lewis, F.M. and Rimer, B.K. Editors, 1990. Health behavior and health
education: Theory, research, and practice (2nd ed.)Jossey-Bass, San
Francisco, pp. 403–424.
Competing interests:
None declared |
| |
Effectiveness of interventions to promote physical activity in children and adolescents:...
Physical activity in childhood and adolescence |
5 October 2007 |
|
|
Joav Merrick,
Medical director
National Institute of Child Health and Human Development, Jerusalem, Israel,
Isack Kandel, Meir Lotan, and Hatim A Omar
Send response to journal:
Re: Physical activity in childhood and adolescence
|
EDITOR---Physical fitness and exercise are important aspects of
health and well-being of persons of all ages. Earlier there has been a
focus on intensive and vigorous exercise, but regular walking and other
moderate physical activities have also been beneficial (1). A recent
systematic review (2) from the Institute of Metabolic Science in Cambridge
looked at 57 studies to determine the effectiveness of interventions to
promote physical activity in children and adolescents. They found that
multi-component interventions, which included both school, family or
community had the greatest potential for being effective.
PHYSICAL ACTIVITY OVER TIME
Tracking physical fitness and activity over time will make our
understanding better concerning when children settle into their long-term
exercise and fitness patterns. It will also provide information as to when
to initiate programs focusing on preventing sedentary adults behaviors.
One study (3) tracked physical fitness and physical activity over a five
year period with children and adolescents in Muscatine, Iowa, USA. They
examined 126 pre- or early-pubescent children (mean age boys 10.8 yr and
girls 10.3 yr). Physical fitness was measured using direct determination
of oxygen uptake and maximal voluntary isometric contraction, while
physical activity was assessed via questionnaire. Boys classified as
sedentary based on initial measurements of TV viewing and video game
playing were 2.2 times more likely than their peers to also be classified
as sedentary at follow-up. Tracking of most physical fitness and physical
activity variables was moderate to high, indicating some predictability of
early measurements for later values. Sedentary behavior tracked better in
boys, whereas vigorous activity tended to track better in girls. These
observations suggested that preventive efforts focused on maintaining
physical fitness and physical activity through puberty will have favorable
health benefits in later years.
A longitudinal study from Belgium of Flemish males from 18 to 40
years of age followed 130 males from age 13 to age 18 years with remeasure
at the ages of 30, 35, and 40 years (4). Physical fitness showed the
highest stability in flexibility (r = 0.91 between 18 and 30 years, r =
0.96 for both the 30-35 and 35-40 ages intervals), while physical activity
showed the highest stability during work (r between 0.70 and 0.98 for the
5-year intervals). Results indicated that for some fitness characteristics
the high-active subjects were more fit than their low-active peers.
Although possible confounding factors were present (e.g., heredity), a
higher level of physical activity during work and leisure time on a
regular basis benefited physical fitness considerably.
Another study from Michigan (5) examined whether organized sports
participation during childhood and adolescence was related to
participation in sports and physical fitness activities in young
adulthood. The analyses included more than 600 respondents from three
waves of data (age 12, age 17, and age 25). Childhood and adolescent
sports participation was found to be a significant predictor of young
adult participation in sports and physical fitness activities.
A study from New Jersey (6) looked at the outcomes of an exercise
program directed towards Black and Hispanic college-age women. Forty-four
women (36 Black, seven Hispanic and one Black/Hispanic) attended exercise
classes three times per week for 16 weeks. Compared to low attendees, the
high attendees had significantly higher exercise self-efficacy (p
<.001), perceived benefits and barriers (p =.004), aerobic fitness,
flexibility, muscle strength and percentage of body fat (all p <.001).
Daily activity levels improved significantly in the high attendance group
following the program (p <.001) and at eight weeks post-program
completion (p =.01).
ADOLESCENT PHYSICAL FITNESS IN ISRAEL
In a study of 13 year olds during 1984-1985 from five Jerusalem
public schools physical ability was defined in the biological dimension by
the running time for 1000 meters and in the psychological dimension by
sport motivation (7). The intervention program involved a periodic and
progressive increase of physical effort of children in 16 gym lessons
during the regular curriculum. The test group improved their running time
and had better sport motivation than the control group with differences
between boys and girls and an influence of sexual maturation on running
time in girls.
As a participant in the World Health Organization (WHO) cross
national study on health behaviors in school aged children (HBAC)
initiated in 1982 data has also been available for Israel on exercise
(8,9). The last results from 1997/98 (9) showed that 76% of 15 year olds
males in Israel (in the US: 74%) and 48% of females (US: 54%) exercised
twice a week or more.
CONCLUSIONS
Body composition, cardiovascular fitness, strength and fexibility
will all benefit from physical exercise and fitness. Intervention and
prevention programs should ensure that fitness in adolescence be continued
in adult and later life to maximize well-being and health (10).
AFFILIATIONS
Joav Merrick, MD, MMedSci, DMSc, is professor of pediatrics, child
health and human development affiliated with Kentucky Children’s Hospital,
University of Kentucky, Lexington, United States and the Zusman Child
Development Center, Division of Pediatrics, Soroka University Medical
Center, Ben Gurion University, Beer-Sheva, Israel, the medical director of
the Division for Mental Retardation, Ministry of Social Affairs,
Jerusalem, the founder and director of the National Institute of Child
Health and Human Development. Numerous publications in the field of
pediatrics, child health and human development, rehabilitation,
intellectual disability, disability, health, welfare, abuse, advocacy,
quality of life and prevention. Received the Peter Sabroe Child Award for
outstanding work on behalf of Danish Children in 1985 and the
International LEGO-Prize (“The Children’s Nobel Prize”) for an
extraordinary contribution towards improvement in child welfare and well-
being in 1987. E-Mail: jmerrick@internet-zahav.net. Website: www.nichd-
israel.com
Isack Kandel, MA, PhD, is senior lecturer/assistant professor at the
Faculty of Social Sciences, Department of Behavioral Sciences, Ariel
University Center at Samaria, Ariel. During the period 1985-93 he served
as the director of the Division for Mental Retardation, Ministry of Social
Affairs, Jerusalem, Israel. Several books and numerous other publications
in the areas of rehabilitation, disability, health and intellectual
disability. E-mail: kandelii@zahav.net.il
Meir Lotan, BPT, MScPT, is a physiotherapist working as lecturer at
the School of Health Sciences, Department of Physical Therapy, Ariel
University Center of Samaria, Ariel, affilated with the Israeli National
Rett Syndrome evaluation team and director of the Therapeutic Department,
Zvi Quittman Residential Center, Millie Shime Campus, Elwyn, Jerusalem. He
has a special interest in physiotherapy and persons with intellectual
disability, Snoezelen and physical activity for children and adults with
intellectual disability with an emphasis on individuals with Rett
syndrome. Awarded in 2000 by the IRSA (Int Rett Syndr Ass) for his service
to individuals with Rett syndrome. Numerous publications in international
peer-reviewed journals in his areas of interest. E-mail:
ml_pt_rs@netvision.net.il
Hatim A Omar, MD, Professor of Pediatrics and Obstetrics and
Gynecology and Director of the Section of Adolescent Medicine, Department
of Pediatrics, University of Kentucky, Lexington. Dr. Omar has completed
residency training in obstetrics and gynecology as well as Pediatrics. He
has also completed fellowships in vascular physiology and adolescent
medicine. He is the recipient of the Commonwealth of Kentucky Governor’s
Award for Community Service and Volunteerism and is well known
internationally with numerous publications in child health, pediatrics,
adolescent medicine, pediatric and adolescent gynecology. Email:
haomar2@uky.edu
Website: http://www.ukhealthcare.uky.edu/kch/physicians/omar.htm
REFERENCES
1. US Department of Health and Human services. Physical activity and
health: A report of the Surgeon General. Atlanta, GA: Centers for Disease
Control and Prevention (CDC), Nat Center Chr Disease Prev Hlth Prev, 1996.
2. van Sluijs EMF, McMinn AM, Griffin SJ. Effectiveness of
interventions to promote physical activity in children and adolescents:
Systematic review of controlled trials. BMJ 2007335:703-15.
3. Janz KF, Dawson JD, Mahoney LT. Tracking physical fitness and
physical activity from childhood to adolescence: the muscatine study. Med
Sci Sports Exerc 2000;32(7):1250-7.
4. Lefevre J, Philippaerts RM, Delvaux K, Thomis M, Vanreusel B,
Eynde BV, Claessens AL, Lysens R, Renson R, Beunen G. Daily physical
activity and physical fitness from adolescence to adulthood: A
longitudinal study. Am J Hum Biol 2000;12(4):487-97.
5. Perkins DF, Jacobs JE, Barber BL, Eccles JS. Childhood and
adolescent sports participation as predictors of participation in sports
and physical fitness activities during young adulthood. Youth Society
2004;35(4):495-520.
6. D'Alonzo KT, Stevenson JS, Davis SE. Outcomes of a program to
enhance exercise self-efficacy and improve fitness in Black and Hispanic
college-age women. Res Nurs Health 2004;27(5):357-69.
7. Halfon ST, Bronner S. The influence of a physical ability
intervention program on improved running time and increased sport
motivation among Jerusalem schoolchildren. Adolescence 1988;23(90):405-16.
8. Harel Y, Kani D, Rahav G. Health behaviors in school-aged children
(HBSC): A World Health Organization cross national study. Jerusalem: JDC-
Brookdale Institute, 1997.
9. Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J, eds.
Health and health behaviour among young people. WHO Policy Series: Health
policy for children and adolescents Issue 1, WHO Regional Office for
Europe, Copenhagen, 2000.
10. Lotan M, Merrick J, Carmeli E. Physical activity in adolescence.
A review with clinical suggestions. Int J Adolesc Med Health 2005;17(1):13
-21.
Competing interests:
None declared |
|
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ANALYSIS:
Adding fluoride to water supplies
Cheng et al. (6 October 2007)
[Full text]
[PDF]
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Adding fluoride to water supplies
Fluoridation and aluminium |
13 October 2007 |
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Christopher Exley,
Reader
Keele University ST5 5BG
Send response to journal:
Re: Fluoridation and aluminium
|
I was surprised that no mention was made of the role that fluoride
plays in increasing human exposure to aluminium via gastrointestinal
absorption? Aluminium binds fluoride with great avidity and fluoride in
drinking water will both facilitate the gastrointestinal absorption of
aluminium which is coincidentally present in drinking water but more
importantly it will increase the absorption of aluminium from ingested
foodstuffs and other beverages.
Fluoridation of the potable water supply will lead to higher human body
burdens of aluminium. Whether a higher body burden of aluminium should be
avoided is, of course, another debate.
Competing interests:
None declared |
| |
Adding fluoride to water supplies
A question of the common good |
12 October 2007 |
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C Albert Yeung,
Consultant in Dental Public Health
Lanarkshire NHS Board, Hamilton ML3 0TA
Send response to journal:
Re: A question of the common good
|
Cheng et al questioned the ethical issue of water fluoridation
surrounding informed consent and human rights. [1] However, there is
another side of the coin.
Clearly there is scope for different points of view on the ethics of
any major issue of public policy, including water fluoridation. Anyone
who takes up the position that the individual has the right to decide the
precise composition of water supply is unlikely to accept water
fluoridation as anything less than an intrusion. Does that mean he or she
can prevent the chlorination of water simply because of a personal
aversion to chlorine? [2]
Drinking fluoride-free water is not a basic human right but a
question of individual preference. In a society where people come
together for mutual benefit, it is a question of balancing such personal
preferences against the common good arising from the lower levels of tooth
decay which water fluoridation brings.
Individuals cannot make decisions about the composition of the public
water supply. These decisions must be made at the community level. The
minority who have an ideological objection to water fluoridation do not
have a right to impose excess risk on the majority, just because of their
personal preference. It could be argued that where there is majority
community support, it is unethical not to fluoridate water supply.
1 Cheng KK, Chalmers I, Sheldon TA. Adding fluoride to water
supplies. BMJ 2007; 335: 699-702. (6 October.)
2 British Fluoridation Society. One in a Million – the facts about
water fluoridation. Manchester: British Fluoridation Society, 2004.
Competing interests:
None declared |
| |
Adding fluoride to water supplies
Water fluoridation and bladder cancer |
10 October 2007 |
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Raymond J Lowry,
Senior Lecturer in Dental Public Health
University of Newcastle NE2 4BW
Send response to journal:
Re: Water fluoridation and bladder cancer
|
Cheng and his colleagues argue that fluoridation might possibly pose
a cancer risk and cite a study from Taiwan by Yang et al(1) to support
their contention. The Taiwan study compared ten municipalities with a
mean natural fluoride level in the water supply of 0.24mg/litre with ten
matched municipalities with a fluoride level of <0.01mg/litre.
(There are no artificially fluoridated supplies in Taiwan.) Yang et al
made twenty-six site-specific comparisons, and in one of these comparisons
showed in females a statistically significant (P <0.05 ) increase in
bladder cancer.
Yang et al suggested that it was biologically implausible for water
fluoridation to cause bladder cancer in females and not in males, and that
with multiple comparisons one significant difference might have been due
to chance. The authors concluded that overall their study, supporting the
views of many others “does not provide evidence that fluoridation of the
water supplies is associated with an increase in cancer mortality in
Taiwan”.
Ray Lowry BDS MBChB FFPH
References
1. Yang CY, Cheng MF, Tsai SS, Hung CF. Fluoride in drinking water
and cancer mortality in Taiwan. Environ. Res. 2000;82(3):189-193.
Competing interests:
None declared |
| |
Adding fluoride to water supplies
By all means, fluoridate. I’ll just refuse to drink it. - Oct 2007 |
10 October 2007 |
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Phillip J Colquitt,
Technicain/RN
Independent Comment
Send response to journal:
Re: By all means, fluoridate. I’ll just refuse to drink it. - Oct 2007
|
As a well filled customer of various GP dentists here in Australia, I
can say that it is the dentist himself who is currently the main threat to
my teeth. Not, as this discussion might suppose, the non-fluoridated state
of the water here in Brisbane. Given that having water at all is a far
greater concern in this sunburnt country.
Taking myself to three different GP dentists, I got three different
opinions. It’s truly amazing the offhand way that one said “that tooth
probably needs to come out”, while the other two said no such thing about
a perfectly well tooth. A specialist prosthodontist was utterly dismissive
of the GP dentist’s extraction plan, leaving me with an impression of GP
dentists as “wanting work”.
Many young folk I’ve met here in Brisbane have perfect teeth, so I
feel the pro-fluoride lobby are focused on the negative outcome – those
with cavities. The discussion would be far more interesting if it revealed
the non-cavitated individual’s fluoridation supplementation technique, if
any occurred at all. Further, it cannot be assumed that fluoride in water
ends up in people, since water is often filtered, as is my own supply. I
don’t know anyone who drinks tap water.
Dentists have been separate from medicine’s mainstream, in “dental”
schools, when they might reasonably be called “minor orthopaedic
surgeons”(of the mouth). Tooth is bone. Possibly due to this “dental”
isolation, many readers may not know of the old dental practice of
“extension for prevention[1]” – this basically means that you get a
filling where you don’t need one, because the dentist is allowed to do
that. The theory is/was that the filling material is more impervious to
cavitation than natural tooth. And now you’re getting fluoride you don’t
need, because the government is allowed to do that(proposed).
By all means, fluoridate. I’ll just refuse to drink it.
1: Rossomando EF. Minimally invasive dentistry and the dental
enterprise.
Compend Contin Educ Dent. 2007 Mar;28(3):166, 168.
PMID: 17385399 [PubMed - indexed for MEDLINE]
Competing interests:
None declared |
| |
Adding fluoride to water supplies
It's time for a moratorium on fluoridation |
10 October 2007 |
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Barry A Groves,
Independent Researcher, maintains www.second-opinions.co.uk
OX7 6LP
Send response to journal:
Re: It's time for a moratorium on fluoridation
|
Recently the BMJ debated ‘informed consent’. Not long ago, we were
also instructed on ‘the precautionary principle’ and advised to err on the
side of caution. Both of these principles are highly relevant in the
present climate of pharmaceutical companies’ and other commercial
influences over medical practice, and medical practitioners.
Cheng et al’s paper on the enduring controversy surrounding water
fluoridation is a case in which both of the principles above should be
considered.
There are thousands of studies into the benefits and adverse side
effects of fluoridation. As Cheng et al say, these studies are not of the
best quality. But this, in itself, should make us reconsider a practice
aimed at whole populations.
Many adverse effects of fluoridation have been cited. Let us just
explore one: cancer.
In the 1970s, a comparison between the ten largest fluoridated cities
and the ten largest non-fluoridated cities of the USA showed that, while
cancer rates had been similar initially, after twenty years the
fluoridated cities had 10% more cancer deaths than the non-fluoridated
ones.[1] These figures were checked and confirmed in 1976 by the US
National Cancer Institute.
The incidence of registered cancers in communities in USA (WHO, 1987)
and the Fluoridation Census 1985 by the US Department of Health and Human
Services enabled scientists to conduct an epidemiological analysis of the
correlation between the two in the United States. They found significant
correlations in both sexes between water fluoridation and numbers of
cancers of the digestive system (tongue, mouth, pharynx, oesophagus,
stomach, colon, rectum and pancreas), the respiratory system (larynx,
bronchi and lungs), and the renal system
In the sexual organs, contradictions were seen. In women, cancers of
the breast, cervix and ovary were increased in fluoridated areas whereas
in males those of the prostate, testis and penis were apparently
inhibited. The authors considered that the different fluoride effects
suggest a possible mode of action of fluoride as an environmental hormone.
The dose-response relationship between the numbers of bone cancers in male
teenagers and the amount of fluoridation was statistically significant.
These significant relationships indicated that fluoride may not be an
initiator but a promoter of cancer.[2]
Because of concerns that fluoride might cause cancer, in 1977 the US
Congress ordered the US Public Health Service to conduct the National
Toxicology Program animal study. The results were published in 1990.[3]
The study showed that sodium fluoride caused osteosclerosis, oral tumours,
osteosarcoma and hepatocholangiocarcinoma at cumulative doses comparable
to those ingested by humans over a number of years.
In the light of the NTP study on rodents and epidemiologic evidence
of an increase in osteosarcoma in boys and young men, especially in
fluoridated areas, Dr. Perry Cohn of the New Jersey Department of Health
surveyed its incidence in seven counties of New Jersey relative to water
fluoridation. He found that in the fluoridated areas, the incidence of
osteosarcoma in boys was up to 4.6 times higher than in the
unfluoridated areas.[4] In a similar study of three New Jersey
municipalities, the figures were up to nearly seven times as high in the
fluoridated areas. Cohn also found that the general population in those
areas was also five times as likely to suffer a cancer.
Cohn’s findings were confirmed in 2001 when Harvard student Elise
Bassin was awarded her PhD. Her thesis was based on some brilliant work
which showed that young boys being exposed to fluoride in their 6th, 7th
and 8th years had a 7-fold increase in osteosarcoma. This important
discovery should have been made available immediately. However, it wasn’t
until 4 years later that it came to light.[5] It was suspected that this delay might be because of an attempted cover-up of her
findings by her professor, Chester Douglass. Chester Douglass has connections with
Colgate.[6]
In 1996 a Japanese study linked fluoride with uterine cancer.[7] This
was hotly disputed, but there is no denying that when fluoridation ceased,
the numbers of cases of uterine cancer went down.
Surely there is sufficient here to invoke the precautionary
principle, to mandate a halt to current fluoridation and to postpone any
proposed future fluoridation schemes at least until such time as it can be
shown without any doubt that fluoridation is safe.
And as the BFS and others continue to deny any adverse effects from
fluoridation, how are health advisers and medical practitioners to adopt a
precautionary, and how can members of the public, who are to be consulted
before any new fluoridation schemes are agreed, to be able to give
informed consent.
References
1. Yiamouyiannis JA, Burk D. Fluoridation of public water systems and
the cancer death rate in humans. Presented at the 67th Annual Meeting of
the American Society of Biologists and Chemists and the American Society
of Experimental Biologists. June 1976.
2. K. Takahashi K, Akiniwa K, Narita K. Cancer-promoting power of
fluoridation. Paper by presented at the 1998 Bellingham Conference of the
International Society for Fluoride Research.
3. Toxicology and Carcinogenesis Studies of Sodium Fluoride (CAS No.
7681-49-4) in F344/N Rats and B6C3F1 Mice. National Toxicology Program
Technical Report TR 393: NIH, U.S. Department of Health and Human
Services, 1990.
