Medicine and Science from The BMJ

We’re taught that patients' ideas, concerns, and expectations are central to a successful consultation, but has ICEing gone too far? A “What your patient is thinking” article published this week talks about the pressure that asking questions in the wrong way can put on a patient. Sophie Cook, education editor for The BMJ, is joined by the author of that article - The BMJ’s patient editor, Rosamund Snow, and by Roger Neighbour, former president of the royal college of general practice, and author of "The Inner Consultation". http://www.bmj.com/content/354/bmj.i3729

The "internal market" was created after the 1987 UK general election focused attention on inadequate funding in the NHS, long waiting lists for elective surgery, and large unwarranted variations in clinical care. Economists attributed these problems to a lack of incentives for efficiency, and the remedies offered included increasing competition in the NHS. Twenty nine years later, this interesting experiment is not likely to have been worth it, says Alan Maynard, professor emeritus of health economics at the University of York. But Michael Dixon, a GP and commissioner in Devon, says that if properly funded and liberated from some of the administrative burdens of "red tape," the internal market could increase accountability. Read their full debate: http://www.bmj.com/content/354/bmj.i3825

2.46 million people in England have osteoarthritis of the hip, and many of those go on to eventually have a hip replacement - which is now widely considered one of the most commonly performed and successful operations in the world. Jessamy Bagenal, clinical fellow with The BMJ, talks to Nick Aresti, a specialist registrar in trauma and orthopaedic surgery and one of the authors of a clinical update on hip osteoarthritis, recently published on thebmj.com In a linked podcast, Nick Nicholas, a patient who has hip OA gives us his perspective. Read the full article: http://www.bmj.com/content/354/bmj.i3405 Listen to the linked podcast: https://soundcloud.com/bmjpodcasts/having-hip-osteoarthritis

2.46 million people in England have osteoarthritis of the hip, and many of those go on to eventually have a hip replacement - which is now widely considered one of the most commonly performed and successful operations in the world. Jessamy Bagenal, clinical fellow with The BMJ, talks to Nick Nicholas, an obstetrician who has had OA and one of the authors of a clinical update on hip osteoarthritis, recently published on thebmj.com In a linked podcast, Nick Aresti, a specialist registrar in trauma and orthopaedic surgery to talks about management of the condition. Read the full article: http://www.bmj.com/content/354/bmj.i3405 Listen to the linked podcast: https://soundcloud.com/bmjpodcasts/treating-hip-osteoarthritis

The drug Truvada, licenced for HIV PrEP, costs £350 a month but is shown to be cost effective in preventing infection. However, in the English NHS, a row has broken out about which body should fund the treatment - NHS England claims local authorities have responsibility, local authorities believe NHS England does. In this podcast Jim McManus, director of public health at Hertfordshire County Council, explains why he believes local authorities cannot afford the treatment, and describes the pressure that public health budgets are under. Read the full editorial: http://www.bmj.com/content/354/bmj.i3515

Guidelines usually assume a rational comprehensive decision model in which all values, means, and ends are known and considered. In clinical encounters, however, patients and doctors most often follow “the science of muddling through. Given that clinical knowledge does not follow the narrow rationality of “if-then” algorithms contained in guidelines, alternatives are desperately needed. Glyn Elwyn, professor at the Dartmouth Institute for Health Policy and Clinical Practice, joins us to discuss what we know about how doctors and patients use evidence, and what the alternative to guidelines could look like. Read the full analysis: http://www.bmj.com/content/353/bmj.i3200

When we think about medical evidence, we think of RCTs, registries and meta-analysis. But these EBM tools have yet to filter into the basic science that underpins clinical science. One person changing that is Emily Sena, research fellow in clinical brain sciences at the University of Edinburgh - and one of the few people who’s trying to meta-analyse animal studies.

The same piece of evidence may reach you via a journalist, or via your doctor - but the way in which that evidence is communicated is changed by your relationship between that person. Julia Beluz from Vox and Victor Montori from the Mayo Clinic join us to discuss if it's possible to reconcile those competing points of view.

