The BMJ Editor's Choice
Familiarity breeds better outcomes
发布：Elizabeth Loder, Head of Research, The BMJ
Let’s be clear: familiarity breeds better outcomes. People who have a usual, continuous source of primary medical care generally do better than those who don’t. We know this, and yet everywhere primary care and general practice are in crisis.
The United Kingdom is no exception. Its medical schools are “training future doctors for yesterday,” say our editorialists John Oldham and Sam Everington (doi:10.1136/bmj.j294). Only 5.9% of UK medical school professors are GPs. As in the United States, there is prejudice and “institutional discrimination” by medical leaders against generalism. The result is that too few medical graduates pursue training in general practice. Instead, most seek specialty training for careers that are more prestigious and promise a better lifestyle. The proposed solution? Tie accreditation and funding to schools that produce doctors whose career choices are in line with population needs.
What is it that general doctors do so well? For starters, they can help keep you out of hospital. Barker and colleagues (doi:10.1136/bmj.j84) find that older patients who received more of their care from the same GP were less likely to be admitted to hospital for so called “ambulatory care sensitive conditions.” These are illnesses such as asthma, diabetes, hypertension, or epilepsy that can usually be controlled with careful outpatient management by a doctor who knows patients well and follows them over time. Admissions to hospital for these problems can be an indication of ineffective outpatient care. In a linked editorial, Peter Tammes and Chris Salisbury (doi:10.1136/bmj.j373) say that policies that promote and support continuity of primary care are needed “to improve job satisfaction for GPs and very likely reduce pressure on hospitals.”
Despite the best efforts of primary care doctors, every year millions of people visit a hospital emergency department. Some are admitted. Most, however, are evaluated, perhaps treated, and then sent home. Of these, a small portion drops dead within the week—0.12% to be exact, finds a study that used US Medicare data (doi:10.1136/bmj.j239).
Because there are so many emergency department visits, the authors calculate that this small percentage translates into 10 093 deaths a year in the US. The most common cause of such unexpected deaths was atherosclerotic heart disease. More deaths occurred among people sent home from hospitals that had lower rates of admissions through the emergency department, even though the patients in those institutions were healthier overall. Could some of these deaths be prevented? It is tempting to speculate that a lower threshold for hospital admission in borderline cases might make a difference, perhaps by allowing doctors to get to know patients and observe their conditions over time. Sound familiar?
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j558 (Published 02 February 2017)
Cite this as: BMJ 2017;356:j558
Tick tock, how long have I got?
发布：Rebecca Coombes，Head of News and Views， The BMJ
The old song tells us “Enjoy yourself, it’s later than you think.” The factors that help predict our life spans provide a clear theme in The BMJ this week. First is the (broadly) good news, from the UK Office for National Statistics: we are all living longer. A girl born in 2015 can expect to live to 83, a boy to 79. The potential causes of variation around average life expectancy are many: genetic inheritance, lifestyle, wealth, employment, and, as John Appleby writes (doi:10.1136/bmj.j346), “consumption of everything—from education to recreational drugs to healthcare.” Our intrepid economist gamely plugs his personal details into a range of online “death clocks” in a bid to cut through the uncertainty and generate a hard life endpoint. Basic ONS life tables suggest that May 2040, about a month after Appleby’s 82nd birthday, is the sobering answer. But the death clocks produce a bewildering range “from 67 (eek!) to 89 (yay!).” He concludes that death clocks should come with a health warning.
After the quick fix of online prediction tools comes a slower cooked but vastly more significant perspective. David Batty and colleagues (doi:10.1136/bmj.j108) provide evidence of a possible predictor of mortality among patients with cancer. Using unpublished data pooled from prospective cohort studies, they find that anxiety and depression may be linked to an increased risk of death from some cancers. The findings are observational, but the authors say they add to the growing evidence that psychological distress could be predictive of certain physical conditions.
From emerging evidence to evidence that is being tragically overlooked. Many thousands of lives were cut short in west Africa in the recent epidemic of Ebola virus disease. A new analysis by a team of international experts reports that a faster, more coordinated response could have prevented 11 000 deaths (doi:10.1136/bmj.j280). Suerie Moon and fellow authors examined seven reports on the global response to Ebola, which they found all largely agreed on what went wrong and what needs to be done. But, they warn, the world will be no better prepared for the next pandemic unless we get increased resources and new monitoring and accountability mechanisms. The clock is ticking.
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j414 (Published 26 January 2017)
Cite this as: BMJ 2017;356:j414
Too much chemotherapy
发布：Fiona Godlee, Editor in Chief, The BMJ
People with cancer are living longer now than 40 years ago. This is clearly good news. But how much of this improvement can we attribute to drug treatment? Not much, concludes Peter Wise this week in an article I humbly suggest all oncologists should read (doi:10.1136/bmj.i5792). The nearly 20% improvement in five year survival over the past four decades is probably mainly due to improved early diagnosis and treatment rather than developments in cytotoxic chemotherapy, he says. And patients are being badly misled by over-enthusiastic accounts of what chemotherapy can achieve. Many expect a cure. In reality they will gain on average only a few months of extra life.
The roots of this over-enthusiasm are sadly familiar but worth recounting in the specific highly charged and intensive context of cancer. Wise, a medical ethics consultant and former consultant physician, doesn’t mince his words. Unrepresentative, industry funded trials that use surrogate endpoints are part of the problem. So too are regulatory failures, perhaps explained by regulatory capture in which “the regulator risks being regulated by the industry that it has been appointed to regulate.”
Unjustified enthusiasm for cancer drug treatments comes at huge cost, financial and personal (including treatment related deaths and reduced quality of life), and increased risk of dying in hospital rather than at home. Many patients don’t realise that opting for supportive rather than active treatment—often called “refusal”—is an option and may give them longer as well as better quality life than chemotherapy. Conflicts of interest among clinicians compound their reluctance to have tricky conversations.
If improved survival is indeed largely due to early diagnosis and treatment, how is this best achieved? Many patients visit their GP with vague or non-specific symptoms. How should these be investigated and followed up without causing unnecessary alarm or wasting precious resources? As Brian Nicholson and colleagues explain (doi:10.1136/bmj.i5515), “safety-netting” aims to ensure that patients don’t drop through the healthcare net and are monitored until symptoms can be explained. But there is little evidence on whether this works or how to do it well. In particular, how much responsibility should patients be expected to take in chasing up and understanding test results? The authors encourage a sharing of this responsibility between clinicians and patients, but also clear communication and robust systems to prevent patients falling through the net.
Wise concludes with a call for higher bars for drug approval for new and existing drugs. Ethical cancer care demands empowerment of patients, he says, with accurate, impartial information followed by genuinely informed consent. And funds and attention should shift to prevention, early detection, prompt and radical treatment of localised and regional disease, and early provision of supportive care. Only then will cancer care serve patients rather than governments and industry.
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6027 (Published 10 November 2016)
Cite this as: BMJ 2016;355:i6027