4. Cohn PD. A brief report on the association of drinking water
fluoridation and the incidence of osteosarcoma among young males. N J Dept
of Hlth, Trenton, New Jersey. Nov 8, 1992.
5. Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride
exposure in drinking water and osteosarcoma (United States). Cancer Causes
Control 2006; 17: 421-8.
6. "Professor at Harvard Is Being Investigated: Fluoride-Cancer Link May Have
Been Hidden". Washington Post, Wednesday, July 13, 2005; Page A03
http://www.washingtonpost.com/wp-dyn/content/article/2005/07/12/AR2005071201277.html
7. Tohyama E. Relationship between fluoride concentration in drinking
water and mortality rate from uterine cancer in Okinawa prefecture, Japan.
J Epidemiol 1996; 6: 184-191.
Competing interests:
Author of "Fluoride: Drinking oourselves to death?" |
| |
Adding fluoride to water supplies
Adding fluoride to water supplies |
9 October 2007 |
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Dr Barry Cockcroft,
Chief Dental Officer for England
Department of Health, New Kings Beam House, 22 Upper Ground, London, Se1 9BW
Send response to journal:
Re: Adding fluoride to water supplies
|
Dear Dr Godlee
‘Adding Fluoride to Water Supplies’ (Cheng KK. et al. BMJ, 6 October)
We welcome the opportunity presented by the paper Adding Fluoride to
Water Supplies (Cheng, Chalmers and Sheldon, 2007) to restate our view
that fluoridation has already made a major contribution to reducing the
burden of dental disease and offers the potential for addressing
persistent inequalities in oral health. We recognise that, as with other
health measures, safety should continue to be monitored and the ethical
dimension discussed.
Naturally, we wish first to address the doubts expressed in the paper
about the Department of Health’s objectivity. It was of course the
Department of Health, which, in 1999, commissioned the University of York
to undertake a systematic review of fluoridation. We responded to the
report with a commitment to sponsor further research strengthening the
evidence base on fluoridation. In 2001, we asked the Medical Research
Council to identify and prioritise the research required to inform public
policy on fluoridation. Then, in 2003, in accordance with the MRC
recommendations, we commissioned the University of Newcastle to
investigate the bioavailability of fluoride from artificial and natural
sources.
The Newcastle study contributed to better understanding of the
health effects of water fluoridation. In some parts of the country,
drinking water is naturally fluoridated at the level used in artificial
fluoridation schemes and generations have been drinking this water without
any evidence of systemic ill effects. The report of the Newcastle study
(1) concluded that there were no statistically significant differences in
bioavailability between artificially and naturally fluoridated water. As a
result, we may continue to have confidence in the safety of fluoridation.
In planning further research, we have agreed to take account of
suggestions that the study be repeated with a larger sample size - within
the inevitable constraints of the funding available.
We do however make no apologies for promoting the benefits of
fluoridation on oral health. We have seen significant improvements in oral
health in the last 30 years, but many people still suffer unnecessarily
from pain and discomfort from dental disease and there are still
inequalities across the country. The most serious consequence is the
extraction of teeth under general anaesthetic which carries a small risk
of serious injury or, very occasionally, death.
There is a strong association between oral health and social class.
The probability of having decay experience in primary teeth is about 50%
higher in the lowest social group compared with the highest(2).
Fluoridation mitigates this association. In Sandwell, the water supply was
fluoridated in 1986. Subsequently, the amount of tooth decay in children
has more than halved. During the same period, Bolton, with a comparable
population mix, saw little change in its children's oral health(3). This
contrast is due to the beneficial effects of fluoridation as evidenced by
the Systematic Review undertaken by the University of York which found
that water fluoridation increases the number of children without tooth
decay by 15 per cent and that on average, children in fluoridated areas
have 2.25 fewer teeth affected by decay (4). This has been calculated as
being equivalent to a 40% reduction in dmft/DMFT(5). There is also
increasing evidence of a longer-term beneficial effect of water
fluoridation on the dental health of adults with a recent meta-analysis
showing a preventive reduction of 27% in dental caries in adults living in
fluoridated areas(6).
All water supplies contain some fluoride, and it was from observing
different patterns of dental decay in areas of differing levels of
naturally fluoridated water, that the benefits of fluoride were first
observed. We acknowledge that good results can be obtained from regular
brushing with fluoride toothpaste. However, tooth brushing alone will not
reduce inequalities in oral health because, as the paper acknowledges, use
of toothpaste is dependent upon individual behaviour. Targeted
fluoridation schemes based on local decision-making - we are not
advocating the fluoridation of the whole country - offer greater potential
because they are a population-based public health intervention.
The York report undoubtedly comprises the most comprehensive review
of research on fluoridation to date. We were encouraged by the positive
findings on the benefits to oral health and the absence of any
demonstrable association with systemic illness but we have taken the
criticisms of the quality of research very seriously. We agree that the
evidence base on the effects of fluoridation on health needs
strengthening. That is why, following the publication of the York review,
the Department asked the Medical Research Council to assess priorities for
future research in the light of the York work. The MRC reported in 2002
(7) and we are committed to a programme of further research based on that
MRC advice. Nevertheless, the fact remains that the York team considered
735 research studies which met the Review’s relevance criteria and could
find no evidence of an association between fluoridation and systemic
illness.
Apart from the protective benefits, the only demonstrable side effect
of fluoridating water is dental fluorosis. This is a cosmetic defect of
tooth enamel which may range from mild flecking, often undetectable
except by a dental expert, to more noticeable marking which may give a
small minority of people concern about the appearance of their teeth.
With reference to the ecological study from Taiwan (8) cited in the
paper, we would like to quote the conclusions reached by the study’s
authors: “Our study found an excess rate of bladder cancer that was
restricted to females. It seems biologically implausible for fluoride to
affect cancer rates for one sex only.” This view is consistent with the
Medical Research Council’s report 6 which recommended that research
priorities should be determined by plausibility of effect.
The question of whether the fluorides added to water should be
licensed depends upon whether they should be categorised as medicines. The
Medicines and Healthcare Products Regulatory Agency consider that drinking
water (whether fluoridated or not) clearly falls within the definition of
'food' for regulatory purposes and is not subject to the licensing
requirements for medicines.
As the authors indicate, in purely legal terms, the ethical
justification for fluoridation depends upon the extent of the benefits to
public health. We are satisfied that the persistence of inequalities in
oral health provides this justification. Parliament has accepted this
argument. Moreover, the circumstances in which fluoridation schemes are
introduced was debated in Parliament as recently as 2005 (9) when new
requirements for consultations were approved by a large majority in both
Houses. Strategic Health Authorities may only make arrangements with a
water undertaker to fluoridate an area where they have conducted open,
wide-ranging consultations.
It is right for those who carry the local responsibility for
preventing disease and promoting health to consider the option of water
fluoridation as an effective means of reducing the burden of dental decay
especially in communities where decay levels remain unacceptably high. The
benefits, safety and ethics have rightly been key issues in previous
consultations on water fluoridation and will no doubt continue to be at
the heart of future consultations.
Yours sincerely
Dr Barry Cockcroft
Chief Dental Officer for England
Professor Sir Liam Donaldson
Chief Medical Officer for England
References:
(1)Maguire A, Moynihan PJ, Zohouri V (2004). Bioavailability of
fluoride in drinking water – a human experimental study. Report for the
Department of Health, University of Newcastle
(2)Steele & Lader (2004): Social factors and oral health in children,
Children’s Dental Health in the UK 2003, Office for National Statistics,
London .
(3) Pitts,N.B.,et al(2005):The dental caries experience of year old
children in England and Wales (2003/04) Community Dental Health 22:46-56
(4) McDonagh et al .A Systematic Review of Water Fluoridation, NHS Centre
for Reviews and Dissemination, University of York 2000.
(5) Worthington,H.V. and Clarkson J. (2003) The evidence base for topical
fluorides (editorial) Community Dental Health 20:74-76
(6) Griffin et al (2007): Effectiveness of Fluoride in Preventing Caries
in Adults, J dent Res 86(5): 410-415
(7) Water fluoridation and Health: Report of a Medical Research Council
Working Group. Medical Research Council. 2002. London
(8) Yang CY, Cheng MF, Tsia SS, Hung CF (2000). Fluoride in drinking water
and cancer mortality in Taiwan. Environ Res; 82(3):189-193
(9) House of Commons Official Report. Third Standing Committee on
Delegated Legislation, 25 Mrach 2005 Col 1-11.
Competing interests:
None declared |
| |
Adding fluoride to water supplies
Ethics of water fluoridation |
7 October 2007 |
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John F Beal,
Consultant in dental public health
Leeds PCT, LS16 6QG
Send response to journal:
Re: Ethics of water fluoridation
|
The ethics of water fluoridation have been widely debated by experts
in ethics(1 2 3), by the Courts (4 5 6), by citizens’ panels (7), and in
the media. Varying, and sometimes conflicting, views have been expressed.
Different people will undoubtedly take different views on ethical issues.
The fact remains that fluoride confers substantial benefit to communities
that receive it.
Whether water fluoridation is medication is irrelevant as the
Medicines Act clearly does not apply to fluoridation which is covered in
separate legislation, namely the Water Act 2003. The issue was debated in
Parliament, in both Houses, and subject to a free vote. Parliament
determined that decisions about the implementation of fluoridation should
be made by Strategic Health Authorities after careful and widespread
public consultation which could, of course, include further debate about
the ethics of fluoridation.
1. Fottrell F (Chairman). Forum on Fluoridation Ireland. Dublin:
Stationery Office, 2002
http://www.dohc.ie/publications/fluoridation_forum.html.
2. Harris J. The ethics of fluoridation. Liverpool: British Fluoridation
Society, 1989
http://www.bfsweb.org/facts/ethics/ethicsharris.htm.
3 Holt R, Beal J and Breach J Ethical considerations in water
fluoridation in Bradley P and Burls A Ethics in public and community
health, Routledge, London, 2000
4. Kenny MJ. FLUORIDATION. Judgement delivered by Mr Justice Kenny in the
High Court, Dublin, 1963. Dublin: Department of Health, 1963.
5. Chief Justice O'Dalaigh. FLUORIDATION. Judgement of the Supreme Court
of Ireland delivered by Chief Justice O'Dalaigh 3rd July, 1964. Dublin:
Department of Health, 1964.
6. Jauncey L. Opinion of Lord Jauncey {Iin causa} Mrs Catherine McColl
(A.P.) against Strathclyde Regional Council. Edinburgh: The Court of
Session, 1983.
7. NICE Citizens Council. Mandatory Public Health Measures. London: NICE,
2005 http://www.nice.org.uk/page.aspx?o=274599.
Competing interests:
None declared |
| |
Adding fluoride to water supplies
Dental benefits of water fluoridation |
5 October 2007 |
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Michael A Lennon,
Professor and Honorary Consultant in Dental Public Health
University of Sheffield
Send response to journal:
Re: Dental benefits of water fluoridation
|
The recent paper by Cheng et al(1) questions the benefits of water
fluoridation. The systematic review conducted by York CRD(2) used two
outcome measures of dental benefit. Evidence rated below level B
(moderate quality; moderate risk of bias) was excluded from this aspect of
the review; twenty-six studies were included (all level B).
First, York showed that the proportion of caries-free children
increased by 14.6% in fluoridated districts. Worthington and Clarkson(3),
Co-ordinating Editor and Editor respectively of the Cochrane Oral Health
Group, have described such a change in the proportion of caries- free
children as “a huge reduction in caries”.
In their second calculation York CRD showed that water fluoridation
reduced the extent of dental caries by a mean of 2.25 decayed, missing and
filled teeth. Worthington and Clarkson(3) calculate this as equivalent to
a “preventive fraction” of 40%. This is close to the figure calculated
from a different data set and widely circulated by the British
Fluoridation Society(4) and others since 1994.
The national caries data cited by Cheng et al hide significant
regional variations, and no one to my knowledge has, over the past twenty
years, proposed a “national” fluoridation programme for the UK. If we
extended water fluoridation from the current 10% to around 30% of the
population, there would be substantial benefits for the many disadvantaged
young children living in deprived areas in the UK with the highest levels
of dental caries.
Professor M. A. Lennon OBE.
Chair, British Fluoridation Society
References
1. Cheng KK, Chalmers I, Sheldon TA. Adding fluoride to water
supplies. British Medical Journal 2007;335:699-702.
2. McDonagh MSPF, Whiting, et al. Systematic review of water fluoridation.
British Medical Journal 2000;321: 855-859.
3. Worthington HV, Clarkson J. The evidence base for topical fluorides
(editorial). Community Dental Health 2003;20:74-76.
4. British Fluoridation Society. One in a Million - the facts about water
fluoridation. Manchester: British Fluoridation Society, 2004
http://www.bfsweb.org/onemillion/onemillion.htm.
Competing interests:
Chair (unpaid) British Fluoridation Society |
| |
Adding fluoride to water supplies
Medication with intent – the case against water fluoridation. |
5 October 2007 |
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Douglas W Cross,
Independent Consultant in Environmental Analysis
Croft End, Lowick Bridge, Cumbria LA12 8EE
Send response to journal:
Re: Medication with intent – the case against water fluoridation.
|
The medicinal nature of the product fluoridated water is not in doubt, since it conforms to both definitions of a medicinal product provided in Article 1.2 (a) and (b) of the latest version of the European Communities medicines directive [1]. It is unquestionably medicinal by presentation and by function. A number of European Court of Justice (ECJ) rulings confirm that the intent to medicate, or even deliberately giving the public the impression that a substance has medicinal properties, is the criterion defining a substance or product as ‘medicinal’:
‘If a product is represented to the public so that any averagely well-informed person gains the impression that the substance might have a beneficial effect on some medical condition, then that substance is a medicine under the terms of this Directive.’ [2]
In the Ter Voort decision the ECJ ruled that:
'A product that is recommended or described as having preventive or curative properties is a medicinal product . . . even if it is generally considered as a foodstuff and even if it has no known therapeutic effect in the present state of scientific knowledge',
The nature of a product as medicinal is established by legal definition, whereas the award of a marketing authorization by the Medicines and Healthcare Products Regulatory Authority (MHRA) is an administrative decision subject to political influence. A medicinal product is, and remains, medicinal regardless of whether or not the MHRA has awarded it a licence. The designation of fluorosilicates as source materials for fluoride in water under the Water Act 2003 does not constitute legal authority for their use as medicinal substances. Dilution is not an issue – even water for injection requires, and has, a medicinal product marketing authorisation, since it is used with the intent to medicate.
The argument that fluoridated water is a food is tenable only if it is not a medicinal product. Any food, including water, that contains a medicinal substance is regulated under the medicines directive. If fluoridated water were to be classed as a food then it would be subject to the directives regulating food supplements and/or food additives. Supplements, and the materials from which they may be derived, are strictly controlled:
'(Preamble 9) – Controversy as the identity of those nutrients that could potentially arise should be avoided. Therefore it is appropriate to establish a positive list of those vitamins and minerals.’ [3]
Annex I of the directive sets out in this positive list; the permissible sources of Annex I substances are specified in Annex II. Only the source substances identified in Annex II may be used as supplementary sources of the named vitamins and minerals. Sodium and potassium fluoride are the only authorised source materials for the ‘mineral’ fluoride. The fluorosilicates used in water fluoridation are not ‘substantially equivalent’ to ‘natural’ or any other fluorides, and are absent from Annex II.
All food supplements must be delivered to the consumer in concentrated pre-packed form. Their promotion as having medicinal properties is prohibited:
'Article 6. No food supplement – including any mineral – may be presented to the public as having medicinal properties.’
It is therefore improper to refer to fluoridated water as providing a ‘supplementary’ source of fluoride for consumers, since this implies that it is a permitted food supplement. The practice of ‘fortifying’ the fluoride content of drinking water to reach the ‘optimal’ concentration recommended for dental health protection is improper – the objective of the European Community’s water quality standards is to ensure that the quality of water is the highest possible, not the worst permissible.
When added to a food, including water, then vitamins and minerals (and certain other technical substances essential for the processing of foods) are classed as additives. The directive regulating the addition of vitamins and minerals and certain other substances to foods [4] lists all permissible food additives in Annex I. No fluoride or fluorosilicate is included in this list; their addition to any food is therefore prohibited, and this would also apply to fluoridated milk targeted at children.
Since fluoridated water is either an unlicensed medicinal product or a food containing an unauthorised additive (or, indeed, both), placing it upon the market is prohibited, and any form of advertising that the product has medicinal properties is banned. As the directives are transposed into UK (and Irish) domestic law, advertising fluoridated water as having medicinal properties is an offence. For example, Clause 3 of the UK Medicines (Advertising) Regulations 1994 [5] states:
‘No person shall issue an advertisement relating to a relevant medicinal product in respect of which no product license is in force.’
This clearly acknowledges that unlicensed medicinal products do exist, and that the absence of a product licence granted by the MHRA does not prevent such a product from being classed as medicinal in law. Similarly, rules on the labelling, presentation and advertising of foods [6] prohibit attributing any ‘preventing, treating or curing properties’ to foods. This has been interpreted by the ECJ as banning all health claims relating to human diseases. [7]
‘Publishing’ and ‘advertising’ are interpreted in extremely wide terms [8], which include issuing verbal recommendations for the adoption of fluoridation for the prevention of dental caries to health professionals, executive agencies and the general public. The ethical implications of doing so, especially for health care professionals, are serious, since offenders may be vulnerable to actions in law by any person claiming to have been damaged by the practice. The provision of ‘consultation’ processes on implementing new fluoridation schemes is also contrary to law, since there can be no debate on whether or not to commit a criminal assault upon the public. The provision of any form of professional or corporate indemnity for such liability, including that offered by the British Government to water companies[9], is at risk – there can be no indemnity for a criminal act.
References.
1. 2004/27/EC on medicines for human use (OJ L 136, 30.4.2004 p.34)
2. Case C-60/89, 21 March 1991, re Manteil and Samanni, European Court Reports 1991;I:1547;
Case C219-91, 28 October 1992, re Ter Voort, European Court Reports 1992;I:5485;
Case C368-88, 21 March 1991 re Delattre, European Court Reports 1991;I:1487;
Case C227-82, 30 November 1983, re van Bennekom, European Court Reports 1983;3883
3. 2002/46/EC on Food Supplements (OJ L 183. 12.7.2002, p51
4. 2006/52/EC amending Directive 95/2/EC on food additives other than colours and sweeteners and Directive 94/35/EC on sweeteners for use in foodstuffs (OJ L 204, 27.7.2006 p 1-13)
5. Medicines (Advertising) Regulations 1994 (SI 1994 No. 1932)
6. 2000/13/EC on labelling, presentation and advertising of foods (OJ L 109, 6.5.2000, p 29)
7. Case C221-00, Judgement of 23/1/2003, Commission/Autriche (Rec. 2003, p.I-1007)
8. 65/65/EEC on medicinal products (OJ No 22 of 9.2.1965, p 369/65)
9. The Water Supply (Fluoridation Indemnities)(England) Regulations 2005 (SI 2005 No. 920)
Competing interests:
None declared |
| |
Adding fluoride to water supplies
Adding fluoride to water supplies |
5 October 2007 |
|
|
Colwyn M Jones,
Consultant in Dental Public Health
Edinburgh EH8 9RS
Send response to journal:
Re: Adding fluoride to water supplies
|
The systematic review of water fluoridation by the York centre for
reviews and dissemination (York CRD) concluded that water fluoridation
works. It found that an extra 14.6% of children would be completely free
of tooth decay with the misery it engenders, and a later estimate of the
preventive fraction is a 40% overall reduction in decay (Worthington,
2003). So we can all agree water fluoridation works.
The glaring omission from the article by Cheung et al is mention of
the pain, disfigurement, embarrassment and cost that preventable dental
decay causes. Although rare, death under general anaesthesia does
tragically happen and tooth extraction is the commonest clinical
indication for general anaesthesia for children in Scotland.
Water fluoridation works as it does not rely on behaviour change and
a number of Cochrane reviews confirm that fluoride in many forms
(toothpaste, mouthrinses, etc.) is complementary to water fluoridation.
Cheng et al develop their section on safety by selectively quoting
from the literature in citing an ecological study. The study conducted
multiple statistical comparisons and only one was significant at the 5%
level, a probability you would expect by chance. Rather alarmingly Cheung
et al then use this data to calculate excess bladder cancer rates in the
UK. However, the original authors state, “Our study found an excess rate
of bladder cancer that was restricted to females...... there is no reason
to expect sex differences in bladder cancer..... Therefore, the
possibility that this is a chance result should be considered....”
Equally spurious would have been to calculate the reduction in other types
of cancer and suggest water fluoridation has a protective effect.