In every 1000 pregnancies, between two and five infants are born to women with epilepsy. For such women, pregnancy can be a time of anxiety over maternal and fetal wellbeing. In 96% of pregnancies they will deliver a healthy child. However, some women will experience an increase in seizure frequency, which can be harmful for the mother or fetus, and evidence comes from observational study and registry data suggests some antiepileptic drugs are associated with an increased risk of congenital and neurodevelopmental abnormalities. Michael Kinney, specialist registrar in neurology, and James Morrow, principal investigator of the UK and Ireland Epilepsy and Pregnancy Register, both based at the Royal Group of Hospitals in Belfast, join us to discuss how to manage epilepsy in pregnancy. Read the review: http://www.bmj.com/content/353/bmj.i2880 For information on joining the UK epilepsy and pregnancy register, call 0800 389 1248 or visit http://www.epilepsyandpregnancy.co.uk/

Delirium is common in the last weeks or days of life. It can be distressing for patients and those around them. A clinical update explains why successful management involves excluding reversible causes of delirium and balancing drugs that may provoke or maintain delirium while appreciating that most patients want to retain clear cognition at the end of life. Kate Adlington, clinical editor at The BMJ, is joined by the authors of the paper - Christian Hosker, consultant liaison psychiatrist at Leeds and York Partnership Foundation Trust, and Michael Bennett, professor of palliative medicine at the University of Leeds. http://www.bmj.com/content/353/bmj.i3085

Global evidence indicates that mandated treatment of drug dependence conflicts with drug users’ human rights and is not effective in treating addiction. Karsten Lunze, associate professor at the Boston University School of Medicine, joins us to describe the evidence, and why he is convinced seemingly counter intuitive hard reduction works. http://www.bmj.com/content/353/bmj.i2943

How can asking patient to tell us their story improve healthcare? Helen Morant, content lead at BMJ, talks us through her project getting healthcare professionals to sit down with patients and record their conversations, and what on earth this has to do with quality improvement. We also hear some of the recordings she has gathered through the project. Here are links to the other podcasts and projects Helen mentions: Story Corps - https://storycorps.org/ The Listening Project - http://goo.gl/3auSHX Beautiful stories from anonymous people - http://goo.gl/78QSjU

Julian Treadwell, Neal Maskrey and Richard Lehman join us in the studio to argue that new models of evidence synthesis and shared decision making are needed to accelerate a move from guideline driven care to individualised care. Read the full analysis: www.bmj.com/content/353/bmj.i2452

There is insufficient evidence to know whether dressings reduce the risk of surgical site infection in closed primary surgical wounds. Jane Blazeby, professor of surgery at the University of Bristol, and Thomas Pinkney, consultant colorectal surgeon at the University of Birmingham, join us to discusses why there is a lack of evidence, and the implications for patient care. read the full article: http://www.bmj.com/content/353/bmj.i2270

Interviews from the Women deliver conference in Copenhagen. Donna McCarraher, director of reproductive, maternal, newborn and child health at FHI 360, explains why women should be at the centre of efforts to mitigate the effect of Zika Virus in Brazil.

Interviews from the Women deliver conference in Copenhagen. Catrin Schulte-Hillen, co-ordinator of reproductive health and sexual violence care at Medecins Sans Frontieres, explains why the development community shouldn't conflate sexual violence and access to abortion.

This week, we look at medication reconciliation. Joshua Pevnick, health services researcher and hospital physician at Cedars-Sinai Hospital, LA, US, talks us through what it is and why it can be so hard to get right. And Emma Iddles, a junior doctor in general surgery at Hairmyres Hospital, Lanarkshire, UK, explains how her project improved medicines reconciliation in the surgical admissions unit of the hospital. For more, read Joshua's full paper, http://goo.gl/O59BWo, and Emma's project write up http://goo.gl/znrNGQ.

We do we know about the weekend effect? As Martin McKee puts it in an editorial on thebmj.com, "almost nothing is clear in this tangled tale" In this roundtable, Navjoyt Ladher, Analysis editor for The BMJ is joined by some of the key academics who have published research and commented on the weekend effect to make sense of what we know and don’t know about weekend care in hospitals. http://www.bmj.com/weekend Taking part in the discussion are: Cassie Aldridge, HiSLAC study project manager at the University of Birmingham Rachel Meacock, research fellow in health economics at Manchester University Nick Black, professor of health services research at the London School of Hygiene and Tropical Medicine Paul Aylin, professor of epidemiology and public health at Imperial College London Nick Freemantle, professor of clinical epidemiology and biostatistics at University College London Peter Rothwell, professor of neurology at the University of Oxford

Katja Iversen, CEO of Women Deliver, joins Rebecca Coombes to explain why the UN sustainable development goals are unachievable if we don't empower women and girls to take control of their health, wellbeing, and reproductive rights. http://womendeliver.org/