Most systematic reviews conclude that the evidence base is poor.
Cheung et al are correct on the necessity for future research on water
fluoridation, and with an estimated 40% reduction in disease it should be
a priority. How can we do this? We must introduce a number of large water
fluoridation schemes and thoroughly evaluate this population based, public
health measure using modern research methods to demonstrate it works,
confirm safety and see if early indications are correct that it reduces
socio-economic inequalities in dental health. The sooner we get started
the better.
References
Worthington HV and Clarkson J. The evidence base for topical
fluorides. Community Dental Health (2003)20:74-76.
Competing interests:
Dentist
Member of the British Fluoridation Society |
| |
Adding fluoride to water supplies
Fluoride Consumption – Much Higher than We Are Told |
5 October 2007 |
|
|
Peter J Mansfield,
Independent Health Adviser
Good Healthkeeping,,
Garrod House, Manby, LOUTH LN11 8UT
Send response to journal:
Re: Fluoride Consumption – Much Higher than We Are Told
|
During the systematic review of water fluoridation which spanned
1999-2000 (1), the dearth and poor quality of scientific evidence was a
major concern. In particular, no acceptable measurements were yet
available of fluoride consumption from all sources in any random sample of
the British population. The National Diet and Nutrition Survey published
in 2003 (2) the first such data, from 24-hour urinary fluoride assays from
most survey subjects.
Urinary values were dealt with in Volume Three of the report . The authors
inferred that 1% of men and 3% of women had intakes of fluoride above the
officially defined safe level of 0.05mg/kg/day. Whilst reviewing the raw
survey data for another research purpose I checked this statement. A
serious error came to light in the authors’ calculation.
The authors seem to have assumed that all fluoride consumed from any
source is excreted promptly in the urine. In fact, 90% of ingested
fluoride is assimilated into the blood stream (3), and half of that is
sequestered in calcified tissues. Only the remaining half, 45% of the
ingested fluoride, is excreted via the urine (4). On this basis daily
fluoride consumption is higher than daily excretion by a factor of 2.2.
When this correction is made, a much larger proportion of the sample is
shown to have consumed fluoride at or above the nationally defined safe
level. The correct figures range from 8.2% among 19-24 year old females to
25.5% for males aged 50-64.The mean for the entire sample (1429) is 20.2%.
This sample does not distinguish subjects receiving fluoridated water from
those who do not. Some 24-hour urines were incomplete, so these findings
under-estimate the truth.
The result suggests that a substantial proportion of the British
population are consuming fluoride in amounts that could be responsible for
undiagnosed symptoms. Persons accidentally consuming fluoride in excessive
amounts deserve to be identified and helped. It is time to raise medical
and dental awareness of this. Might not a square to detect fluoride
concentration be added alongside glucose to the urine testing dipstick?
The authors of the Survey Report and the relevant civil servant have been
advised of this apparent error, and have not refuted it. The Food
Standards Agency is considering its response.
References
1 McDonagh M, Whiting P, Bradley M et al. A systematic review of
water fluoridation. NHS Centre for Reviews and Dissemination: University
of York, 2000.
2 Henderson L, Irving K, Gregory J. The national diet and nutrition
survey: adults aged 19 to 64 years. HM Stationery Office, 2003;3:129-135.
3 World Health Organisation Monograph Series No 59. Fluorides and
Human Health. Geneva: World Health Organisation, 1970:75-89.
4 National Research Council (US). Health effects of ingested
fluoride. Washington: National Academy Press,1993:128-133.
Competing interests:
None declared |
|
|
FEATURE:
Should general practitioners resume 24 hour responsibility for their patients? Yes
Jones (6 October 2007)
[Full text]
[PDF]
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Should general practitioners resume 24 hour responsibility for their patients? Yes
Not either or... |
13 October 2007 |
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Steven Ford,
GP
Haydon & Allen Valleys Medical Practice
Send response to journal:
Re: Not either or...
|
Editor
There need be no contest here, merely the flexibility to adopt the
approach that best suits the patients, doctors and geography.
My own practice did its own OOH until confronted by 'force majeur'
and I only stopped doing OOH altogether when it degenerated into a call
centre operation.
A diversity of provision arrangements is the right approach.
Yours sincerely
Steve Ford
Competing interests:
I am a GP |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
GP Land |
13 October 2007 |
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|
Dr. Raja Baber Sheraz,
GP ST2
Staff hostel, West cumberland hospital, Whitehaven, CA28 8JG.
Send response to journal:
Re: GP Land
|
Gp treats the whole patient, not "chest pain", "ankle fracture" or
"another neck of femur". Thats what we call as "Holistic approach" in our
GP land.
Even if the GP works from 0800 to 1700 it does not mean that he/she is not
owning the patient. GP gets the feedback from the patient very next day
that is not the case in minimum three monthly hospital consultation. At
the moment the balance is right between the primary & secondary care.
Yes i do support the transition of some specialist work into community,
closer to patients own home provided by their own doctor. GPWSI Cardiology
is an example!
To maintain & improve the quality of general practice we need to give
our GP`s a suitable work life balance by giving them the choices of opting
in or out of out of hours work.
General practice has become a emerging popular choice among our post
foundation programme doctors. Bringing out of hour work into primary care
"24 hours responsibility" may affect the future career choices!
In the current setting General practitioners are doing a great job in
providing excellent healthcare to the local community.
Suggestion: Why not make small primary care zones & GP`s can do out of
hour work in their own practice zones. The benefit would be that patient
requiring home visit won`t see a new face!
I am sure with this healthy debate we might find an acceptable solution to
all which continues to provide the best primary care to our local
communities. The important bit would be to include hospital Consultants,
GP`s, Current out of hour providers, media & most importantly our own
patients!
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
In support of the GP Co-op |
12 October 2007 |
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john m caine,
GP
parbold, lancs, wn8 7nb
Send response to journal:
Re: In support of the GP Co-op
|
Prof. Roger's arguments for the return of 24 hr 7/7 responsibility
seem to
be that it would improve GP training, reduce admissions and improve
patient
use of the service and their safety. Oh and that patients would like it
and it
might be cost effective.
His evidence for these assertions is what exactly?. He states that
Heath's (1)
opinion was that 'OOH was becoming a shambles' -yet her article is
actually
calling for an end of the cheaper skill-mixing attempts of some OOH
services
to introduce non-GP first contact clinicians into OOH and promots the
GP
Co-ops who have managed to stay in business by opting -in.
He claims that Wanless (2) blamed the steep rise in A&E; attendances
to
changes in OOH arrangements - but Wanless actually blames the A&E;
obsession with 4 hr waiting times along with the OOH changes and gives
no
evidence for either - In fact the steepest year on year rise in new
contacts
occurred between 2002/3 and 2003/4 (15% increase) before the new contract
came into effect c/w 9% between 2003/4 and 2004/5, and 6% and 2% in the
last 2 years.
He claims that OOH is provided by 'less experienced clinicians'.
Where is his
evidence for this assumption?. Does he have a breakdown of the OOH
workforce, that no one else has, or is he still peddling the media
prejudice?
My prejudice is that the vast majority of complaints in the MPS
report he
quoted will be in those organisations whose main aim is to provide a
service
based on cost rather than quality, i.e. the private companies and the in-
house
PCT run organisations- by the way how does the rise in OOH complaints
compare with the number of complaints about the NHS in general? Is there a
general increase in complaints across the NHS or just in those who are
getting the worst press?
It is difficult to see what points he is trying to make from his
international
comparisons. Australia have a private health care system where GPs get
paid
for each contact and where GPs can reckon on only a third of their
registered
patients seeing them regularly -the others popping into whichever GP takes
their fancy. Roger espouses their stringent guidelines for communication
but
doesn't elaborate on these. My personal experience of working OOH and in
hours in Australia is that continuity of care is a shambles. The OOH
quality
standards in this country (3) insist on all OOH contact records being
faxed/
emailed to the patient's GP by 8am the next morning- If only information
regarding our patients’ attendance at A&E; or Walk-in centres came as
quickly
( I’ll leave to one side the scandalous time it takes to get outpatient
letters
or discharge summaries)
In Canada they apparently have a system of extended rotas, which he
claims
is what Heath also calls for. This sounds fine to me but we haven’t we
been
there already? Oh yes I remember they are called GP co-ops!
Where these have been allowed to carry on- either by opting in and
doing
their own thing a la Heath, or by opting out yet being unmolested by PCTs-
they continue to provide a high quality service, staffed by local
experienced
GPs, with excellent lines of communication, and support for younger
doctors
and training for registrars- does that tick all your boxes?
1.Heath I. Out of hour’s primary care—a shambles? BMJ 2007; 334:341.
2.Wanless D, Appleby J, Morrison A, Patel D. Our future health secured? A
review of NHS funding and performance. London: King's Fund, 2007.
3. national quality requirements in the delivery of Out of Hours
services:
2006
Competing interests:
full time GP and OOH Director |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
24hour responsibility |
11 October 2007 |
|
|
ravinder Norman,
GP
YATELEY GU46 7LS
Send response to journal:
Re: 24hour responsibility
|
NO to OOH-our daily practice demonstrates that the more availability
we have the greater uptake .NHS Direct A&E; walk in clinics do not
necessarily prove that there is a need.[A vacuum is filled]Other than true
emergencies -of which there are few-most of health care needs can be dealt
with during normal working hours. A trial of GP's in A&E; only demonstrates
how perceived needs by the public and desire to be seen when, where etc, fuelled by the Governments desire to give everyone what they want rather
than sensible use of services -this is not rationing-creates a need where
there wasn't any.
The best way as was just beginning to be shown by fund holding then by
local GP co-ops is that given funding and support and the trust by MPs
.GP's can deliver very good, comprehensive services.
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
depends on format |
11 October 2007 |
|
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Duran Kandhai,
GP-Principal
Newport, NP19 8XR
Send response to journal:
Re: depends on format
|
GPs are independent contractors and I feel that any action even by
stealth to impose working unsociable hours(out of hours; 24/7 care) is
certainly not acceptable and should forcefully with full support by all
stakeholders be rejected. Nonetheless I agree that many GPs would be
willing to work OOH(Out Of Hours; 24/7 care)and indeed should have the
opportunity to do so in a suitably priced contract, i.e. that reflects the
risks, time investment and sacrifice of family/social life. Furthermore
some arrangement should be possible whereby the GP who worked the evening
or night before should have at least the next morning off.
This would be the only way forward to achieve 24/7 care that is acceptable
to both patients and doctors. Let's not forget that patients nowadays
regard a tired and overworked doctor as "non acceptable" or "risky".
Competing interests:
I'm a GP Principal |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
24 hours |
11 October 2007 |
|
|
Gregory M Read,
GP
Fressingfeld Medical Centre IP21 5PJ
Send response to journal:
Re: 24 hours
|
I would love to go back to the good old days of 24hr responsibility
(it was actually one of the reasons I chose general practice as a career),
if there was the necessary support for carrying it out, in both financial
terms and in generating an attitude from the patients that it was not an
extension of our daytime work - an attitude persistently encouraged by the
present Government with its obsession with access. Unfortunately, neither
of these pre-requisites will happen.
The Government has blatantly encouraged patients to expect a service
at weekends and out of hours that is unacceptable to most hardworking
general practitioners - this attitude is based on the Tesco's model of
"get what you want when you want it" even if it is 3 o'clock in the
morning. The difference is that Tesco's know that they can afford to do it
making a fabulous profit to boot and also employ their staff on a shift-
based system. The person on the cash till at 3 o'clock in the early hours
won't be there holding the fort at 9 o'clock later the same morning! The
deliveries arrive and the shelves are stocked to accomplish a seamless
shopping experience even though it is at a time when most people are
asleep. I doubt whether hospitals and other areas of the NHS will be able
to provide an equivalent routine service during these times to make our
efforts worthwhile when we are providing the required routine OOH service
that will be expected of us. If one looks at the way most PCT's organise
their finances in order to pay off the massive debts that were there when
they came into being, they exert a huge downward pressure on practices to
do everything as cheaply as possible or stop commissioning certain
services because they are too expensive. How on earth are they going to
afford a 24hr service manned by doctors when they are finding it so
difficult to provide one on the cheap at present with nurse practitioners
and paramedics and bases spread so thin that our patients sometimes have
to travel 50 miles to see a doctor or other healthcare practitioner. I
worked out that when I did my OOH work and Saturday mornings for the first
10 years in practice, I earned about a pound an hour! I also missed my
young daughter growing up in her early years because of the times that I
wasn't there. This is something that I would not accept again, especially
as I am much older and I wouldn't expect my younger colleagues to be put
in the same position. Even when we set up an innovative General Practice
Co-operative in our area, it was apparent, as time went by, that the
service was starting to be abused by an increasing number of unnecessary
calls and the added stress that came with them. And of course to provide
this service we had to pay back our membership by working the requisite
number of shifts.
Professor Jones, I'm afraid, is typical of the type of GP, who,
despite of his excellent skills as a GP, has found other things to do in
the world of academia - and this is not denigrating that what he does
isn't important for British General Practice. If I am wrong then I
apologise, but I doubt whether he spends every week of his working life
from 8-6.30, on the coalface, seeing patients and, thus, in his own way,
he has already opted out.
I hope that I am not a dinosaur and that there maybe many GPs who
feel the same as me. If it comes to the crunch then I will consider my
options and retire early, even though it will affect my financial future.
I don't think anyone would disagree with the fact that a doctor based OOH
system and thus, a return to 24hr responsibility would be the gold
standard for general practice OOH but, it requires a sea change in
attitude, particularly from this and future Governments - they cannot rely
on doctors goodwill to work unsociable hours for no additional income
because it's perceived to be a duty that comes with the job. I think that
this was why so many of us decided that enough was enough in 2004 and
opted out. The only way that a return to 24hr responsibility will work, is
if the number of GPs working in the NHS increases dramatically in order to
allow a practice-based shift system to work effectively and safely, as
well as there being a secure and protected financial package for those who
carry it out.
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
Not keen! |
11 October 2007 |
|
|
Rosemary B Martin,
GP principal
M14 6 XU
Send response to journal:
Re: Not keen!
|
The day job has undoubtedly got harder under the new contract. The
patients
who consult by day have every bit as much right to a good service and the
two
jobs cannot safely be done by the same person.
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
The Good Old Days |
10 October 2007 |
|
|
David Howard,
GP and Trainer
Stonehaven, AB39 2TR
Send response to journal:
Re: The Good Old Days
|
Why would anybody want to go back? We can still work out of hours if
we want to for raesonable remuneration. Those who prefer a good night`s
sleep can go to work refreshed. Recruitment has improved. What were the
chances of seeing your own patient previously out of hours unless you
worked very onerous rotas? Those who advocate a return to the good old
days are aiding our masters in an effort to cut the cost of OOH care pure
and simple.
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
gp 24hr resposibility |
10 October 2007 |
|
|
tariq m hama,
gp principal
kimberley ng16 2nb
Send response to journal:
Re: gp 24hr resposibility
|
gps too have families which require valuable protected time
why should they be denied this
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
in the long run - giving up out of hours has been a bad thing |
10 October 2007 |
|
|
edmund willis,
gp
bridge street surgery, brigg, north lincs, dn20 8nt
Send response to journal:
Re: in the long run - giving up out of hours has been a bad thing
|
GP's are perceived as overpaid and lazy, and we are being punished by
the government for it.
If we had kept control of out of hours - we would have a much better
standing as a profession, and have a lot more support from the public. The
government would have been much less likely to use us a general whipping
boy.
My regular patients are amazed when they see me working for one of
the remaining outof hours coops. They beleive the media which tells them
that gp's dont do out of hours.
The perception that we all were doing out of hours before and now
none are is particularly absurd as very few GP's were formerly unable to
use deputising services.
The double whammy we are in now is that PCT's now realise how much it
costs to organise an effective service and are providing a token service -
for example 1 doctor on at night for the city of hull and a huge
surrounding area! The resulting service is terrible for patients.. and who
gets the blame?? why us of course who provided a mostly good service
cheaply for years.
We need to offer to take this job back - there are now lots of
doctors who are prepared to work out of hours. If we did this we would
improve our reputation, and that would work to our advantage in the long
run. We would also resist the the tide of Emergency care practitioners,
nurse prescribers, specialist nurses, counsellors, who threaten to take
over 'Primary Care'.
Competing interests:
i am a gp who does out of hours work |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
In reply to Mr Wintertton above... |
9 October 2007 |
|
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David P Jones,
GP - full time
Bangor, Gwynedd
Send response to journal:
Re: In reply to Mr Wintertton above...
|
Part time - I wish.
I work full time - 5 days a week - mostly 11-12 hour days with a "working
lunch" and afternoon coffee, if I am lucky, whilst I scramble through
mountains of paperwork.
I take 6 weeks holiday a year, as my partners do, which means when they
are away (which effectively is half a year) their work needs covering.
I would like to know what other entitlements you allude to as it is clear
to me you have no idea of the primary care set up.
You, as a paramedic, will work a shift system. You will have time off to
compensate and your hours are governed by the European Working Time
initiative, unlike mine that do not come under this legislation.
Individual GP's cannot cover their patients 24 hours a day and remain in
safe control and you would not want me to be taking critical decisions for
your patients (or indeed your family should they be unfortunate enough to
need care) at 3am when I have been working without a break for 20 hours.
Think about it that way then think again ................
Competing interests:
Full time working GP |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
yes responsibility is for doctors to bear |
8 October 2007 |
|
|
robert derek wintertton,
paramedic
medical centre nw6 3jr
Send response to journal:
Re: yes responsibility is for doctors to bear
|
yes doctors should bear responsibility for their patients 24 hrs. there are holidays and other entitlements to enjoy.
part time apart from health and family reasons should not be out of right.
patients suffer form the current system with increase of hospital referals
and improper control of hypertension, diabetes, anticoagulant
therapy. patients require help and if you are not dedicated enough do not
come to medicine. it is not shop keeping. sincerely
WINTERTTON(MR)
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
OOH, General Practice and Sanity |
8 October 2007 |
|
|
David P Jones,
GP - full time
Bangor, Gwynedd
Send response to journal:
Re: OOH, General Practice and Sanity
|
Like many of the previous responders, I worked in the "old system".
We covered our own patients, 24/7/365. We did ridiculous numbers of
unnecessary day time home visits, we rarely did any primary prevention and
our surgery work essentially involved acute illness, diagnosis and
referral of more serious conditions, the occasional terminal care, and
repeat prescribing. House calls for minor problems were common and we
soon realised that for every 1 call, approximately 7 patients could be
seen in surgery. As time went by, we took on increasing amounts of
primary prevention, so much so that by the time the 2004 contract was in
place, I would imagine most practices, like ours, were up-to-scratch.
At about the same time, in our part of the UK, a difficult semi-rural /
rural area, a Co-operative was formed. Instead of 4 doctors being on-call
covering 20,000 patients in one area, 3 covered a vast area covering
100,000 patients. And guess what? The expected warnings that things
would be unmanageable did not materilise.
The reason why this was so was because it was set up using data from other
areas, we listened to others who had done it before us, and we learned.
Now, 2004 contract. Why has this not been such a breeze?
In my opinion, Government and advisers did not listen. They were told the
likely problems. They were told GP's were already up to scratch with
preventive care, they were told the budget for OOH was woefully inadequate
(I personally informed the Welsh Assembly this in my discussions as the
Chair of the local OOH in a meeting between us, NHS Direct, who triaged
for us and the Assembly) - but all along they knew best and now they are
looking for scapegoats.
No GP is going to go back and work at the rate they were previously paid,
and the introduction of market forces to primary care is a cross that this
Government and their advisers are going to have to carry.
My current work load, with all that it entails, does not allow time for
OOH to be done. I would not be safe and I would therefore be doing my
patients, and those of my colleagues, no service.
It is time for the DOH advisers (whoever these faceless people may be) and
the Government to wake up and smell what they have have landed the
profession in, start to take advice from the ground workers (sorry
professor but being in an academic unit and a surgeon does not qualify
you to pontificate on my professional working life) who have been involved
in the best Primary Care Service IN THE WORLD. And no, my hand did not
slip and press caps lock by mistake - it was a shout!
Competing interests:
GP principal |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
Family Physicians |
8 October 2007 |
|
|
Milind A Patil,
Medical Advisor, Pharma Company
410206
Send response to journal:
Re: Family Physicians
|
In fact, we in India, had this custom of calling GPs as family
physicians. I remember my childhood days; the family physician was
considered as not only a doctor but also a friend, philosopher and guide.
He was not treated as a supplier of some services for a cost!!
Unfortunatly, today this is not the case.
Yes, GPs should take 24 hour responsibility for their patients.
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
No need for extended hours |
7 October 2007 |
|
|
chris jenkins,
gp
sw9 9tj
Send response to journal:
Re: No need for extended hours
|
As a GP most of the patients that I see are either retired, have
chronic illesses and cannot work, are under 5, or at school, are non-
working refugees or asylum seekers, single parents, and working people off
sick looking for certification. Most of these, especially the elderly do
not want surgeries open after dark in the evening. Surely it would be
easier and cheaper to let woking people see a second gp near where they
work to sort out their mainly self imiting conditions. We already have a
mechanism for doing that, its called 'Immediately Necessary Treatment', or
for more detialed problems temporary registration for up to three months.
What services are going to have to be sacrificed for paying for largely
unnecessary extended hours
Competing interests:
I am a GP |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
TORONTO: After Hours medicine. |
7 October 2007 |
|
|
Alexander FRANKLIN,
Physician
Private Practice
Send response to journal:
Re: TORONTO: After Hours medicine.
|
Dr.JONES mentions Canada. Am MBBS(Lond.1959);here since 1970.Can only
speak for TORONTO where situation is mixed.
The most personal service is given by GPs who charge up to $3,500 a
year to register with their practice. They will usually answer a reserved
telephone line at any time.
GPs can also forward calls to a House Call service which arranges for a
Home visit by a doctor in a particular area. The House call doctor bills
the Ontario Health Insurance Plan(OHIP) directly, fee depends on time of
visit-usually about $100, and pays a commission,(usually 30%),to the firm.
GP groups will often take calls until 9 p.m. for which they are paid extra
by OHIP. Afterwards a taped message usually advises patients to go to
their nearest emergency department. There is also a Government-paid 24
hour Nurse telephone advisory service. By the way,Criminal Lawyers are
available at any time; their fees about $500-700 an hour. From personal
experience in UK & Toronto, House Calls are rarely Medically Necessary
.Usually an excuse to save petrol and transportation costs plus the
advantage of not having to wait in a GP's surgery during working hours. A
convenience, just like home delivery by the baker,grocer and milkperson
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
Should general practitioners resume 24 hour responsibility for their patients? Yes |
6 October 2007 |
|
|
Imran Arfeen,
VTS Trainee ST2
Scunthorpe General hospital, dn 15 7bh
Send response to journal:
Re: Should general practitioners resume 24 hour responsibility for their patients? Yes
|
I agree as a Gp registrar while working in OOH I realize the patient
care is effected because of continuity of care, I am not sure about
financial issues, My view is solely on Patient point of View.
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
FINGS AINT WHAT THEY USED TO BE.. |
6 October 2007 |
|
|
Graeme Mackenzie,
OUT OF HOURS GP
NORTH CUMBRIA
Send response to journal:
Re: FINGS AINT WHAT THEY USED TO BE..
|
I am probably well qualified to comment on this issue having done 20
years as a GP principal and am now employed as a full time salaried GP in
out of hours(OOH). My comments are as follows;
Emergency OOH is an increasingly specialist role or should be. I was
surprised how I had to skill up when I took by present job. Now that I am
focussed on emegency primary care I realise that as a principal before co-
operatives I wasn't doing that good a job.
Rather that turn the clock back we need to move forward with specialists
in primary care OOH. We possibly even need a separate defined speciality
with recognised qualifications and bespoke/mandatory training. These
doctors will in turn be able to extend their role and work much more with
secondary care, not only to reduce admissions but to receive early
discharges as well as defining best practice. Best practice is not
necessarily reducing admissions, it is doing the best or the potential
best for the patient. It is about avoiding, avoidable morbidity.
There are many reasons why GP principals and daytime GPs cannot return
wholesale to OOH. Geography is one, as many GPs no longer live in their
practice areas. Many good co-operatives now have teams of OOH
specialists. Replacing those with GPs who have not done signficant OOH for
a while would be a risky business.
Many co-operatives are now very professional with excellent call handling
procedures, nurse practitioners, triage nurses and well developped links
to district nursing and palliative care services. Is it suggested that we
return to GPs sitting at home writing the calls down on the back of a
cornflake packet? Does he suggest that instead of one point of contact,
patients across an area take pot luck with whatever system practices have
in place to handle their OOH commitment?
Large co-operatives have well stocked emergency centres and vehicles with
systems to maintain drugs and equipment. Many patients now benefit from
immediate access to oxygen, pulse oximetry, IV lines, defibs, nebilisers,
palliative care drugs and equipment and more. Large co-operative teams can
back each other up if busy. Is it suggested that we return to the days of
one GP struggling to cover a large practice with relatively limited
amounts of equipment and drugs and absolutely no back up. Are GPs going to
start visiting everyone as they did before? If not, you will need centres.
Is every practice going to open all hours? If you centralise the treatment
centres you are just recreating what we have now!
OOH organisations and co-operatives provided a focus for complaints and
comments on OOH care. Before them, there was nowhere for complaints to go
because they would be against a practice or individual GP. Patients were
less likely to complain in these circumstances and the complaints would
not be recognised as relating to OOH care.
The quality of care I provided as a GP principal working for a co-
operative and now provide as a salaried GP is far superior to what I
managed before when I had responsibility for regular on call.
I resent the implication that OOH GPs are inferior in quality doing the
more focused job of OOH. If you are just doing OOH, is the hypothesis not
that you will be better.
In the perfect world we would all want the doctor we knew seeing us at
whatever time we wanted. That doctor would be fully conversant with all
out medical history and when called would be polite and helpful to every
patient he saw as well as very competent on OOH care. We all know that
world never existed, that many GPs chronically resented the on call in a
way which must have affected the quality of care, that with the amount of
information on patients record nowadays it is safer to assume nothing:
something the OOH GP automatically does.
The future of OOH care may well be with highly trained, reflective OOH
primary care specialists who are motivated to provide best and appropriate
care under an umbrella of extended training and large supportive
organisations.
Competing interests:
OUT OF HOURS SALARIED GP |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
Whos falt is this anyway and why make it any worse than it already is ? |
5 October 2007 |
|
|
Alex G. Robertson,
GP principle
western avenue medical centre, chester, ch1 5pa
Send response to journal:
Re: Whos falt is this anyway and why make it any worse than it already is ?
|
Imposing a return to 24 hour responsibility will only exacerbate the
predicted recruitment crisis. Those GP’s that are due to retire in the
near future will see this as a reason to retire early ( as has happened
with most major contract changes in the past). These people have seen to
many changes in the last 30 years with out being subjected to this. The
whole hearted welcome given to the opt out and its’ over whelming uptake
surely points to the truth of this. The demands of out of hours care are
no longer part of our duties and we should not be looking at taking them
on again. However if we are forced to comply with this we should not make
the same mistake as the government. We should ensure that we are
appropriately remunerated for the task.
We can not be held responsible for the idiocy displayed by this government
in the past. It was obvious to all what was going to happen. I seem to
recall that there were even questions on the Today program on radio 4
about this very issue. A survey carried out by the BBC at the time showed
that the vast majority of us would opt out given the opportunity,
something denied by the health minister as I recall. Now look at what has
happened, as predicted we walked, and I for one can see no compelling
reason to walk back. Out of hours is not our responsibility. It belongs to
the PCT’s and ultimately the department of health. Where the system is
failing they should sort it out. You wouldn’t take a second hand car back
to its’ previous owner after 5 years hard use to complain that the tyres
are bald. So why do we feel responsible for the current state of out of
hours prevision in those areas where it is obviously failing.
Competing interests:
I am a GP and I also work in out of hours |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
General practitioners still do provide out-of-hours care |
5 October 2007 |
|
|
Robert L. Morley,
General Practitioner
Erdington Medical Centre 103 Wood End Road Erdington Birmingham West Midlands B24 BNT
Send response to journal:
Re: General practitioners still do provide out-of-hours care
|
Both Professor Jones and Dr. Herbert appear to make the same mistake
in confusing the provision of out- of -hours GP care with the
responsibility for organising it.When the profession voted to accept the
new contract it did not make "the difficult decision to withdraw provision
of out- of- hours", rather it chose to accept a contract which gave
practices the option of whether or not to continue to organise as well as
to provide twenty-four hour cover.
Two facts need to be clearly understood.Firstly,many
practices,particulary those with excellent GP co-operatives, chose to
retain responsibility for twenty-four hour care.They continue to do this
at financial cost to themselves because they recognise the value of this
service compared to the PCO-commissioned alternative.Secondly,general
practitioners still provide the out-of-hours medical care required for
the patients of "opted-out" practices. GPs in these practices may have
opted out of twenty-four hour responsibility;they clearly have not opted
out of providing out-of-hours care and continue to provide it for the
patients on their lists and those of other practices.
Profesor Jones' article also implies that GPs in training and in the
early years of practice gain no out-of-hours experience, and that they no
longer do home visits.I am at a loss to explain this misconception.
Competing interests:
None declared |
| |
Should general practitioners resume 24 hour responsibility for their patients? Yes
Out of hours GPs are well qualified , good doctors |
5 October 2007 |
|
|
Caroline A Mitchell,
GP/ Senior Lecturer
Woodhouse Medical Centre, S13 7LY
Send response to journal:
Re: Out of hours GPs are well qualified , good doctors
|
This article initially implies that patients are only safe in the
hands of experienced GPs but concludes with the suggestion that younger
GPs could take a greater share of the ‘red eye’ shifts. Out of hours
providers recruit fully qualified GPs to their rotas and all GP registrars
have supervised out of hours training. This article unfairly implies that
they are an inferior and under-qualified cohort. NHS complaints have
increased- both in and out of hours. Commercial out of hours providers
thrive but many providers were also established as true local GP co-
operatives, where local GPs ‘opt in’ to shifts which most fit their
working and home lives. All commercial and private out of hours providers
have accountable clinical governance systems, where patient safety and
good communication are paramount, and from personal experience, operate in
a highly supportive and safe environment. Faced by an unsustainable
increase in out of hours demand, and significant difficulties recruiting
new partners, local GPs formed a city-wide co-operative which provided
modern, safe premises, drivers & transport to bring patients to the
primary care centre. Over 18 months there was a dramatic reduction in
calls; to some (not the disabled and terminally ill), the attraction of
an out of hours contact was a convenient but inappropriate home visit. The
ability to opt into or out of shifts, in large efficient rotas,
transformed my professional and personal life. In 1993 I was a single
parent with a young baby. I would have lost my job had supportive partners
not covered the 6 to 8.30 am for my 1:4 rota and without the support of
friends who looked after my son until after at 11pm, evenings and weekends
(an expensive deputising service covered 7 hours).
Competing interests:
None declared |
|
|
FEATURE:
Is there enough evidence to judge midwife led units safe? Yes
Page (29 September 2007)
[Full text]
[PDF]
|
Is there enough evidence to judge midwife led units safe? Yes
Ongoing research on planned place of birth and safety |
4 October 2007 |
|
|
David M Puddicombe,
Research Assistant
National Perinatal Epidemiology Unit, University of Oxford OX4 1AG,
Mary Stewart and Rachel Rowe
Send response to journal:
Re: Ongoing research on planned place of birth and safety
|
In the most recent issue of the BMJ the Head to Head feature focused
on whether or not there is enough evidence to judge midwife led maternity
units safe (BMJ 2007;335;642 & 643). This article was of particular
interest to us at the National Perinatal Epidemiology Unit (NPEU) because
we are currently conducting the Birthplace in England Research Programme
(Birthplace) http://www.npeu.ox.ac.uk/birthplace, which incorporates the
Evaluation of Maternity Units in England (EMU) cited by Professor Drife.
Birthplace is funded by the National Institute for Health Research (NIHR)
and the Department of Health (DH) and comprises a series of related
studies to compare the safety and cost effectiveness of planned place of
birth and describe how provision of maternity services affects women’s
experiences.
This whole research programme is predicated on the fact that there is
currently insufficient evidence to say whether there is a difference in
outcomes according to planned place of birth for women at low risk of
complications during labour and birth.
Birthplace includes a large national prospective cohort study which
will compare the safety and cost effectiveness of births planned at home,
in midwifery units and in obstetric units irrespective of the actual place
of birth. A feasibility study to determine whether births planned at home
can be included is ongoing. If it is not possible to include planned
birth at home, the national study, which will begin in January 2008, will
compare births planned in midwifery units and births planned in obstetric
units. Results from the national cohort study will be available by the
end of 2009.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
5 year survey in Isles of Scilly |
4 October 2007 |
|
|
Toby Dalton,
General Practitioner
The Health Centre, St.Mary's, Isles of Scilly TR21 OHE
Send response to journal:
Re: 5 year survey in Isles of Scilly
|
We have recently conducted a five year survey of our midwifery
service. And ALTHOUGH we do transfer roughly half of those initially
determined as low risk, the satisfaction of the mothers surveyed and the
outcomes for all have been good.
We, as GPs, do the ALSO course ( advanced life support in obstetrics), and
attend every delivery in support of our midwifery service.
I am very much in favour of Midwife led care. Toby Dalton.
Data AVAILABLE at your request.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Midwifery down the drain |
4 October 2007 |
|
|
Anne Savage,
retired
N/A
Send response to journal:
Re: Midwifery down the drain
|
Professor Drife's defence of 'hospital is best'will not be well
received in this area where our local hospital has been severely censured
and a legal case is threatened over an intrapartum death and, last year, a
hospital up the road was put under 'special measures' following an
unacceptably high number of maternal deaths.
I was a GP Obstetrician back in the last century. Four of us in the
area provided obstetric care for any woman in the area who was suitable
for delivery in a Maternity Hospital, a Mother and Baby Home, where the
'normal' girls were delivered on site ,and for a number of home
deliveries. We had all conducted twenty normal deliveries and seen ten
'abnormals' as students and had had post-graduate training. We worked
with a team of six midwives, were always available and frequently present
during the second stage but never took over the delivery. It was a team
effort and included the local hospital where we received excellent back-
up and we also could call on two flying squads. An additional safeguard
was a system of 'Midwives' Aid' whereby any midwife could summon any
doctor on the obstetric list in times of crisis. We had no neonatal
deaths, though one very premature baby died in hospital following a
prolapsed cord.
This excellent service was largely disbanded when consultant
obstetricians became frightened that they would be responsible for doctors
they could not directly control. Some year later, when I was working part
of the time in Africa I used to do short locums to 'keep my hand in'. I
was shocked at the attitude of midwives in too many places, bored,
discontented and unresponsive to women's needs. I sympathised with them,
up to a point. Their skills were downgraded, the most junior doctor to
arrive in the labour ward could and often did, ignore their advice. In the
end it was the women who suffered.Our local paper has been flooded with
letters complaining of the poor treatment they experienced and many are
now booking with Independent Midwives.
This seems to be the worst of both worlds. It is Professor Drife and
his colleagues who are responsible for this sad state of affairs but I
worry about the government telling women they can have home deliveries but
not reestablishing the safeguards. One thing that could be done is to put
the midwives in charge of the labour ward, allow them direct contact to
the consultant and why not teach the senior staff to intubate and do
simple repairs?
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Are midwife-led maternity units safe? |
3 October 2007 |
|
|
Dr Mike Bull,
Retired GP
Oxford
Send response to journal:
Re: Are midwife-led maternity units safe?
|
I was a GP obstetrician in Oxford from 1956 to 1992 and during that
time cared for about 2,000 pregnant women. When I commenced practice some
40% low risk women were booked for home confinement. I was rapidly
convinced that no case could be classified as normal until the baby was
crying in the cot and the placenta was safely in the bucket. As a
consequence I initiated the Oxford GP Maternity Unit, at first situated
alongside the Churchill Hospital Consultant Obstetric unit but later fully
integrated into the John Radcliffe Hospital. I carefully audited results
from this unit for 25 years and, although all cases were selected on the
basis of low risk, some 30% required to be transferred to consultant care
during pregnancy and another 15% due to complications arising during
labour. Whilst we were able to offer a relaxed and supportive style of
care to individuals, we were situated physically so that complications
could be dealt with promptly due to the proximity of consultant staff and
equipment. I have no doubt that maternity care should now in all cases be
offered in such a situation.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
No |
3 October 2007 |
|
|
Ian A L Treharne,
Consultant Obstetrician
QE 2 hospital al74hq
Send response to journal:
Re: No
|
I agree with Prof. DRIFE, that there is no evidence to support
Midwifery led units.
Working in a unit where there is a proposed merger of two units 13 miles
apart I have reservations
If cases of major post partum
haemorrhage in home births have to travel extra
miles for treatment the outcome may not be as good as in cases in hospital. Safety of mother and baby
should come before financial restraints.
Competing interests:
Consultant Obstetrician |
| |
Is there enough evidence to judge midwife led units safe? Yes
Author's Response |
3 October 2007 |
|
|
Lesley Page,
Professor in Midwifery
King's College London SE19NH
Send response to journal:
Re: Author's Response
|
Dr Bury suggests that women should give birth in hospital in case
unpredictable complications such as post-partum haemorrhage occur. The
point that I made was that the focus on single indicators of safety has
taken our attention away from the real problems facing modern maternity
services. These include a steadily rising intervention rate (i.e.caesarean
section), and the failure of modern maternity services to close the gap in
both perinatal and maternal mortality rates between rich and poor, and
between different ethnic groups. Nearly a quarter of women in the UK are
delivered of their babies by caesarean section. This high caesarean
section rate is associated with significant morbidity for the mother, a
higher maternal mortality rate and an increased risk, including the risk
of stillbirth, in subsequent pregnancies. The intervention rate should not
be considered as a secondary outcome measure, it is a primary outcome
measure.
The conclusion that planned home birth is no less safe than hospital
birth for women without complications was based on the systematic review
and meta-analysis referenced in the article. The reviewed studies included
all outcomes of both groups including those women and babies who had been
transferred to hospital. The analysis revealed no statistical difference
in mortality between planned home and planned hospital birth: the
confidence interval was not compatible with extreme risks in any of the
groups (odds ratio (OR) =0.87, 95%confidence interval (CI)=0.54-1.41).
Furthermore there was a lower frequency of low Apgar scores (OR =0.55;
0.41-0.74) in the home birth group. The meta-analysis also showed that
fewer interventions occurred in the home birth group. (1). The lower
intervention rate may be one of the reasons to choose home birth. Of
course the evidence on home birth must be interpreted with caution. In the
absence of a large enough randomized controlled trial, despite the
matching of groups and controlling for confounding variables in
observational studies, there is a possibility of bias. The most likely
source of bias being that women who have elected to have their babies at
home are motivated to avoid interventions.
Women making the choice between home and hospital birth need to know
the risks and benefits of all settings, and of any uncertainty in the
evidence base. As Olsen commented ‘it cannot be claimed that planned
hospital birth is safe for all babies, nor can it be claimed that planned
home birth is safe for all babies’. (1) The National Institute for Health
and Clinical Excellence (NICE)guidelines for intrapartum care of healthy
women and their babies during childbirth state that ‘women should be
offered the choice of planning birth at home, in a midwife-led unit or in
an obstetric unit’. (2)
1. Olsen O. Meta-analysis of the safety of home birth. Birth 1997;
24:4-13.
2. National Collaborating Centre for Women’s Health.Intrapartum care
of healthy women and their babies during childbirth. [Nice Clinical
Guidelines]. London: RCOG Press; September 2007.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
midwifery led-units: choice and safety |
3 October 2007 |
|
|
Fatima A Husain,
Consultant Obstetrician & Gynaecologist
Heatherwood & Wexham Park Hospitals NHS Foundation Trust, SL2 4HL,
Phillip W. Reginald
Send response to journal:
Re: midwifery led-units: choice and safety
|
Dear Editor,
We read with interest the views of both authors and wish to make the
following points:-
Childbirth is not risk free. Although the process is a natural one,
it is not declared safe until the baby is delivered and the third stage is
complete. Risk categorisation of a pregnancy is possible, but
complications are usually unpredictable needing urgent attention. When
this happens in an isolated midwifery led unit (MLMU), transferring the
patient to hospital is the only option. Outcome is then variable and
depends on the nature of the complication and transfer facilities
available. Each patient intending to deliver in a MLMU should be given
explicit information emphasizing that this is the only option in the event
of a complication. This could reduce the number of deliveries in, and
question the viability of, isolated MLMUs.