Travellers’ diarrhoea is one of the most common illnesses in people who travel internationally, and depending on destination affects 20-60% of the more than 800 million travellers each year. In most cases the diarrhoea occurs in people who travel to areas with poor food and water hygiene. Mike Brown, consultant in infectious diseases and tropical medicine at the London School of Hygiene and Tropical Medicine, explains the approach to the prevention and treatment of diarrhoea in travellers. Read the full review: http://www.bmj.com/content/353/bmj.i1937

Providing information to enable informed choices about healthcare sounds immediately appealing to most of us. But Minna Johansson, GP trainee and PhD student at the University of Gothenburg, argues that preventive medicine and expanding disease definitions have changed the ethical premises of informed choice and our good intentions may inadvertently advance overmedicalisation. Read the full analysis: http://www.bmj.com/content/353/bmj.i2230

Or, the one where Fiona Moss and Don Berwick tells us what they think quality improvement is. Fiona Moss is dean, Royal Society of Medicine, and Don Berwick is president emeritus and senior fellow, Institute for Healthcare Improvement. Don's talk and the interview with Fiona were both recorded at the International Forum on Quality and Safety in Healthcare, Gothenburg, April 2016. Watch out for the extended versions of these recordings, up next Friday.

Medical error is not included on death certificates or in rankings of cause of death. Martin Makary, professor of surgery at Johns Hopkins University School of Medicine, joins us to explain why we don't measure medical error, and why it is so important that we start. Read the full analysis: http://www.bmj.com/content/353/bmj.i2139

Nicholas Hopkinson, reader in respiratory medicine at Imperial College London, joins us to explain why a new report from the Royal College of Physicians supports the role of electronic cigarettes as part of a comprehensive tobacco control strategy. Read the full analysis: http://www.bmj.com/content/353/bmj.i1745

The BMJ recently held a discussion between experts in the fields of general practice, emergency medicine, and paediatrics about the state of out of hours care in the UK, and crucially offered their vision for a better service. Are children a special case, can urgent care ‘hubs’ be a silver bullet, is NHS 111 up to the job of triaging patients, do there enough clinicians involved in out of hours care, and are other countries doing a better job? The state of out of hours care can best be described as ‘patchy,’ with some, even most, people receiving good and timely care although from a confusing plethora of different bodies - walk-in centres, urgent care centres, out of hours centres, telephone consultation and - that most recognisable of all NHS brands - Accident and Emergency. But there are also very serious deficiencies attributed to core problems identified by our experts below. Around the table were: Clifford Mann, president of The Royal College of Emergency Medicine and an emergency medicine consultant in Taunton in Somerset; Neena Modi, professor of Neonatal Medicine in the Imperial College, London and president of Royal College of Paediatrics and Child Health; and Professor Martin Roland, professor of Health Service Research at the University of Cambridge and who has 35 years experience as a GP. Read the write up:

It's bad practice to prescribe a brand name drug when a cheaper, viable and approved generic is available. But, particularly in the US, this happens too much, at major cost to the health system. The team behind Michigan State University's paediatric clinics set out to increase their prescribing of generics, and found that much of the problem was that whilst brand names lodged in staff and patient's minds, generic names were easily forgotten. Sath Sudhanthar, paediatrician and assistant professor in paediatrics, and Kari Chandler, nurse manager, tell Harriet Vickers how they overcame this and tripled the team's generic medication prescription rate. Read their full report: http://qir.bmj.com/content/4/1/u209517.w3931.full

Sudden cardiac death of young athletes needs to be avoided but does screening really help? Hans Van Braband, researcher at the Belgian Health Care Knowledge Centre, joins us to explain that the evidence for screening doesn't show benefit, and may lead to harm. Read the full analysis: http://www.bmj.com/content/353/bmj.i1156

Sheyna Gifford has an unusual claim to fame—she is the first doctor ever to work on Mars. Not the planet Mars, of course, but Mauna Loa, a volcano in Hawaii, whose dusty, rust coloured landscape is probably the closest on earth to the red planet. She is serving on the Hi-Seas programme, a mission run the University of Hawaii and funded by NASA, whose purpose is to simulate a three year voyage to Mars and back. Since last August Gifford and six other scientists have been living in a 1000 square foot solar powered dome, which they rarely leave. The project is treated as a real mission to Mars so the crew have all the supplies for their year long stay and, because of the time delay between Mars and Earth, they cannot speak to the outside world. They can, however, communicate by email, so Sheyna sent The BMJ this voice file to answer 15 of our questions. Questions: Anne Gulland Copyright: Sheyna Gifford, MD, 2016.