Positive birth experience and safety are important but should not be
confused or allowed to compromise each other. Efforts must be made to
provide a positive experience in the safety of a hospital maternity unit
and possibly in an integrated MLMU.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Risk to babies with home delivery and midwife led units |
3 October 2007 |
|
|
Philip Murray,
Clinical Research Fellow
Endocrine Sciences Research Group, Core technology Facility, University of Manchester, M13 9NT
Send response to journal:
Re: Risk to babies with home delivery and midwife led units
|
To suggest that there is likely to be no increased risk to a baby
from a planned home/midwife centre delivery does not make sense. For those
developing signs of fetal distress they will have to be transferred to a
consultant led unit. This will inevitably add some time delay prior to
delivery and for a very small number of babies this time delay will be
significant leading to possible brain damage and death.
There will also be babies born unexpectandly flat. Although midwives
are well trained in neonatal resuscitaion their skills are not likely to
be as good as a middle grade paediatrician present in hospital.
I accept that the number of these babies is likely to be very small
and that there are high intervention rates in consultant led units but I
do feel that all mothes opting for home/midwife led units should be warned
of the likely increased risk to their babies.
These comments apply only to midwife led units not on the same site
as a consultant led unit.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Midwife led unit’s needs more evidence prior to independent practice |
2 October 2007 |
|
|
Chelliah R Selvasekar,
Specialist Registrar in Colorectal Surgery
Christie Hospital, Manchester M20 4BX
Send response to journal:
Re: Midwife led unit’s needs more evidence prior to independent practice
|
I read with interest the debate on midwife led obstetric care.1 There
is currently not much evidence for an independent midwife led unit.2 The
aim for this government initiative appears to reduce the cost which will
compromise quality.
I can comment from my personal experience when my wife was admitted
for childbirth in an NHS hospital where I was working and found an
appalling practice when my wife was in labour for nearly three days
without being seen by a consultant and managed by midwifes without much
continuity of care. Finally when my son was born he developed severe
sepsis which I believe is due to prolonged labour and was cared by
neonatologists at the local hospital and then transferred to a tertiary
unit, where it was a consultant led practice. I was able to appreciate the
difference in the care, the communication among the health professionals
and to the patients was exemplary in the consultant led set up compared to
the midwife practice. When I made an official complaint about the lack of
adequate obstetric care and lack of communication to improve the quality
of the midwife service at the local hospital, the explanation was
suboptimal and to my surprise I have noted similar traumatic experience in
other midwife led units since then from colleagues and friends.
Hence I think before the government introduces the midwife led service, it
should assess the available evidence and have an optimal safety plans to
ensure midwife care is adequate and not compromise the mother and baby. It
is not only important to know the positive side of the mid wife led
service, but we as the end users of healthcare should be aware of the
negative aspects, near misses, assess the way to prevent mishaps and avoid
the ego and tunnelled vision among the midwifes and encourage them to work
as a team, audit their work and be more open to ensure welfare of mother
and baby. At the end of the day we should understand that the obstetrician
has a global approach to patient care as they have gone through a standard
medical training whereas the midwife training is limited to a specialty
and their overall approach is minimal, hence need to be supervised by an
obstetrician for the welfare of the society.
Reference List
1. Page, L. Do we have enough evidence to judge midwife led
maternity units safe? BMJ 335, 642-643. 29-9-2007.
2. Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus
conventional institutional settings for birth. Cochrane Database Syst Rev
2005; CD000012.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
'From cradle to grave' |
2 October 2007 |
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Anna E Livingstone,
General practice principal
The Limehouse Practice Gill Street Health Centre London E14 8HQ
Send response to journal:
Re: 'From cradle to grave'
|
Yes, I agree, birthing centres and home are places of low risk for birth, for women for whom normal deliveries can be expected, and for their babies and I've followed the evidence and arguments across three decades. Here we see Page, midwife, female, with references discretely hidden on the web, pitted against Drife, male, obstetrician, with ostentatious confidence intervals bold on his pages 'not significant but significant'. The age old battle for control of women's bodies continues between midwives and surgeons. However the latter have to bear the responsibility of clinically unjustifiable rises in Caesarian rates,with concomitant maternal complications, and lower breast feeding rates, while in wealthier countries skills have been lost across the board in safely conducting vaginal deliveries that are in the least complex. If you want a safer vaginal breech delivery you need to go to a poor country.
But, what of the women ? They don't exist in isolation at a brief period of time spanning pregnancy and the puerperium, but as part of families and a local community, with other influences and aspects to their lives and health which knit in with the childbearing experience. It is shocking that Page doesn't mention general practice at all, and worse than that O'Drife seems to have know idea of the substantial role in maternity care played by many general practitioners and general practices. General practice, can and does bring together local people as patients and families, health visitors, GPs and receptionists who know them all and can identify and support through medical and psychosocial risks. We have been part of such a team in our practice since the early eighties and are not special in this. Local community based services where delivery support is part of ongoing care is what most of the women we see want, whether that delivery be at hospital or outside, and there is great interest in the soon to open birthing centre nearby.
Competing interests:
I am an NHS GP working in a practice antenatal clinic with midwives and health visitors |
| |
Is there enough evidence to judge midwife led units safe? Yes
Places of birth- Satisfaction or Safety? |
2 October 2007 |
|
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Bode Williams,
Consultant Obstetrician and Gynaecologist
Frimley Park Hospital NHS Trust, Surrey, GU16 7UJ
Send response to journal:
Re: Places of birth- Satisfaction or Safety?
|
I read with the interest the ongoing debate about the comparative
safety of different places of birth for ‘low-risk’ pregnancies. This is
based on the misleading notion that pregnant women can be divided into low
or high risk groups at the beginning of their pregnancies according to
prior history and offered appropriate level of care. Everyone knows that
risk assessment is a continuing and dynamic process throughout pregnancy
and childbirth. Regrettably, clinical risk scoring systems do not work
well in pregnancy. Hence, the vast majority of women who develop life-
threatening complications during labour and childbirth including shoulder
dystocia and postpartum haemorrhage are so-called ‘low-risk’ pregnancies.
The stark reality is that midwives and doctors cannot predict these
childbirth complications in advance in any individual pregnancy and
current obstetrics management is based on timely intervention when they
occur.
It seems that the real choice for pregnant women and their supporters is
to decide whether to take a chance hoping that nothing will happen and
give birth in the ‘plush home from home’ surroundings of the stand-alone
midwifery led units in the quest for satisfaction. The alternative is to
choose ‘well-resourced’ hospital labour wards with proven safety track
records in dealing with relatively uncommon but life threatening
childbirth complications.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Place of Birth |
2 October 2007 |
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Melvyn F Docker,
Retired Medical Physicist
ex B'ham Women's Hospital B15
Send response to journal:
Re: Place of Birth
|
Is there enough evidence to judge the safety of midwife led units? I
believe that the birth experience is probably better in these. BUT the
safety of mother and child must of greater importance. The midwife led
unit must be a small one attached to a hospital with full obstetric and
theatre facilities! Melvyn Docker
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
NO, midwifery-led care is a risky business. |
1 October 2007 |
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Olakunle Fajemirokun-Odudeyi,
SPR Gynaecological Oncology Leeds
St James's University Hospital Leeds LS9 7TF
Send response to journal:
Re: NO, midwifery-led care is a risky business.
|
There is no evidence that midwifery-led care is safer compared to
consultant-led care and it can in fact have negative impacts on birthing
experience.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Damaged babies |
30 September 2007 |
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Lydia M Stevens,
GP
TW8 8DS
Send response to journal:
Re: Damaged babies
|
The articles are short on details regarding perinatal morbidity
rather than mortality, which I'm sure reflects the lack of evidence.
A case that sticks in my mind from my training was that of a transfer from a midwifery unit some miles away. This child of a "low
risk" mother was unexpectedly born "flat." Apparently, there had been no attempt at resuscitation until 20 minutes after birth, when the only anaesthetist in the hospital arrived, having
previously been in theatre with a patient he couldn't leave.
My understanding is that midwives who only work in low risk units get very
little practice in resuscitation, its not the same on a dummy how ever
often their "skills" are updated, because nearly all their babies are born
screaming. Perinatal mortality is a tragedy but brain damaged babies who
could potentially have been saved by timely paediatrician is even more so,
and a huge cost in litigation and lifetime care of a quadraplegic child
with severe cerebral palsy (as resulted in this case). Every baby is
essentially "untested" until born so even "low risk deliveries" sometimes
result in unexpectedly sick infants that need expert care immediately.
By all means let women come in last minute and go home very soon, but for
the unexpected calamity I am sure where I would want to be.
Whatever happened to "Domino" deliveries where community midwives helped
the labour at home, came in with the mother for the last phase, and quick
discharge if all well. Most women were in only 6 hours - perfect
compromise?
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Safety and Quality of care really matter |
30 September 2007 |
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Sally K Tracy,
Professor Women's Health and Midwifery
University of Technology, Sydney, NSW, AUSTRALIA
Send response to journal:
Re: Safety and Quality of care really matter
|
“Head to Head” this week clearly illustrates the chasm that continues
to divide maternity service policy both in the UK and elsewhere. Page
correctly identifies that the problem lies in ‘the move to have all women
give birth in hospital’ as ‘one of the biggest uncontrolled medical and
social experiments of the 20th century’. Drife, on the other hand makes
claims that a confidence interval that is ‘only just’ not significant is
relevant in the discussion about evidence. (Hopefully the rationale to
accept or reject research guiding the newly announced NICE guidelines for
intrapartum care was not based on similar opinion!) Clearly the
opportunity was missed to judge the effectiveness of hospital birth before
all women were advised it was the safest place; however there are
important quality signals which we should not continue to ignore. These
include for example the amount of pain and suffering associated with
increased surgical intervention in birth. Maternal mortality has not
improved with rising rates of caesarean section and the increased
incidence of life saving hysterectomy following catastrophic post partum
haemorrhages is alarming. Every professional concerned with the health of
mothers and infants should be eager to find solutions to improve these
events.
Drife’s claim that ‘safety is never absolute’ signals an opportunity to
centre practice changes on sound principles of risk management combined
with simultaneous and continuous evaluation of processes of care. Adhering
to processes of clinical improvement alongside the introduction of birth
centres and midwifery group practices should guarantee the safest possible
future maternity care. Advising a woman on the safety of birth in hospital
or at home relies on so many more aspects than we have been prepared to
acknowledge previously. As Page asserts the domination of a medical view
of birth and sole reliance on perinatal mortality measures has blinded us
to other equally important factors that drive safety in maternity care.
Competing interests:
None declared |
| |
Is there enough evidence to judge midwife led units safe? Yes
Single measure of safety |
30 September 2007 |
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A Sajayan,
Anaesthetist
Hertfordshire
Send response to journal:
Re: Single measure of safety
|
The argument that Prof.Page give in favour of midwife lead centres in
my opinion is just a reflection of the age old frustration among the
midwives against the 'intervening' doctors(includes obstetricians and
anaesthetists).
She complaints that all the discussions are centred around a single
measure of saftey ie,perinatal mortality.Which is the most important end
point in a stressful process like pregnancy other than being rewarded with
a healthy baby?So it is quite understandable and acceptable that the whole
process will be discussed on this outcome and how to make that safer.
In her article the doctors are pictured as the monsters who interfere
unnencessarily in a natural process waiting for an opportunity to pull the
patient in to the theatre for a caesarean section.
The cat comes out of the bag in the sentence ''midwifery had been
taken from its community base ...and lost its professional autonomy and
influence''.I think this fear of losing influence is a basic problem with
most if not all midwives and that reflect in their attitude towards
doctors.
While she rightly suggest that we need both approaches in balance,her
definition of the roles of midwives and obstetricians and the lack of
positive experience and personal approach in the latter group lacks
quality evidence,just like the cochrane studies she quoted.
As an anaesthetist who has seen many 'straightforward' pregancies
ending up in major complications without much notice,I believe a lot needs
to be done in terms of infrastucture like transportation,obstetric unit
availabilty at reasonable distance,patient screening
mechanisms,understanding of limitations and above all a mutual respect
between the two (three including us anaesthetists)professions to make the
outcome of the whole exercise better.
Given a choice between a holistic,total apporoach with no guarantee
of timely 'intervention' and a so called 'fragmented' care with a
guaranteed intervention if needed,I know which one I will choose.
Competing interests:
None declared |
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VIEWS & REVIEWS:
MTAS or a tale of evidence heedless medicine
Nachev (22 September 2007)
[Full text]
[PDF]
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MTAS or a tale of evidence heedless medicine
Selection methodology: more fiction than fact, and a worrying future |
12 October 2007 |
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A Thomson,
Doctor
London
Send response to journal:
Re: Selection methodology: more fiction than fact, and a worrying future
|
Although Prof Patterson claims that "there is over a century’s
literature on selection methodologies," it is disappointing that 7 out of
8 of her references are self-citations.
Prof Patterson fails to address the question "why change?" other than
stating that the reasons for change rested on the potentially flawed
belief that doctors should be forced to choose a speciality with no prior
relevant experience. She neither questions nor attempts to justify the
validity of such a significant assumption - how can she then justify any
process which is based on it?
Her account of the development process, if true, is very worrying -
although she attempts to distance herself from the disaster, she does
admit her involvement, with the admission that selection forms
for entry above ST1 were hastily cobbled together "from existing
application forms", that there is no evidence of their validity outside of
GP selection.
Prof Patterson was aware of the flaws, and could have used her
authority as an expert in selection methodology to halt this sorry process
which wasted so much time. She could have objected, refused to allow her
work to be implemented in this way and firmly recommended continuing with
current selection procedures. Why did she do none of these things? Why did she press
ahead with an enormous human experiment for which no ethical approval had
been sought or granted, and to which the subjects had not consented. Her
reply addresses none of these questions, and I find it rather sinister
that she is already looking to the future without attempting to learn from
the terrible mistakes in her recent past.
Competing interests:
Dr Thomson was one of the thousands of UK doctors who were sacked and made to reapply for their own jobs using flawed selection methods which Prof Patterson and the Work Psychology Partnership helped to develop. |
| |
MTAS or a tale of evidence heedless medicine
Unsatisfactory response by Ms Patterson |
12 October 2007 |
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Peter von Kaehne,
General Practitioner
Scotland
Send response to journal:
Re: Unsatisfactory response by Ms Patterson
|
Although there is over a century’s literature on selection methodologies, [...]
This could suggest that there are heaps and heaps of data available on the subject, that Ms Patterson's role was only one of sifting the abundant and overwhelming evidence and that the medical profession was grossly negligent in its previous blatant disregard of good science on the subject.
And yet, all but one quote in Ms Patterson's response appear to be self references.
What does this tell us?
While I am in no position to judge even remotely how close and how responsible Ms Patterson's outfit was, the response by Ms Patterson leaves me in little doubt that she was too close and had too much responsibility.
So, please leave us alone with your suggestion that you share the anger of the profession. Chances are, that you are a perfectly valid target for the anger of the profession. Your letter at least does not reassure me on that account.
Competing interests:
None declared |
| |
MTAS or a tale of evidence heedless medicine
No defence |
11 October 2007 |
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ben dean,
sho
oxford
Send response to journal:
Re: No defence
|
Fiona Patterson is clearly attempting to distance herself from the
complete and utter failure of MTAS 2007 with her above response that lists
many references that are used as so called 'evidence'. The process that
she had a large part in creating and forcing upon us was certainly not
suitable for the selection of any trainees; irrespective of whether they
were Foundation trainees, ST1s, ST9s or monkeys. I have not managed to
find a single Foundation trainee who thinks that their selection process
over recent years has been anything other than a load of politically
correct hogwash.
The MTAS process and the use of white space questions were proven
beyond any doubt to be rubbish of the highest order, and certainly not fit
for use in any selection process. If Prof Patterson wants evidence, then
I think the year 2007 provides an overwhelming quantity of evidence that
should should force her to go back to the proverbial drawing board before
inflicting any more of this upon unsuspecting juniors.
Undoubtedly Prof Patterson was only one of many of a dysfunctional
heirarchy that was to blame, however she is a little naive if she thinks
that she can talk her way out of any responsibility so easily. The future
is indeed challenging and this is because so many people including Prof
Patterson did so much to create a completely useless selection process
last year. I suggest if this argument becomes about evidence, then the
events of 2007 can provide more concrete evidence than any number of
psychoeducationalist trials.
Competing interests:
None declared |
| |
MTAS or a tale of evidence heedless medicine
Evidence heedless medicine |
11 October 2007 |
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John Sanderson,
Professor of Clinical Cardiology
B16 8AH
Send response to journal:
Re: Evidence heedless medicine
|
Belatedly I have just read Dr Nachev's brilliant analysis of the
failure of MTAS. The lack of any experimental evidence is typical of most
social or health economics policy. The contrast between the introduction
of a new medicine and a new administrative 'therapy' or reorganization
could not be greater. It appears that major NHS changes are introduced
based on no-more than anecdotal evidence which would not be tolerated in the
realm of medical therapeutics. Why are not the same standards applied and
a proper controlled trial done of some of the proposed changes? It is not
too difficult to envisage two differing policies being tested in two
health care regions and the results tested after 5 years like in a
clinical trial. The RCT has been one of the greatest steps in medicine and
as we all know the results of a large clinical trial are often the exact
opposite of the expected, obvious or 'logical' conclusion. Massive social
and administrative changes are often introduced on a whim and a feeling
that it must be right. The same mistakes are about to be made by Darzi and
his collegues in the government with respect to general practice and
polyclinics. No doubt millions of pounds more will be wasted on major
stuctural changes with zero evidence of any actual benefit.
Competing interests:
None declared |
| |
MTAS or a tale of evidence heedless medicine
Re: Selection methodology; fact, fiction and the future |
11 October 2007 |
|
|
Alison L Gill,
ST2 Medicine
Harrogate District HospitalHG2
Send response to journal:
Re: Re: Selection methodology; fact, fiction and the future
|
Ms Patterson's points would be far more credible were it not for the
fact that seven of her eight references were self-citations!
She accepts that pre-existing "selection practices in medicine have
been effective", and that few "understand what a clinician does on a daily
basis". What qualifications then does she have to make such
recommendations and changes to medical selection and training?
She reports having "learned more from collaborating with the medical
profession than from any other" - so why during this shambolic recruitment
system, did she not think it necessary to consult with exactly those
people that were to be affected by the changes?
Competing interests:
MTAS applicant, four interviews, offered two posts, only to find months down the line that I should have been offered all four but due to a "system error" I was listed as having accepted an offer before I was even made aware of it! |
| |
MTAS or a tale of evidence heedless medicine
Re: Selection methodology; fact, fiction and the future |
11 October 2007 |
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Matthew J Daniels,
FTSTA ST2 CMT
Addenbrookes Hospital, CB2 0QQ
Send response to journal:
Re: Re: Selection methodology; fact, fiction and the future
|
In Professor Patterson statement is clear that her expectations for
the process and the reality of its implementation were quite at odds.
Why then has it taken until October 2007 for these concerns to be
voiced?
I recall one of the white box questions in the probity section -
"Give a specific example of a time when you became aware that a clinical
mistake had been made, either by you or someone else. How did you deal
with this situation and how did your actions contribute to the outcome?"
As the Fidelio group have already reminded us; "All that is necessary
for the triumph of evil is that good men do nothing."1.
1 Brown M et al The Lancet 2007; 369:967-968
Competing interests:
Dr in training disillusioned by the whole process |
| |
MTAS or a tale of evidence heedless medicine
Re: MTAS or a tale of evidence heedless medicine |
11 October 2007 |
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Alison S Carr,
Deputy Postgraduate Dean, NHS Education South West (Peninsula Institute)
Plymouth PL6 8DH
Send response to journal:
Re: Re: MTAS or a tale of evidence heedless medicine
|
Dear Editor
I would like to correct some of the details that have been cited by
Dr Nachev
on the development of resources for recruitment and selection into
specialty
training in 2007. The author suggests that the criteria and procedure for
selection in MTAS were principally designed by a handful of organisational
Psychologists from Work Psychology Partnership and that the selection
methods developed have never been used to select specialist trainees.
Neither of these suggestions are correct.
Professor Fiona Patterson and her colleagues from Work Psychology
Partnership have worked alongside the medical profession for over 12 years
in helping develop recruitment and selection methodology for recruiting
specialist trainees such as General Practitioners, Obstetricians,
Paediatricians,
and Surgeons. This team specialise in recruitment and selection
methodology and have applied their knowledge base to medicine in liaison
with specialists from the medical specialties. Work Psychology
Partnership
have worked with GPs for over ten years in developing the recruitment and
selection processes used successfully for recruitment into general
practice
training. In addition, for several years they have worked developing and
evaluating recruitment and selection pilots into surgery with the Royal
College of Surgeons. In fact almost all of the research published on
recruitment and selection into medical training has been published with
Professor Fiona Patterson as one of the authors.
In this article, Dr Nachev remarks that every slide of the material
prepared for
the Department of Health he had seen was emblazoned with Work Psychology
Partnership logo (www.mmc360.com/documents/
recruitment_to_specialist_training.pdf). In fact most of these slides
were
designed by myself in my role as Honorary Associate Dean for the National
Recruitment and Selection Project 2007. In this role, I was one of three
doctors who accompanied the methodology team on Deanery roadshows
around the United Kingdom providing information for Deanery staff and
trainers on the processes of recruitment and selection into specialty
training
proposed for 2007.
In addition, it must be stressed that the medical input to the
recruitment and
selection process was provided by doctors and that processes used were
introduced with consultation of the Royal Colleges, Work Psychology
Partnership acting as Consultants in recruitment and selection
methodology.
The criteria for recruitment and selection into Specialty Training, from
which
the methodology was developed, were those as laid down by the PMETB
(http://www.pmetb.org.uk/index.php?id=456).
Competing interests:
None declared |
| |
MTAS or a tale of evidence heedless medicine
More light less heat |
11 October 2007 |
|
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Frank R Smith,
Primary Care Taskforce Lead
South Central SHA Highcroft Winchester SO22 5DH
Send response to journal:
Re: More light less heat
|
The BMJ of the 22nd September has a number of pieces on medical training.
The Editor has 'pondered the BMJ's coverage' but she should re-assess her sanctioning of Nachev's personal view as completely counter-productive to the debate, despite its tabloid appeal in playing to the masses of (deservedly)unhappy junior doctors.
Selection science is not an oxymoron, and whilst longitudinal studies still need to be done, there is evidence building of the utility of different selection methods compared to the traditional CV and interview.
The Tooke analysis of the events of 2007 is likely to identify some key learning points. The BMJ should aim for more light but not heat in this debate.
Competing interests:
Have worked on developing selection for GP with Professor Patterson |
| |
MTAS or a tale of evidence heedless medicine
Selection methodology; fact, fiction and the future |
4 October 2007 |
|
|
Fiona Patterson,
Professor of Organisational Psychology and Partner Work Psychology Partnership
City University, London. EC1V 0HB
Send response to journal:
Re: Selection methodology; fact, fiction and the future
|
This response has been amended on legal advice.
Although there is over a century’s literature on selection
methodologies, rarely has any process provoked such fierce debate as MTAS.
The problems surrounding selection methodology are multi-
faceted and multi-dimensional, well beyond disregarding CVs, relying on
‘white space’ questions and poor IT delivery.
For the distress caused, I share the anger of the profession. The inquiry
led by Sir John Tooke details the facts about our role in the process
(http://www.mmcinquiry.org.uk). Here, I highlight critical issues to
encourage close scrutiny of facts surrounding principles, methodology and
context underlying MTAS, so there is learning for the future.
Clearly, in the past, selection practices in medicine have been effective.
Although few would deny there is scope for improvement, the CV and
interview process has generally worked well. So why change? MTAS was
devised alongside the MMC programme introduced by the Department of
Health, where the fundamental principles underpinning gateways to
progression were changed overnight. Consequently this changed the rules
governing selection. Traditionally, medicine has relied on robust CV
indicators of attainment such as work experience and College exams for
selection decisions. The MMC pathway relied on the belief that doctors
could be selected to specialities without any prior experience in that
specialty. The selection methodology in MTAS was designed for ST1, not for
thousands of doctors already working in specialties. Under MMC principles
and in compliance with PMETB (http://www.pmetb.org.uk/index.php?id=456),
we were advised that work experience and exams could not be scored, or
used to rank applicants. The introduction of run-through ST1 posts was
new.
I have worked on selection methodology in medicine for over 12 years. This
work informed selection centre development and the introduction of new
shortlisting tests in General Practice (GP) 1-3. In 2007, all deaneries
worked together through a GP national office, where thousands of doctors
are successfully appointed using this process 4. Since 2002, in
partnership with doctors we developed selection methodology for many
secondary care specialties 5-7 and for graduate entry into medical school
8. Although commonality exists across all specialities and levels,
selection criteria for each are distinct, with evidence supporting
different priorities between specialties.
Having completed this work, in 2004, I was invited to meet the MMC team to
advise on selection methodology into specialty training. I recommended
developing a national test for shortlisting (supported by early evidence
from GP) and validated selection centres with full College involvement and
large-scale consultation. Following this meeting, I received no further
correspondence from the MMC team and no pilots were put in place.
In May 2006, we won an open competition tender organised by the Department
of Health. Our work included advising on selection methodology for
Foundation programmes and the GP selection process. For specialty
selection, the scope of work states; “The number of applicants expected to
apply for entry into Specialty Training is approximately 6,000 and that
applications will be via a single electronic national portal entry system
(separate project) the working assumption for the closing date will be 5th
January 2007.” At the outset we were asked to advise on selection
methodology for ST1. We were not asked to deliver selection methodology
for doctors in ‘transition’ via ST2, ST3, ST4 and FTSTAs, nor academic
posts. We believed these arrangements would be delivered via local
processes.
The rules and parameters governing MTAS were defined by MMC, based on
PMETB principles and via the COPMeD steering group, represented all
stakeholders. Given the time scale (less than 16 weeks) there was no
option but to use materials from existing application forms used (over
several years) for entry into specialist training. By contrast, in
collaboration with the GP national office, my team designed the
shortlisting test with GPs, which has shown to work well.
For the future, the GP model has been identified as best practice.
However, this model cannot be transferred into all specialties. Medicine
is a broad discipline and secondary care is significantly different
requiring bespoke selection methodologies. There is added complexity due
to different selection ratios for both specialties and locations. ‘One
size’ cannot fit all. Some believe selection practices in other
professions can be readily transferred but medicine, in the UK, is truly
unique. For those deciding policy, few understand what a clinician does on
a daily basis. A significant challenge is to translate the needs of the
profession to policy makers.
I have advised on selection methodology in all sectors. In the past 12
years I have learned more from collaborating with the medical profession
than from any other. Unlike selection approaches used by some
organisations, I applaud the focus on psychometric scrutiny, the need for
validatory evidence and the demand to treat human beings with respect and
dignity in the process. The fact is, MTAS was not designed by
psychologists. Without a full understanding of the issues, we cannot hope
to navigate the future, which looks yet more challenging.
References
1. Patterson F, Ferguson E, Lane PW, Farrell K, Martlew J, Wells AA.
Competency model for general practice: implications for selection,
training and development. Br J Gen Pract 2000;50:188-93.
2. Patterson, F., Lane, P., Ferguson, E. & Norfolk, T. A competency
based selection system for GP trainees. BMJ 2001 323, 2.
3. Patterson F, Ferguson E, Norfolk T, Lane P. A new selection system to
recruit general practice registrars: Preliminary findings from a
validation study. BMJ 2005;330:711-4.
4. Plint, S., Gregory, S., Evans, G. (2007). Recruitment to GP specialty
training 2007. BMJ Career Focus 335: gp73-gp75
5. Randall R, Davies H, Patterson F, Farrell K. Selecting doctors for
postgraduate training in paediatrics using a competency based assessment
centre. Arch Dis Child 2006; 91:444-8.
6. Randall R, Stewart P, Farrell K, Patterson F. Using an assessment
centre to select doctors for postgraduate training in obstetrics and
gynaecology. The Ostetrician and Gynaecologist 2006;8:257-62.
7. Rowley D, Patterson F. The right choice: A pilot selection centre to
improve selection of future surgeons. Surgeons News, October 2007.
8. Kidd J, Fuller J, Patterson F, Carter Y. Selection Centres: Initial
description of a collaborative pilot project. Proceedings for the
Association for Medical Education in Europe (AMEE) Conference, September
2006, Genoa Italy.
Competing interests:
I am a Partner in the Work Psychology Partnership who were awarded a contract by the Department of Health to advise in selection methodology in June 2006. We were investigated for competing interests for earlier publications but no accusation was upheld, including that from the BMJ. |
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EDITORIALS:
Chronic fatigue syndrome or myalgic encephalomyelitis
White et al. (1 September 2007)
[Full text]
[PDF]
|
Chronic fatigue syndrome or myalgic encephalomyelitis
Miscommunications and Misunderstandings |
5 October 2007 |
|
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Douglas T Fraser,
n/a
London W6
Send response to journal:
Re: Miscommunications and Misunderstandings
|
Professor Peter White of St Bartholomew's Hospital rightly points out
that "the history of this field has been littered with miscommunications
and misunderstandings".
Professor Stephen Stansfeld of St Bartholomew's Hospital communicated
in 2004 that (1):
"The interface between physical and mental illness (is) typified by
Chronic Fatigue Syndrome. On the interface between physical and mental
illness, research continues into chronic fatigue syndrome and the
development of
treatment trials led by Dr Peter White".
Professor John Garrow, a consultant physician at St Bartholomew's
Hospital, communicated in 2005 that (2) "the most valuable message I
gained from the second session was the observation by Professor Peter
White (Psychological
Medicine, St Bartholomew's Hospital) that patients with chronic fatigue
syndrome (CFS, or ME) have a worse prognosis if the diagnosis they are
given is ME than if it is CFS. He concludes that chronic fatigue implies a
physiological state that the patient may overcome by suitable exercises,
whereas ME implies a viral disease of the brain and muscles over which the
patient has no control."
In their 2007 public communication from the St Bartholomew's Hospital
Chronic Fatigue Syndrome/ ME Service website, there is an article
entitled: 'Expectations for Outcome' (3).
After removing some slightly extraneous material for the sake of
clarity, it basically communicates that:
"We have found that three-quarters of our patients with CFS/ME
significantly improve or recover with treatment in our clinic; research
has suggested that a quarter recover their health and a further half
significantly improve. Some of those who recover don't actually recover,
some don't even improve, and some should go elsewhere".
In 2007 Jason and Brown stated that (4): "Relatively few patients
with CFS completely recover from the illness, with a recovery rate of 0-6%
and increased disability in 10-20% of patients over time", while the CDC
state
(5) : "Improvement rates varied from 8% to 63% in a 2005 review of
published studies, with a median of 40% of patients improving during
follow-up. However, full recovery from CFS may be rare, with an average of
only 5% to 10% sustaining total remission".
Assuming that the Jason, Brown and CDC figures are not unreasonable,
the St Bartholomew's Hospital Chronic Fatigue Syndrome/ ME Service website
communication should perhaps then read:
"We have found that three-quarters of our patients with CFS/ME
significantly improve or recover with treatment in our clinic; research
has suggested that very few recover, some improve and a significant number
get worse. Whilst in
our service, some of those who recover don't actually recover, some don't
even improve, and some should just go elsewhere".
Chia and Chia found that (6) "Enterovirus VP1, RNA and non-cytopathic
viruses were detected in the stomach biopsy specimens of CFS patients with
chronic abdominal complaints. A significant subset of CFS patients may
have
a chronic, disseminated, non-cytolytic form of enteroviral infection,
which could be diagnosed by stomach biopsy".
Dr Jonathan Kerr commented that (7) "the role of enterovirus
infection as a trigger and perpetuating factor in CFS/ME has been
recognized for decades...however, several negative studies combined with
the rise of the
psychiatric 'biopsychosocial model' of CFS/ME have led to a diminished
interest in this area...the importance of gastrointestinal symptoms in
CFS/ME and the known ability of enteroviruses to cause gastrointestinal
infections, led John and Andrew Chia to study the role of enterovirus
infection in the stomach of CFS/ME patients...these intriguing data for
which there is ample supporting data strongly suggest a new and hitherto
unrecognized disease mechanism in CFS/ME patients, which in my opinion,
could trigger and perpetuate this disease...The role of EV infection of
the stomach in the pathogenesis of irritable
bowel syndrome also needs to be clarified in light of these results."
Referring to the 'biopsychosocial model' which has distracted
scientific research and funding into the disease, PACE trialist and
Professor of Cognitive Behavioural Therpay Trudie Chalder insightfully
communicated that (8):
"It is theoretical and it doesn't lead us anywhere".
More precisely, the psychiatrist Dr Niall McLaren wrote (9):
"In practice, if we want to know whether Engel's biopsychosocial
model is truly a model, or just a case of wishful thinking, then a simple
test will decide the
issue. Try making, say, a prediction about a man's psychological state
from his biological data, or vice versa. Or perhaps try to predict wholly
from sociological data which girls will develop post-partum mental
disorders as young women or psychoses in old age. Since nothing like this
can be done, Engel's 'model' is not a model in any interesting sense of
the term" and (10): "In a word, the officially-endorsed biopsychosocial
model is pure humbug, i.e. (some)thing that tricks or deceives; nonsense,
rubbish, just because it does not exist."
Hopefully, the recent advent of the internet (11) should help clear
up any "miscommunications" and "misunderstandings".
Douglas T Fraser
(1) Department of Psychiatry, Barts and the London UK
http://tinyurl.com/2ac2zl
(2) http://www.healthwatch-uk.org/newsletterarchive/nlett58.htm
(3) http://www.bartscfsme.org/expectations.htm St Bartholomew's
Hospital Chronic Fatigue Syndrome/ ME Service: ('view source' - "Chronic
fatigue syndrome, ME, London, St Bartholomew's Hospital, CBT, Peter
White") - "Expectations for Outcome - We have found that three-quarters of
our patients with CFS/ME significantly improve or recover with treatment
in our clinic; research has suggested that a quarter recover their health
and a further half significantly improve. For some people recovery may
not necessarily mean a return to their previous lifestyle, if this
contributed to them becoming ill in the first place. Some patients may not
improve whilst in our service, but we would expect to help them to cope
better with their illness and manage symptoms more effectively. Some
patients may find other approaches to managing their ill health more
helpful than those we provide here".
(4) Functioning in individuals with chronic fatigue syndrome:
increased impairment with co-occurring multiple chemical sensitivity and
fibromyalgia Molly M Brown and Leonard A Jason Department of Psychology,
DePaul
University, Center for Community Research, Chicago, IL, USA Dynamic
Medicine
2007 http://www.dynamic-med.com/content/6/1/6
(5) http://www.cdc.gov/cfs/cfsbasicfacts.htm
(6) http://press.psprings.co.uk/jcp/september/cp50054.pdf Chronic
Fatigue Syndrome is associated with chronic enterovirus infection of the
stomach -Journal of Clinical Pathology Sept 13 2007
(7) Enterovirus infection of the stomach in Chronic Fatigue Syndrome
/ Myalgic Encephalomyelitis (CFS/ME) Jonathan R Kerr St George's
University of London J Clin Pathol.14 September
2007.http://jcp.bmj.com/cgi/content/abstract/jcp.2007.051342v1
(8) Page 15 - "Biopsychosocial Medicine An integrated approach to
understanding illness" Edited by Peter White, Department of Psychological
Medicine, St Bartholomew's Hospital, London, UK April 2005 OUP
(9) www.futurepsychiatry.com/rev_thesis/Rev%20Chapter%207.doc
(10)McLaren N. The biopsychosocial model and scientific fraud. Paper
presented to annual congress, RANZCP, Christchurch May 2004 available from
the author at jockmcl@octa4.net.au
(11) http://en.wikipedia.org/wiki/Internet#Growth
Competing interests:
None declared |
| |
Chronic fatigue syndrome or myalgic encephalomyelitis
ME as an inclusion of CFS |
3 October 2007 |
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Les O SIMPSON,
retired experimental pathologist
Dunedin, New Zealand 9077
Send response to journal:
Re: ME as an inclusion of CFS
|
None of the many spirited responses to the White et al editorial have
drawn attention to the urgent need to dissect ME from the all-embracing
concept of CFS.
It seems incomprehensible that there has been a multiplicity of guidelines
produced for the management of a disorder for which there is no accepted
aetiology or pathophysiology. Possibly, to a major extent, this simply
reflects the rejection of earlier concepts.
In the second edition of his book, Ramsay noted that the clinical identity
of the ME syndrome was based upon three distinct features.
"1. A unique form of muscle fatigability whereby even after a minor
degree of physical effort. three, four or five days, or longer, may elapse
before full muscle power is restored. (NB. Strenuous activity changes the
shape populations of red cells in both healthy and unwell subjects.)
2. Variability and fluctuations of both symptoms and physical findings
in the course of a day. (A blood sample taken during remission showed
normal features, but six hours later, after a relapse a blood sample was
grossly abnormal.)
3. An alarming tendency to become chronic.
Ramsay discussed the clinical features of ME under three headings.
1. Muscle phenomena. He noted, "...it is important to stress the fact
that cases of mild or even moderate severity may have normal muscle power
in a remission."
(NB It is rare for remissions to be mentioned let alone discussed and no
guideline provides an explanation of their happening. A short paper
titled, "The implications of remissions in ME," was quickly rejected by
the BMJ.)
2. Circulatory impairment. This was manifested as cold extremities and
facial pallor.
3. Cerebral dysfunction. The cardinal features were the impairment of
memory and the power of concentration, plus emotional lability.
It seems strange that Ramsay did not consider that the cerebral and muscle
dysfunction might be related causally to the circulatory impairment, as it
seems that this could be the key factor in the pathophysiology of ME. A
major problem relating to acceptance is that the problems concern altered
blood rheology - and blood rheology is not taught in medical schools.
My work indicates that ME is a dysfunctional state resulting from
inadequate rates of delivery of oxygen and nutrient substrates, due to
impaired capillary blood flow, to maintain normal tissue function. Some
of the background to this claim is summarised below.
In 1986 we reported that ME blood filtered poorly (1) and in the following
year reported similar findings with regard to MS blood. In addition MS
blood viscosity was increased and changed red cell shapes were observed by
scanning electron microscopy.(2) A study which showed that the red cells
of healthy animals and humans could be classified into six different shape
classes (3) was followed by a report that ME blood contained high levels
of cup forms, which would help to understand the poor filterability of ME
blood.(4) The results from a further 99 cases were presented at the
Cambridge Symposium in 1990. In 1992, New Jersey Medicine published an
article relating to idiopathic chronic fatigue in which I pointed out that
individuals who by chance had smaller than usual capillaries would be at
risk of developing chronic sickness after exposure to an agent which
changed the shape populations of red cells.(5)
The implications for ME were discussed in a 1997, invited paper titled,
"Myalgic encephalomyelitis (ME):a haemorheological disorder manifested as
impaired capillary blood flow."(6) In 2001 we reported the results from
red cell shape analysis of more than 2100 blood samples from members of ME
groups in four countries.(7)
It should be noted that SPECT scans show the expected effects of shape-
changed, poorly deformable red cells in reducing cerebral blood flow in
regions which by chance have smaller than usual capillaries.
It has been reported that SPECT scans in three different psychiatric
disorders showed reduced blood flow in different regions of the brain, so
it could be expected for psychological/psychiatric problems to emerge in
some ME people as a part of their dysfunctional state.
References.
1.Simpson LO et al. Pathology 1986;18:190-2.
2.Simpson LO et al. Pathology 1987;19: 51-5.
3.Simpson LO. Br J Haematol 1989;73:561-4.
4.Simpson LO. NZ Med J 1989;102:106-7.
5.Simpson LO. NJ Med 1992;89:211-6.
6.Simpson LO. J Orthomol Med 1997;12:69-76.
7.Simpson LO et al.J Orthomol Med 1997;12:221-6.
Competing interests:
None declared |
| |
Chronic fatigue syndrome or myalgic encephalomyelitis
PSYCHIATRISTS SAY: CBT for ME does NOT work |
2 October 2007 |
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Tessa Vinicius,
GP
Amsterdam, Netherlands
Send response to journal:
Re: PSYCHIATRISTS SAY: CBT for ME does NOT work
|
NICE says CBT works for ME, and they say that is evidence based.
Apart from that many patients have been saying that it doesn't work, there
have also been many psychiatrists who have done the same. Dr Stein from
Canada has been mentioned, but in a recent article in The World Journal of
Biological Psychiatry, April 2007, Dr Sanders and Dr Korf, from a
psychiatric department in Groningen, The Netherlands, reported the
following: "The psychiatric and psychosocial hypothesis DENIES the
existence of CFS as a disease entity." Now this reminds me very much of
the NICE guidelines; who don't even mention the WHO listing of ME as a
neurological illness. But please read on, because these psychiatrists have
a lot more interesting things to say: "In CFS cognitive behavioural
therapy is most commonly used. This therapy, however, appears to be
INEFFECTIVE in many patients. The suggested causes of CFS and the
divergent reactions to therapy may be explained by the LACK of recognition
of subgroups. IDENTIFICATION of subtypes may lead to MORE EFFECTIVE
therapeutic interventions." I have put these words in capitals, so it is
easier to read, and as this appeared in April, NICE should have known
about it.