In February World Health Organization (WHO) declared the microcephaly epidemic in South America an international public health emergency. Today, the US Centers for Disease Control and Prevention, the CDC, has confirmed that it’s is Zika virus which is causing that microcephaly. The outbreak was originally spotted in Recife, in Brazil, and it’s from there that the authors of this research paper have been carrying out imaging of the skulls of babies born with microcephaly and probable Zika virus infection - to establish patterns of damage in the brain. We're joined by Maria de Fatima Vasco Aragao, professor of radiology and scientific director of Multimagem Radiology Clinic, Recife. Also, Vanessa Van Der Linden, paediatric neurologist and clinic director of Association for Assistance of Disabled Children Recife. Read the full research: http://www.bmj.com/content/353/bmj.i1901

James Barrett, president of the British Association of Gender Identity Specialists, and Nina, a trans woman, join us to discuss how difficult it can be for trans people to access gender clinics, and what barriers are faced by the community after their transition has been completed. Read James Barrett's personal view: http://www.bmj.com/content/352/bmj.i1694

Alcohol consumption has been a perennial problem, but recently The economic downturn and rises in alcohol taxation seem to have stemmed the persistent rise in associated mortality. Nick Sheron, head of clinical herpetology at Southampton university, and one of the authors of an analysis article, explains how government fiscal policy has the ability to immediately reduce alcohol related deaths.

Abi Rimmer, BMJ careers reporter, talks to the cast of hospital comedy Greenwing, who explain why they're supporting junior doctors on the picket line. Read her report: http://bmj.co/1oJ2W41

Abi Rimmer, BMJ Careers reporter, talks to junior doctors on the picket line at Northwick Park Hospital. Read her report: http://bmj.co/1qydmFq

The Francis report, the Berwick report, the Keogh review - all of these have highlighted how important learning from mistakes is in healthcare. Reporting incidents is key to this, and in this podcast Jen Perry, from BMJ Quality, tells Harriet Vickers the whats, hows and whys of incident reporting. And Emily Hotton, previously a foundation doctor at Royal United Hospital Bath, UK, talks about how her project helped junior doctors at the hospital become more confident at incident reporting, and bumped up the number of incidents they logged. Read Emily's full report: http://qir.bmj.com/content/3/1/u202381.w2481.full Check out BMJ Quality: http://quality.bmj.com

Plan, do, study, act cycles, or PDSA cycles, are the basis of many quality improvement projects, they're a model to trial changes and feed the lessons from each test into the next. Why are they a popular method, and how do you get the best out of them? And what on earth happens when they explode? Harriet Vickers asks Julie Reed, National Institute for Healthcare Research CLAHRC (Collaboration for Leadership in Applied Health Research and Care) for north west London. Read all of Julie's paper (for free): http://qualitysafety.bmj.com/content/25/3/147 Check out BMJ Quality: http://quality.bmj.com

As France has moved in recent weeks to clear camps where migrants stay while trying to cross illegally into Britain, Médecins Sans Frontières has just opened a new one. Sophie Arie talks to Caroline Gollé, medical coordinator at the Médecins Sans Frontières​ La Linière camp​. Read more about the camp: http://www.bmj.com/content/352/bmj.i1696

Depression in pregnancy affects up to 10% of women, a rate only slightly lower than in the postpartum period. Yet, as few as 20% of pregnant women with depression receive adequate treatment. Louise Howard, professor in women’s mental health at King's College London, joins us to discuss the clinical review on depression in pregnancy. Read the full article: http://www.bmj.com/content/352/bmj.i1547

However well intentioned, working in detention centres amounts to complicity in torture, says David Berger, a district medical officer in emergency medicine at Broome Hospital in Australia. However, Steven Miles, chair in bioethics at the University of Minnesota thinks that they play an important role in telling the world about conditions in these camps. Read the full debate: http://www.bmj.com/content/352/bmj.i1600

Jeremy Hunt is a health secretary under pressure. In this exclusive interview with The BMJ’s editor in chief Fiona Godlee, the man who could soon become England's longest serving health secretary insists he has more to give. The steady hand brought in to steer the NHS away from the front pages has been shaking in recent months, but the grip seems to be intact. As he greets The BMJ in his Whitehall office, Jeremy Hunt does not betray the signs of a man buckling under the pressure despite a tumultuous few months that have left many NHS staff feeling downtrodden, battered, and bruised—and that have brought calls for his resignation after he was rebuked for misrepresenting data published in The BMJ to support the case for seven day working in the NHS. Read Gareth Iacobucci's report of the interview: http://www.bmj.com/content/352/bmj.i1632