I would think that the best way forward, would be a radical revision
of the NICE ME guidelines, and to do what the Canadians did, and what
these psychiatrists have now advised to do as well. Separate ME from other
illnesses with fatigue, so you can offer those others proper treatment,
and you can start looking for a cause and hopefully a cure for ME.
Competing interests:
None declared |
| |
Chronic fatigue syndrome or myalgic encephalomyelitis
Actometers or pedometers should be used in rehabilitation studies in the field to check whether the interventions are actually leading to (substantial) increases in activity levels |
30 September 2007 |
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Tom Kindlon,
Unavailable for work due to ill-health
Dublin, Rep. of Ireland
Send response to journal:
Re: Actometers or pedometers should be used in rehabilitation studies in the field to check whether the interventions are actually leading to (substantial) increases in activity levels
|
The authors make reference to the PACE trial [1], a major trial in
the area. It seems particularly curious that this trial will use
actigraphy watches before the patients start the trial, but will not use
them again on the patients during or at the end of the trial. This would
give information on whether the patients are increasing their total
activity levels or simply doing the activity that is part of the trial in
the place of other activity they used to do, but which they have cut down
on or cut out altogether.
This is important given previous studies in the area. For example,
one study [2] "using a 26-session graded activity intervention involved
gradual increases in physical activity" found that "from baseline to
treatment termination, the patient’s self-reported increase in walk time
from 0 to 155 min a week contrasted with a surprising 10.6% decrease in
mean weekly step counts."
Another study [3], investigating CBT this time, is regularly quoted
as having showing the effectiveness of CBT for CFS. However if one
examines the actometer data from this study from the group given CBT, the
increases in activity were minimal [4]. For instance, the baseline average
was 67.9, which increased to 68.8 after treatment and to 72.2 at follow-
up. Approximately 4 points. Not unlike the medical care controls, who went
from 64.9 to 68.7 in the same period.
Given the costliness of the trial - over £3m (of UK taxpayers' money)
- it is disappointing that the PACE Trial is not using objective outcome
measures which were previously recommended in a review of CFS
interventions [5]:
"Outcomes such as "improvement," in which participants were asked to rate
themselves as better or worse than they were before the intervention
began, were frequently reported. However, the person may feel better able
to cope with daily activities because they have reduced their expectations
of what they should achieve, rather than because they have made any
recovery as a result of the intervention. A more objective measure of the
effect of any intervention would be whether participants have increased
their working hours, returned to work or school, or increased their
physical activities."
Perhaps it is not too late for this data to be collected from some
participants?
[1] White PD, Sharpe MC, Chalder T, DeCesare JC, Walwyn R; on behalf
of the PACE trial group. Protocol for the PACE trial: a randomised
controlled trial of adaptive pacing, cognitive behaviour therapy, and
graded exercise, as supplements to standardised specialist medical care
versus standardised specialist medical care alone for patients with the
chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC
Neurol 2007;7:6.
http://www.biomedcentral.com/1471-2377/7/6
[2]. Friedberg, F. Does graded activity increase activity? A case
study of chronic fatigue syndrome. Journal of Behavior Therapy and
Experimental Psychiatry, 2002, 33, 3-4, 203-215
[3]. Prins JB, Bleijenberg G, Bazelmans E, et al. Cognitive behaviour
therapy for chronic fatigue syndrome: a multicentre randomised controlled
trial. Lancet 2001; 357: 841-47.
[4]. Van Essen, M and de Winter, LJM. Cognitieve gedragstherapie by
het vermoeidheidssyndroom (cognitive behaviour therapy for chronic fatigue
syndrome). Report from the College voor Zorgverzekeringen. Amstelveen:
Holland. June 27th, 2002. Bijlage B. Table 2.
[5] Whiting P, Bagnall A.-M., Sowden AJ, Cornell JE, Mulrow CD,
Ramirez G (2001). Interventions for the Treatment and Management of
Chronic Fatigue Syndrome: A Systematic Review. JAMA 286: 1360-1368
Competing interests:
None declared |
|
|
FEATURE:
Hyperactivity in children: the Gillberg affair
Gornall (25 August 2007)
[Full text]
[PDF]
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Hyperactivity in children: the Gillberg affair
Assessment for the Swedish Research Council |
12 October 2007 |
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Denny H Vågerö,
Professor, director
Centre for Health Equity Studies, CHESS, Stockholm University/ Karolinska Institutet
Send response to journal:
Re: Assessment for the Swedish Research Council
|
Jonathan Gordall quotes me in his article. Allow me to clarify.
I was asked by the Swedish Research Council to review some of the
critique against Gillberg, specifically the harsh critique against
Gillberg's work formulated by Eva Kärfve in her book"Brain Ghosts"
(available only in Swedish). My judgment (see below), as well as that of
professor Ottoson, concerned what was written by Eva Kärfve and whether
her critique of the Gillberg group was unfair and could be said to
constitute scientific misconduct. We were not asked, and found no
particular reason, to look into whether she was collaborating with the
scientology church or not - in fact this is irrelevant to the primary
conflict between Kärfve and Gillberg. Neither were we asked to, or did we,
look into the events leading up to the destruction of Gillberg’s large
data material. Both of these aspects are central in Gordall’s article and
in the 22 (so far) rapid responses.
The reviews commissioned by the Swedish Research Council in 2006 have
only been available in Swedish. I think they would help the reader of BMJ
to understand the roots of the controversy and to move beyond the bitter
accusations and counter-accusations. My review and that of professor Jan
Otto Ottoson came to similar conclusions. Finally the Swedish Research
Council followed our advice that Kärfve’s criticism should not be
dismissed as scientific misconduct.
Below is my statement for the Swedish Research Council.
To the Swedish Research Council
I, the undersigned, have been requested by the Swedish Research
Council to present my views on the Lund University communication of 26
March 2005 concerning the claim that Eva Kärfve had been guilty of
scientific misconduct. A preliminary approach was made to me in the late
autumn of 2005, and this was followed by a definite request in February
2006. The Lund University communication raises a number of issues. The
Swedish Research Council, however, primarily wanted me to take a position
on the question of whether Eva Kärfve’s research could be described as
scientifically dishonest on the basis of three passages in her book
Hjärnspöken (‘Brain Ghosts’) specified in the university communication.
My opinion on these three points is as follows:
1. Kärfve (page 15) writes that Gillberg and Landgren ignored or
dismissed findings that indicated the relevance of social factors, such as
social class or housing conditions, for minimal brain dysfunction (MBD).
Is this claim misleading or untrue?
Gillberg discussed psychosocial conditions and social class in a
number of different places in his doctoral thesis. He finds, for instance
(page 103, table III), that social class, poor housing areas and rented
flat accommodation are highly correlated to the MBD diagnosis. Similarly,
the mother’s stress load is significantly correlated to the MBD diagnosis
in the child. He nevertheless concludes (page 112) that “Social
disadvantage is in itself not an etiological factor”.
This certainly looks like a dismissal.
The keywords in seeking to understand Gillberg’s conclusion are in
itself. On page 112, he explains: “Social class, although in itself highly
correlated to the MBD diagnosis, was not in any way a factor directly
affecting the background variables studied.” Instead, the etiologically
operative background factors to which weight is attached are for instance
“prenatal non-optimal factors” and “hereditary non-optimality” etc.
Gillberg appears to be arguing that since social class and housing area
are not linked to these background factors, they cannot be of etiological
interest. But if social class and housing area are highly correlated to
MBD, despite not being correlated to variables such as “prenatal non-
optimal factors”, a reasonable conclusion would instead seem to be that
social class is an (‘upstream’) etiological factor that operates via some
other mechanism than the ones discussed above. Thus an important discovery
is left hanging in the air, without any interpretation.
Alternatively, social class may nevertheless have affected the
factors grouped under the heading “prenatal non-optimal factors”
(including for instance low weight at birth and premature birth) without
such a link being detected in this particular study, targeting as it does
a relatively limited number of persons (= low statistical power). In
Sweden, low birth weight and premature birth were more common among
working-class mothers and mothers with little education during this
period. Gillberg himself notes in his thesis the relevance of low birth
weight and “small for gestational age” as etiological factors for MBD
(pages 110–111). Thus it would have been reasonable to expect that
“prenatal non-optimal factors” would mediate the observed correlation from
social class to MBD in Gillberg’s study. Here, too, an unanswered question
is left hanging in the air.
The factors grouped under the heading of “hereditary non-optimality”
also include some with a social content. Late puberty among older
relatives is taken to be suboptimal heredity. But the age of entry into
puberty has been shown to be highly differentiated by social class in all
countries where the matter has been examined. This background factor,
therefore, might equally well be interpreted as a social factor as an
hereditary one.
Kärfve may be wrong to argue that Gillberg ignored the impact of
social class and housing area on the development of neuropsychiatric
diagnosis. She is right, however, to argue that he dismissed them as
significant causal factors. Gillberg’s reasons for dismissing them are
hardly convincing, at least not in light of our current knowledge in this
area. Even if Gillberg had devoted greater attention to this issue, it
goes almost without saying that a sociologically trained person would want
to analyse this point in greater depth and to partly dispute it. Kärfve’s
criticism in this respect cannot therefore be described as illegitimate.
2. Kärfve (pages 49–55) discusses what is termed the Mariestad study
by Magnus Landgren, Christopher Gillberg et al. The study is included in
Landgren’s thesis. Lund University’s communication asks for comments on
what Kärfve says about this study on page 52 in her book. In describing
the authors’ work, she talks about them “rummaging through old patient
records”, accuses them of cynicism and urges that their work be rejected.
Kärfve’s tone is bantering. Is she misleading, scientifically dishonest or
propagating an untruth?
Kärfve comments on the fact that five children who were screened as
positive and whose parents subsequently declined to take part in the
clinicial study were nevertheless included in it. Landgren and his
colleagues give the children neuropsychiatric diagnoses with the aid of
patient records (“a thorough evaluation of all previous records and of the
screening results” [page I:5 in Landgren’s thesis]). The diagnoses are
given without the team having met the children. Examination of the records
led to five children being given the following diagnoses: motor perception
dysfunction, mental retardation, DAMP, ADHD, and in one case a combination
of ADHD/DAMP.
This procedure contrasts sharply with the account of how other
children in the study were given their diagnoses, namely through “…in-
depth neurodevelopmental/neuropsychiatric assessment. This comprised a
detailed history, psychiatric and neurodevelopmental examination,
neuropsychological assessment and evaluation of speech and language
performed by the author (ML), psychologists and speech therapists…. a
medical, developmental and behavioural history was taken at interview with
the parents, using a standardised interview schedule…etc.” (Page I:3 in
Landgren’s thesis.)
Diagnosis setting and diagnosis criteria are one of the most
controversial aspects of the Gillberg group’s research. There is good
reason to critically discuss the way these five diagnoses were made. The
study is a limited one, at least in terms of statistical ‘power’, and it
is not clear to what extent the addition of these five diagnosed children
to the other 58 diagnosed children has affected various conclusions in the
study. The methodological problem is left unsolved. Landgren’s discussion
fails to tackle the problem; instead, the mothers’ reluctance to take part
in the study is seen as possible confirmation of the neuropsychiatric
diagnosis given to the children. Nor is there any discussion of the
ethical problem of including the five children in the study against their
parents’ wishes.
I am of the opinion that Kärfve’s criticism on this point – despite
the severe language it is couched in – is neither dishonest, untrue nor
unreasonable.
3. Point 3 in the Lund University communication principally concerns
pages 45–55 in Kärfve’s book. These sections mainly deal with how
Gillberg’s and Landgren’s theses estimate the prevalence of MBD (Gillberg)
and DAMP and other diagnoses (Landgren). Gillberg makes specific estimates
of the prevalence in Sweden based on their studies. Kärfve is highly
critical of how Gillberg’s prevalence estimate is strongly influenced by
two cases that were transferred from the control group to the group with
MBD. As a result, MBD prevalence among boys is estimated at almost 10 per
cent. This illustrates how small changes in the material can have a major
impact on estimates. Kärfve has similar objections to Landgren’s
estimates.
Probably a more important problem concerning the estimation of
prevalence of such neuropsychiatric diagnoses among children in Sweden is
the extent to which the authors’ material is selected. Even if the
intention is to base the study on the population as a whole, a step by
step process occurs until those who are to take part in the study are
finally selected. The selection covers such aspects as the researchers’
choice of study venue, whether the children attend preschool, parental
decisions whether or not to take part in a survey, decisions by preschool
staff whether or not to distribute the survey questionnaires, parental
decisions as to whether their children should be clinically examined or
not, and the researchers’ decisions whether to expand groups or move
people between groups. It is by no means certain (especially in the case
of the Göteborg study) that prevalence estimates are actually based on a
sample of children that is representative of the child population in each
venue, not to mention Sweden as a whole. A full discussion of possible
bias in the estimation is needed. Nor have Landgren and Gillberg included
any statistically calculated confidence intervals with their estimates.
This is otherwise common practice, especially if working with
representative samples. Thus it is difficult to express any opinion at all
on the value of Gillberg’s estimation from 1981 that 7.1 per cent of
Swedish children have MDB.
Viewed objectively, therefore, Kärfve’s criticism of what she calls
Gillberg and Landgren’s neuropsychiatric mathematics is not particularly
startling.
Conclusions
Lund University has asked for an assessment of certain passages in
Eva Kärfve’s book, ‘Brain Ghosts’. Are they examples of scientific
misconduct? Kärfve does not pursue any neuropsychiatric research of her
own – in her book she makes no reference to publications of her own in
this field – and can therefore hardly be accused of scientific misconduct
in the sense of having invented her observations, falsified her findings
or showing negligence in the presentation of her data. Original research –
the base on which scientific knowledge is built – must of course be the
area of activity subjected to the closest scrutiny, whether cheating or
dishonesty is suspected or not.
In the present case, the question is whether Kärfve’s critique of
research undertaken by others is dishonest. All three points raised in the
Lund University communication concern Kärfve’s discussion of the Gillberg
group’s research, not her own studies (in the same book) concerning the
ideological roots of some of the ideas that both laypersons and
professionally trained experts possess/have possessed concerning mental
ill-health and its causes. Scientific critique should also be subject to
scrutiny, of course, but can the same criteria be applied?
Scientific critique, whether strongly polemical or not, should in my
opinion be considered a legitimate activity even when the person levelling
the criticism does not primarily belong to the research community being
criticised. Advancing one’s criticism outside academia, as part of the
public discourse, is also legitimate. Normally, scientific critique helps
improve the research in question. Research controversies, even when marred
by irrelevancies, often generate new perspectives on old truths or
unresolved scientific issues. In that sense, scientific critique is one of
the conditions of research and a prerequisite for knowledge growth.
Kärfve’s sociological expertise means that she is competent to assess
various aspects (but not all) of the Gillberg group’s research. Research
methodology and analyses of causal links are (or should be) essentially
the same in all disciplines primarily concerned with studying human beings
and human society. If they nevertheless differ, there is every reason to
express oneself with care and to carefully encourage interdisciplinary
understanding.
Kärfve’s book is largely a polemical publication of a general nature
– primarily intended, perhaps, to influence the community at large and
policymakers, and only as a secondary consideration addressing the
specialised circle of people working scientifically with these matters.
One might take the view that Kärfve is unnecessarily disputatious in tone,
or sometimes goes a bit far, but writing a polemical publication on
scientific issues that is partly or largely aimed at a general readership
can hardly be equated with scientific misconduct. On the contrary, it is a
time-honoured tradition in many scientific fields.
I believe it would be of benefit to the scientific discourse if Eva
Kärfve were also to express her views precisely and scientifically in the
sociological or medical science press. An unfortunate aspect of the
conflict currently surrounding neuropsychiatry is that it risks drawing up
unproductive battle lines between social scientists and the medical
profession. Ranging the ‘biological’ against the ‘sociological’, or
‘biologism’ against ‘sociologism’, may be popular nowadays, but it is
totally fruitless. Most biological processes are affected by people’s
relations to one another, i.e. by society. Equally, social processes are
affected by biology. If we are to understand how, we need a dialogue
between disciplines. If the Swedish Research Council has a part to play in
connection with the Kärfve-Gillberg conflict, it should be to promote such
a dialogue and to prevent bloc-building and disciplinary trench warfare.
Some unique research material has been destroyed. The development of
children’s mental health in modern Swedish society is in many ways a cause
for concern. We need to bury the hatchets.
Stockholm, 20 March 2006
Denny Vågerö
Professor, Member of the Royal Swedish Academy of Sciences
(Translation by Stephen Croall)
Competing interests:
None declared |
| |
Hyperactivity in children: the Gillberg affair
Industry of Death? |
12 October 2007 |
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Vanna Beckman,
Free lance journalist and writer
Kungälv, Sweden
Send response to journal:
Re: Industry of Death?
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Steven Rose uphelds at least two different professional roles – one
as a basic neuroscientist and another one that is deeply involved in
political and ideological struggles in fields not directly connected with
his neuroscientific research. Unfortunately in his writings he often
doesn’t keep these roles apart but appears with the authority of the all-
knowing scientist also when struggling against the well established
diagnosis of ADHD, what he regards as the excessive use of anti-
depressants or everything that he includes under the heading of
neurogenetic determinism.
Read for instance the chapter Explaining the brain, healing the mind?
in his book “The 21st Century Brain. Explaining, mending and Manipulating
the Mind” (2005) - and I think most people would join me in appointing
Steven Rose a pronounced advocate for the anti-psychiatry camp. He devotes
much space to the tragic cul-de-sacs of psychiatric practice like lobotomy
and barbiturates, in a condescending tone ridicules the “so-called
‘evidence-based medicine’“ and the “bible of DSM”. Talking of SRRIs he
stresses the suicide risk, the big money involved and Peter Breggin’s
ideas that many psychiatric disturbances be caused by drugs. His picture
of psychiatry is all black and sinister, without mentioning the
considerable advances made during the last half century in the quest to
alleviate the burden of mental conditions.
After having described what he calls the epidemic of depression and
anxiety and the widened criteria for bipolar disease and schizophrenia he
asks if it is “as some conspiracy theorists (such as the scientologists)
suspect, a medicalising myth through which people are kept in thrall by a
sinister psychiatric establishment?” (page 225). After finishing the book
it is difficult not to draw the conclusion that his own answer must be in
the positive. I have absolutely no suspicion that Steven Rose has direct
relations to scientology, but nevertheless many of his themes coincide
with the writings of Thomas Szasz, Peter Breggin and others in their
rather homogeneous anti-psychiatric ideology whose most aggressive
megaphone is the Church of Scientology with its DVD “Psychiatry – Industry
of Death”.
Vanna Beckman,
freelance journalist and writer, Kungälv, Sweden
Competing interests: None declared
Competing interests:
None declared |
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Hyperactivity in children: the Gillberg affair
Apology for a slur required |
3 October 2007 |
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Steven P R Rose,
Emeritus Professor of Biology
Open University, Milton Keynes MK7^AA
Send response to journal:
Re: Apology for a slur required
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I have no axe to grind in this rather heated debate and have played
no part in it.
However, as the freelance journalist Vanna Beckman arbitrarily drags my
name
into the discussion by alleging, without evidence, that I 'belong to the
camp of
anti-psychiatrists' and am close to 'but fear to be connected with'
scientologists,
it is time to demand an apology. I do not know who Ms Beckman is, have
never
knowingly corresponded with her, and wish to make it categorically plain
that I
have abolutely no time for or truck with scientology. Nor, as a bsic
neuroscientist, am I an 'anti-psychiatrist', by which I assume she means
an
adherent to the school of Laing and others from the 60s. What I am and
remain,
is a sceptic about the nature and scale of the current diagnoses of
attention
deficit hyperactivity disorder amongst children, the claims that such
diagnoses
have a reliable base in genetically based disturbances of neurotransmitter
metabolism, and the uses of powerful medication to conrol the condition.
Competing interests:
None declared |
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FEATURE:
Should we consider a boycott of Israeli academic institutions? No
Baum (21 July 2007)
[Full text]
[PDF]
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Should we consider a boycott of Israeli academic institutions? No
Professor Baum still not answering and handing over to IMA |
12 October 2007 |
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Christopher J Burns-Cox,
consultant physician
Southend Farm,,
Wotton-under-Edge GLOS GL12 7PB
Send response to journal:
Re: Professor Baum still not answering and handing over to IMA
|
Yet again (October 4) the Professor has not responded to the facts in
the reports from multiple Human Rights Organisations listed by Derek
Summerfield.For an academic deliberately to ignore the evidence is strange
indeed and suggests an attempt at denial. There is plenty of evidence of
the disgrace of Israelis officially, purposefully and deliberately causing
pain and suffering to Palestinian detainees - amongst others. The Israeli
government has claimed that detainees are 'under constant medical
supervision'.
In 2001 the BMA, a close friend of the IMA, published a handbook 'The
Medical Profession and Human Rights'. It was written by its Human Rights
steering group chaired by Professor Vivienne Nathanson. It includes a
description of prolonged torture of a Palestinian detainee (p64) and
states that the Israeli authorities use 'forms of pressure which might
constitute torture or cruel and degrading treatment'. (Evidence obtained
under torture is legally valid in Israel.) The book (p65) states that
'Israeli doctors examined detainees prior to interrogation to ensure they
were fit enough to withstand the 'moderate physicial pressure'.
I can see it is very difficult for a Zionist and for the IMA to
accept that the Israeli government and Medical Association is involved in
torturing and that denial is one, albeit disgraceful, way of coping but
the facts are thoroughly out in the public domain.
Seek ye the truth where it may be found, Professsor Baum, but I am
not sure the IMA is its sacred repository!
The IMA in its response is still in denial and veers off the point in
an oft repeated fabrication that Palestinian ambulances frequently carry
bombs and suicide bombers. In fact the Jewish American Medical Project has
recently analysed these stories and found only one instance and the truth
of that was debatable. The Jerusalem Post agreed with this report! What is
undoubtedly true and carefully documented is the slaughter of Palestinian
health workers and attacks on ambulances being shot at and many staff
injured and killed.
Appended to the IMA response are two letters. The first is to
Officials including the Chief Medical Officer and Chief Military
Prosecutor of 'the territories'asking for a meeting and reassurance about
the state of health of the Palestinians. This interest might be reassuring
but why was the letter sent as recently as July 12 2007? Is this merely
belated or sent as a tactic in panic?
It is tragic that those Israeli doctors who do chose to practice according
to internationally acceptable ethical standards are led by an organisation
that betrays them so openly.
All the Palestinian health organisations and Physicians for Human Rights
Israel have called for the IMA to be boycotted and a group of UK doctors
agrees. We have waited too long already.
It is in the interests of Israelis, their doctors and of the Palestinians
that the IMA be boycotted to help it come to its senses. It would be a
surprise, but a wonderful one, if the BMA acted according to its official
principles and assisted in this.
Competing interests:
None declared |
| |
Should we consider a boycott of Israeli academic institutions? No
Professor Baum, as a Doctor: please treat the cause not the symptom |
12 October 2007 |
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Mamdouh EL-Adl,
Consultant Psychiatrist
Princess Marina Hospital, Upton, Northampton NN5 6UH
Send response to journal:
Re: Professor Baum, as a Doctor: please treat the cause not the symptom
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Editor
It seems that Professor Baum did not pay any attention to treating the
cause & decided to limit his article to looking for a symptomatic
treatment!
1.Israel is a democracy!
2.Israel is multicultural!
3.If you want to boycott, do not use USB!
4.Some Jews established a charity in Gaza to treat Palestinian children.
5.Israeli Doctors treat Palestinian & Israeli patients equally!
6.Boycott will harm peace initiative!
1.Israel is a democracy: Does any democracy have the right to occupy
the land of another nation? Of course no. Thus being democratic does not
give Israel the right to occupy Palestine. However the elected Israeli
Prime Minister has a different view.
The Israeli plan:- "I believed, and to this day still believe, in our
people’s eternal and historic right to this entire land." Ehud Olmert,
Israeli Prime Minister, to the US House of Representatives, June 2006 [1}
Does Professor Michael Baum support this view?
2.Israel is multicultural! [2]
- Israel is the only country that considers religion as the nationality of
its citizens i.e. any Jew is entitled to be an Israeli citizen anytime
s/he wants. It is important to know that the numbers of Palestinians in
Israel (Muslim & Christians) is in progressive decline due to the
aggressive Israeli policies supported by the Israeli military machine.
-Israel was established in 1948 based on the claim that the Jews
lived in this land 5000 years ago & have the right to return to it.
On the other hand the Palestinians who were driven out of their lands by
the Zionist armed groups since 1948 are denied the right to return back to
their homes. The Israeli government denies the Palestinians the right to
return after 50 years, while the Zionists claim the right to occupy
Palestine 5000 years later.
-Yuri Avneri, an Israeli peace activist stated in one of his
articles: “When tanks overrun cars, destroy houses, topple electricity
poles, open water pipes, leave behind them thousands of homeless people
and cause children to drink from puddles in the street, it causes terrible
hatred. A Palestinian child, who sees all this with his eyes, becomes the
suicide-bomber of tomorrow”[3]. Is this what could be considered by
Professor Baum multicultural!
3.Professor Baum stated in his article: “If you want to boycott, do
not use USB, .. because it is made in Israel!!” [2]. The right question
should be: Is their a reason to boycott? If the boycott is for supporting
human rights, should we sacrifice supporting human rights to use the
Israeli made USB!!
4.Some Jews established a charity in Gaza to treat Palestinian children!
Does this justify the Israeli occupation of Palestine & the violation
of basic human rights of the Palestinians? Establishing this charity
neither justifies the occupation nor reduces the size of the crimes that
have been committed & still continued against the Palestinians since
the establishment of the Zionist state.
5. Israeli doctors treat Palestinian & Jewish patients equally
[2].
- Is equity in care a basic human right or a privilege offered to
Palestinian patients by the kind hearted occupying power? Under the IV
Geneva Convention, the occupying power is responsible for the people under
its occupation. So the healthcare of all Palestinians living under the
Israeli occupation is the responsibility of Israel. Lastly, it should be
said: Do not treat the Palestinians when ill if treating them justifies to
you occupying their land.
Doctors are taught in the medical school to treat the cause & not
to limit their care to treating the symptom. However Professor M Baum in
his article did not condemn the Israeli occupation of Palestine & its
disastrous impact on the life of all Palestinians. Instead Professor Baum
was only minded with highlighting the help offered by Israeli doctors to
relief some of the Palestinian misery. Michael Baum should have bravely
stated that the route cause of the problem is Occupation & should have
called for the end of this occupation. However he has chosen not to treat
the cause, Why?!.
I wonder: Would Professor Baum pass a medical student in the exam if
this medical student focused only on the symptomatic treatment.
6.Boycott will harm peace initiative! Where is peace?
Can we have Peace without Justice?!!!!!
Dani Filc, chairperson PHR Israel PHR Israel stated:
When extreme poverty results from the deliberate destruction of the
economic infrastructure, we would expect them to make their stand clear as
to the dire results on Palestinians’ health and demand the end of this
policy. When faced with a humanitarian crisis, we would expect them to
lead a struggle for changing the policy that causes it, at least regarding
the health issues [4].
Dr M EL-Adl
Consultant Psychiatrist
References
1. Halpin D, Educate How? www.bmj/rapidresponse, accessed on 10.08.07
2. Baum M, Should we consider a boycott of Israeli academic institutions?
No. BMJ 2007;335(7611):125 (21 July),
doi:10.1136/bmj.39266.509016.AD
3. Avneri Y, wais.stanford.edu/Israel/israel_viewofyury42002.html - 5k,
accessed on 10.08.07
4. Dani Filc, Do we take ethics seriously? www.bmj/rapid response,
11.05.07/accessed on 10.08.07
Competing interests:
None declared |
| |
Should we consider a boycott of Israeli academic institutions? No
The threatened academic boycott of Israel and the accusation that the Israel Medical association (IMA) is complicit in the torture of prisoners. |
4 October 2007 |
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Michael Baum,
Professor of Surgery
University College LondonLondon W1N 6AH
Send response to journal:
Re: The threatened academic boycott of Israel and the accusation that the Israel Medical association (IMA) is complicit in the torture of prisoners.
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One of the ugliest consequences of the debate on the threatened
academic boycott of Israel was to provide another opportunity for Dr Derek
Summerfield to repeat his libel that the IMA is complicit in the torture
of Palestinian detainees. My initial response and that of the IMA were
insufficient to convince a number of your readers and the latest posting
(14th September) from a Doctor Brian Robinson stated; “Prof Baum has still
not provided independent evidence to justify his exoneration of the
Israeli Med Assoc: does it exist?” In addition I have received several
hate filled e mails implying that our silence could be interpreted as
guilt.
It is of course easy to make accusations but it takes time to collect the
evidence to refute these allegations. I alerted the editor of the BMJ that
I was working with the IMA to produce a once and for all statement that
the IMA is not an arm of the Israeli government or the Israel Defence
Force (IDF) and is not complicit in the torture of prisoners. I’m now
happy to post it on their behalf. It has to be remembered that it is
impossible to prove a negative. For example no one could prove that
British doctors, members of the BMA, have never been involved in the
torture of IRA prisoners during the Irish troubles or in the present war
against the Taliban in Afghanistan.
I have
reasonable hope that the open minded and uncommitted of the readership
will accept that the IMA is not involved in torture and takes its
responsibility for the health and welfare of both Palestinian and Israeli
Arabs very seriously. In
the end peace can only emerge from the tentative journey from hate and
fear, to mutual respect, trust and eventually to reconciliation.
Yours Sincerely,
Michael Baum
Response from the Israel Medical Association (IMA) to Derek
Summerfield in the British Medical Journal (BMJ)
We have been asked to refute the allegations and so-called “evidence”
produced by Derek Summerfield in his never-ending campaign against Israel.
Unfortunately, it is next to impossible to refute baseless allegations.
The burden of proof should be on Summerfield to prove that his “facts” are
true, and not on Prof Baum or the IMA to prove that they are not. I am
curious to know what evidence Summerfield himself would provide to prove
he is not involved in torture if we had accused him of being so.
Nonetheless, as our silence is erroneously interpreted as admission,
we will address some of the points raised by Summerfield in his most
recent letter to the BMJ (Response and challenge to Professor Baum: what
counts as evidence? BMJ 335 (7611) 125).
The first source Summerfield brings is a quote by Amnesty
International that Israeli doctors working with the security services
“form part of a system in which detainees are tortured, ill-treated and
humiliated in ways that place prison medical practice in conflict with
medical ethics.” This statement is a blanket allegation without any proof
attached. How can one hope to refute such allegations? One can show Dr
Summerfield thousands of Israeli doctors whose ethical standards are above
impeachment and who are no in no way involved in anything that can be
construed as torture. Yet neither he, nor anyone else, has, despite
repeated entreaties on our part to do so, provided us with the name of one
doctor involved in torture in order that we might properly investigate the
allegations.
Summerfield states that Physicians for Human Rights-Israel (PHRI)
reported in 2003 that since 1992 they had been attempting to get the IMA
to join their opposition to torture, but in vain. I can state with
certainty that the IMA has always opposed torture, and, in addition, in
the last several years, we have worked hand in hand with PHRI on various
issues. In a recent three month period, ten letters went out to various
officials and bodies in the army, government etc. after we received
potentially problematic information from PHRI. Summerfield further claims
that “Amnesty told me in the 1990s that they too had made various
approaches to the IMA on this account and had always been rebuffed.”
Unfortunately, no one at the IMA has any idea to what approaches he or
they are referring.
Summerfield slams Prof. Baum for using the statements of Dr Blachar
as evidence against his claim that the IMA is complicit in the ill-
treatment of prisoners. And yet he cavalierly asserts that “Torture
continues to state policy in Israel” by relying on a Btselem report (an
organization that can not be called neutral in their allegiances) that
cites testimonies of 73 Palestinian detainees to “confirm that almost all
Palestinian detainees suffer physical and mental abuse amounting to
torture.”
Summerfield continues to make unequivocal and uncorroborated
statements such as “Palestinian health professionals are regularly shot
dead or wounded on duty.” He also notes that health workers in
ambulances are questioned and searched, people are detained at checkpoints
and the security barrier has negatively affected coherence in the primary
health system, statements which are likely true. Unfortunately, we are
well aware of the difficult living conditions in which the Palestinian
population finds itself. As long as terrorists continue to infiltrate
from the Palestinian territories, the roadblocks are regrettably a
security necessity. Further, ambulances and ill patients have abused the
system in attempts to commit terrorist attacks, such as the 2005 case of
Wafa al-Bas who took advantage of a humanitarian medical clearance granted
to her by Israel to attempt a suicide bombing at Israel’s Soroka Hospital,
the very hospital in which she was hospitalized for over a month early
this year while doctors worked tirelessly to save her life, after she was
severely burned in an accident at home.
In addition, ambulances have been used on more than occasion to
transport terrorist or explosives. For instance, on March 26 2002, Ahmed
Jibril, a Tanzim operative and ambulance driver for the Palestinian Red
Crescent (PRC) was arrested while driving an ambulance belonging to the
PRC in which were found an explosives belt and explosives under the
stretcher on which lay a sick Palestinian child. Nidal Abd al Fatah
Abdallah Nidal, an ambulance driver from Qalqilya employed by UNWRA,
admitted to using the ambulance to transport weapons and explosives for
Hammas. And Waffa Idris, a PRC employee, perpetrated the suicide bombing
on Jaffa Street in Jerusalem in January 2002. She was dispatched by a PRC
ambulance driver who is also a Tanzim operative, and she was assisted by
another PRC employee. It is also believed she may have traveled in a PRC
vehicle, and used PRC documents to go through IDF checkpoints.
Unfortunately, these are not isolated incidents.
Summerfield notes that “PHRI accused the IMA of basically being an
arm of the political establishment.” However, neither he nor PHRI has
provided any reason or evidence to support such an absurd claim.
Unfortunately, I can not address, nor do I want to, all the usual
rants made by Derek Summerfield, and his reliance on such known
“politically neutral” bodies and figures such as Amnesty International,
Btselem, Edward Said and Noam Chomsky to support his positions.
Summerfield also takes issue with the fact that the WMA and the BMA have
repeatedly refused to condemn the IMA and oppose an academic boycott
against Israel. Does he feel that they, too, are an arm of the Israeli
political establishment or perhaps there are unbiased, rational people who
see things differently from him?
Although, we do not feel the need to defend ourselves against the
likes of Dr Summerfield, we will nonetheless cite a few examples of
actions taken by the IMA and Israeli doctors in an effort to alleviate the
difficult situation of Palestinian civilians:
1. 2,346 Palestinian children with birth defects were treated last
year in Israeli hospitals (up from 1,604 in 2005), 29, 919 Palestinian
patients were granted permits to undergo medical treatments in hospitals
in Israel (up from 24,076 in 2005), and 1,600 Palestinian emergency
patients were transferred by ambulance from the PA to hospitals in Israel
(up from 800 in 2005).
2. IMA has intervened in cases where a Palestinian patient was to be
evicted from an Israeli hospital due to lack of funds. For example, in
one instance a patient was to be evicted from a Tel Aviv hospital because
no money was forthcoming from the PA; IMA chair of ethics convinced the
hospital to waive the charges if money was not received from the PA.
3. IMA has intervened, including petitions to the High Court of Justice,
in situations where Palestinian patients, physicians or medical students
encountered difficulties at Israeli checkpoints. Two examples: Joint IMA
-PHR petition to HCJ regarding patients in need of life saving treatment
(a settlement was reached in this case) and another regarding an entry
permit for an AIDS patient (in this case, the petition was dismissed when
the court found that there was a legitimate security interest in
disallowing his entry).
4. The IMA has called for funds to be transferred to the PA in the form of
food and medicine so that help could be given where it is truly needed,
including a letter to the Minister of Health to see what the government is
doing to prevent a shortage of medicine and medical supplies to the
Palestinian territories.
5. The IMA has, at several points in the past, attempted to meet with its
Palestinian counterparts in an effort to foster mutual cooperation and
better understanding, including the release of a joint statement. Almost
none of these meetings have taken place, because of refusal on the
Palestinian side.
6. IMA has issued ethical statements regarding imprisonment in hospitals
and has intervened where necessary.
7. IMA attempted to assist Al-Quds University in East Jerusalem gain
recognition by the Council for Higher Education.
8. IMA issued a recent appeal to Israel Railways Authority regarding the
unnecessary detention/discrimination by railway authorities of two Arab
physicians.
9. IMA established a hotline for Arab physicians wishing to complain of
discrimination at airport and action taken on their behalf.
Although we are an apolitical organization, we certainly do speak out
on behalf of the assurance of proper health services for the Palestinian
population. I attach a sample letter (Appendix A) in this regard.
Regarding Gaza in particular, I would remind you that Israel withdrew from
the Gaza strip two years ago, in accordance with Palestinian wishes and at
great economic and emotional expense to its own population, many of whom
find themselves without jobs, homes or stability to this day. It is
therefore incumbent upon the Palestinian leadership to ensure the health
care services of its population there. Nonetheless, in cases where
necessary health care was unavailable in either Gaza or the West Bank,
Israel has frequently taken it upon itself to provide these services,
often at its own expense.
Regarding the issue of torture: we will once again-hopefully for the
final time- unequivocally state that we completely oppose the involvement
of physicians in anything that can be construed as torture. The IMA has
taken a public stand against torture in various forums, in letters to the
BMJ and as a signatory to the Tokyo Declaration. I attach a sample letter
(Appendix B) we have recently written on this matter to Mr. Yuval Diskin,
head of the Israel Security Agency (ISA). We also recently addressed this
issue in the Knesset (Israeli Parliament) where we stated our position
that doctors employed by the ISA or security services and involved in the
questioning of Palestinian detainees or prisoners are absolutely forbidden
to take part or assist in any way in questioning that is accompanied by
torture. (July 3, 2007). Finally, we have been working for the last
several months to incorporate a translation (done by PHRI) of the
Norwegian Medical Association/World Medical Association course on “Doctors
working in prisons: human rights and ethical dilemmas”; this course was
recently made available to Israeli doctors.
Summerfield interprets the silence of Baum and the IMA as an
admission of guilt. In actuality, it derives not from guilt but from an
intense weariness of having to respond time and time again to baseless
attacks from someone with a very clear agenda. Summerfield expects self-flagellation on our parts for wanting to live in peace, to protect our
children from attack, for trying to balance security needs with the very
real and pressing need to assure proper health services for all, Israeli
and Palestinian. But for that we can not, and will not, apologize.
Malke Borow, JD
Manager, Division of Law and Policy
Israel Medical Association
Appendix A
July 12, 2006
To: Maj.-Gen. Joseph Mishlav, Coordinator of activities in the
Territories
Brig.-Gen. Yechezkel Levi, Chief Medical Officer
Brig.-Gen. Avichai Mandelbeit, Chief Military Prosecutor
Re: Invitation to a meeting regarding the health status in the
territories-promoting cooperation between the IMA and relevant bodies
The IMA has been repeatedly approached by both local and foreign
organizations regarding the status of the civilian population in the West
Bank and Gaza.
It goes without saying that we do not address political or security
issues; nonetheless, we are sure that you share our belief that we must do
everything in our power to preserve an acceptable level of health even
during armed conflict and to concern ourselves with the essential
humanitarian needs of the civilian population.
The IMA is interested in trying to advance fruitful cooperation with
you, in order to improve the channels of communication and activity
between us, to understand the scope of inquiries you receive and to see
how the IMA can take part in medical and humanitarian aid to the civilian
population during this difficult period.
Therefore, we would kindly request a joint meeting.
We will be in touch within the next few days in order to schedule
such a meeting and hope you will positively answer our request.
Sincerely,
Dr. Yoram Blachar
President
Israeli Medical Association
(Translated from the Hebrew)
Appendix B
July 12, þ2007
To:
Mr. Yuval Diskin
Head of the Israel Security Agency
Re: Reports of B’tselem and the Center for the Protection of the
Individual on the matter of torture and abuse of Palestinian detainees-
implications for medical personnel working in interrogation centers
We would appreciate your response to the enclosed letter, which was
forwarded to us yesterday.
It appears from the letter that the report in question allegedly
raises suspicion that the ISA still uses physical and emotional measures
that can be defined as torture.
We would note that the position of the IMA on this matter remains as
it always was, namely that it is absolutely forbidden for doctors employed
by the ISA or security services and involved in the questioning of
Palestinian detainees or prisoners are absolutely forbidden to take part
or assist in any way in questioning that is accompanied by torture.
We, too, would like to receive answers to the questions posed in the
letter of Physicians for Human Rights, and would appreciate a response at
your earliest convenience.
Sincerely,
Dr. Yoram Blachar
President
Israeli Medical Association
(Translated from the Hebrew)
Competing interests:
I wrote the opposing piece in the debate |
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