Nick Oliver, consultant diabetologist at Imperial Healthcare NHS Trust and Philippa Cooper, who has type I diabetes, join us to explain how structured education works for patients, and give tips on self management. Read the full review: http://www.bmj.com/content/352/bmj.i998

Gareth Iacobucci talks to Candace Imison, director of policy at The Nuffield Trust, about the problems facing GPs, and how primary care could be changed. "5 minutes with... Candace Imison": http://www.bmj.com/content/352/bmj.i1378

As the junior doctors in England strike, concerns for the workforce are foremost in the minds of those running the NHS. A summary is available here: http://www.bmj.com/content/352/bmj.i1510 In The BMJ roundtable, recorded at the Nuffield Trust Health Policy Summit on Friday 4 March 2016, we asked our participants if they think the NHS is in crisis, and what they think can be done to help those working across the system. The participants were Clifford Mann, president of the Royal College of Emergency Medicine, Samantha Barrell, chief executive at Taunton and Somerset NHS Foundation Trust, Candace Imison, director of policy at the Nuffield Trust, Richard Jones, consultant cardiologist, Saira Ghafur, specialist registrar, Neena Modi, president of the Royal College of Paediatrics and Child Health, Claire Lemer, consultant in general paediatrics, Ben Mearns , chief of medicine at Surrey & Sussex Healthcare NHS Trust, Sarah Pickup, deputy chief executive at the Local Government Association, and Jeremy Taylor, chief executive of National Voices.

“Juliet”, a woman living in London, was diagnosed with a mysterious illness in November 2015, Ian Cropley, a consultant in infectious disease from The Royal Free London NHS Foundation Trust, was there to investigate. In this podcast, we find out how Zika, once a little known virus causing a rash and fever, has subsequently become a global health emergency. We also discuss how the infection is linked to microcephaly, and what we still need to understand to control the disease. All Zika virus resources from BMJ are now freely available on www.bmj.com/freezikaresources.

How should health professionals engage with this increasingly popular but unproved practice? Aubrey Cunnington, a consultant paediatrician from Imperial College London joins us to discuss. Read the full editorial: http://www.bmj.com/content/352/bmj.i227

The Department of Health is proposing to extend charging for migrants into some NHS primary care services and emergency departments. Although the government asserts that the NHS is “overly generous to those who have only a temporary relationship with the UK,” Lucy Jones, UK lead for Doctors of the World says these proposals will disproportionately harm vulnerable undocumented migrants. Read the full editorial: http://www.bmj.com/content/352/bmj.i685

In recent weeks, the firearms controversy has again lit up the media in the United States, with clarification that anyone engaged in the business of selling firearms must get a license and conduct background checks. But, argues Fred Rivara from the Seattle Children’s Research Institute and Harborview Injury Prevention and Research Center, we may never know its effects because of the continuing ban on federal funding of research into gun violence. http://www.bmj.com/content/352/bmj.i578

This week, junior doctors in England have taken industrial action for the second time in as many months after failing to reach agreement with the government over their proposed new contract. Tom Moberley and Abi Rimmer, from BMJ Careers, went to the picket lines at Northwick Park Hospital, and University Hospital Lewisham to talk to the doctors, and their supporters. Keep up to date with the junior doctor's continuing industrial action with our live blog: http://blogs.bmj.com/bmj/2016/02/08/junior-doctors-strike-february-2016-live-blog/

The Rapid diagnostic tests have the potential to reduce the overtreatment of malaria by 95%, but time and extensive logistical, behavioural, and technical interventions may be required to achieve this. Eleanor Ochodo from the Centre for Evidence-Based Health Care, at Stellenbosch University, joins us to discuss. Read the full article: http://www.bmj.com/content/352/bmj.i107

Iqbal Malik, consultant cardiologist at Imperial College Healthcare NHS Trust in London, joins Mabel Chew to discuss the role of angioplasty and stenting in patients with stable angina. Read the full article online: http://www.bmj.com/content/352/bmj.i205

Are you having a dry January? In this podcast Ian Gilmore, honorary professor at Liverpool University, and Ian Hamilton, a lecturer in the Department of Health Sciences at York University, debate whether campaigns such as this have any public health benefit. Read the full head to head article: http://www.bmj.com/content/352/bmj.i143