38 e-Letters

published between 2017 and 2020

  • Choice of words is crucial in effective communication

    Improving communication in decision-making is a worthy goal and the choice of words is crucial. Sayma and colleagues (1) have not considered the implications of some of their choices.

    Firstly, throughout the article they have used the word ‘advanced’ when describing decisions and care plans. This is a common misspelling but such issues are not superior formats but are care plans and decisions made in advance. Secondly, the authors mention ‘ceilings of care’ but do not explain that there are no ethical or legal permissions that allow care to be limited. This term is often misused when what is meant is a limit to treatment options. Finally the use of ‘escalation’ in care plans has been shown to be threatening to patients.(2) The term is too often used by clinicians without considering how this might be considered by patients.

    None of this should not detract from the value of the information provided during the study, but perhaps the authors will think carefully in future about their choice of words.

    Claud Regnard

    1. Sayma M et al. Improving the use of treatment escalation plans: a quality improvement study. Postgrad Med J, 2018; doi: 10.1136/postgradmedj-2018-135699.
    2. Fritz Z, Fudd JP. Development of the Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a cross disciplinary approach. J Evaluation in Clinical Practice 2014; 21: 109-117.

  • The role of the dedicated nurse practitioner and other issues

    I agree with the authors of this excellent review that blood pressure(BP) measurement is often performed carelessly, and this is true both in primary and in secondary care. Although both doctors and nurses are responsible for this state of affairs, appropriately trained and dedicated(in terms of their job description) nurse practitioners are the ones who would be best placed to comply with the requirements for correct blood pressure measurement within "real world" time constraints(1). My proposal is to allocate a 10-15 minute slot for the nurse practitioner to measure the blood pressure in the relaxed environment of her own consulting room. Thereafter she can hand the patient over to the doctor to fulfil his own 10 minute or so time slot.
    Choice of diuretic medication for management of hypertension is the other issue specially relevant to the elderly. Although diuretics of first choice for antihypertensive treatment are typically either thiazides or indapamide, what needs to be recognised is that susceptibility to diuretic-related hyponatraemia involving those two drug subclasses is uniquely age-related, patients aged 60 or more being the ones most vulnerable to this complication(2)(3)(4)(5)(6). It is even conceivable that symptoms of drug-related hyponatraemia such as falls(2)(3) , might, on occasion, be misattributed to attainment of goal blood pressure, even if that target blood pressure is a modest one, with the consequence that antihypertensive...

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  • Response to: "Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys". A medical student perspective.

    Dear authors,

    Your recent report titled “Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys”(1) provided a thought-provoking read.

    As highlighted in your report, the uptake in training for specialties such as general practice continues to remain low. I strongly agree that in order to address this it is necessary to identify the factors that determine career choice in junior doctors. Furthermore, to encourage doctors to peruse undersubscribed specialties, it may be useful to identify the stage in training that the foundations of career choice are made. This may provide an opportunity to spark interest about these low uptake specialties in doctors who are still open minded about their future career.

    Your report demonstrates that even very early on in training, many doctors have a definite choice about their future specialty (1). Data collected from students at Brighton and Sussex medical school demonstrated that specialty choice is highly influenced by student’s experiences at medical school (2). I am a fourth year medical student, currently rotating through these various specialty placements and beginning to realistically consider my own personal career options. I too believe that the clinical phase of medical school may hold a unique window to motivate students to become interested in those undersubscribed specialties.

    Earlier this year a cohort study at the University of Dundee showed t...

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  • Promoting resilience among physicians is not an effective way to tackle burnout.

    In recent times, a lot has been spoken about the concept of ‘promoting physician resilience’ to tackle burnout.(1)(2) However, since the definitions and the strategies of resilience revolve around intrinsic factors, there is skepticism about this concept.(3) Now that the focus is being shifted towards the external factors influencing the burnout, this systematic review by Fox et al redefines ‘resilience’ in order to incorporate these external determinants into the domain of resilience.(4) While this letter agrees with the views portrayed by the authors of the review, it additionally discusses certain drawbacks of stressing the promotion of physician resilience.
    Though the resiliency training program, focusing on personal and psychological empowerment of physicians, temporarily improved the resiliency rates, it did not reduce the reported levels of fatigue among the participants.(2) Such resiliency methods in isolation do not seem to have a long-term benefits on the day-to-day practice in medicine. However, they may be handy even as a standalone strategy, in recharging the professionals in certain temporary situations like epidemic breakout, disaster scenario, warfare etc. Another drawback of repeated usage of resilience strategies is that it may render them ineffective with time, even in the same individual in whom the same strategies would work wonders earlier. In addition, repeated resiliency sessions could dilute the strive for perfection in medicine be...

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  • Re: [Medical research and audit skills training for undergraduates: An international analysis and student-focused needs assessment]

    Dear Sir,

    It was a pleasure reading Fitzgerald’s study on provision of research/audit opportunities and skills required to conduct such projects[1]. As medical-students, it was revealing to read statistics on how our contemporaries reported lack of formal research opportunities and training. As part of Europe’s largest medical school[2], one with a strong reputation that no doubt hinges on viable research output, we were not surprised by these results.

    Though we agree with the article’s conclusions, we’d like to offer our thoughts on factors affecting student output and improvements that could be made.

    From our experience, the main ways students are granted research opportunities are through Student Selected Components (SSCs) and intercalated BScs. Timescales for these are 5-6 months, with most having a shorter duration. Usually this is enough for a topic introduction, let alone information accumulation for an acceptable paper. Moreover, iBSc-derived research offers opportunities to access respected research teams and get better publications. We know students published in Nature due to their iBSc modules[3]. However, these modules are invariably oversubscribed, meaning students without sufficient marks are often excluded. Lastly, because of time and location demands on students during clinical years, it is likely most student publications come from research exposure during iBSc. The importance of this publication route needs further investigation....

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  • Response

    I was disappointed by this attempt to rebut my hypothesis.

    My hypothesis was not inchoate (OED “confused or incoherent”) as they obviously understood exactly what I wished to suggest – the conventional wisdom might be wrong or at least need some modification and that Carbon dioxide excretion may play a part in weight regulation.1

    We agree that the general public and health professionals are bewildered about weight regulation. That is not a reason to stop thinking and restate conventional wisdoms.

    We agree that “the majority of people they surveyed believed that that ”fat shed during weight loss was converted to energy rather than excreted as carbon dioxide and water.” That is not a reason to stop thinking and rely upon conventional wisdoms. I recall a paper that made the point that exhaled Carbon Dioxide might be relevant to fat loss.2 Indeed most people seem to assume that weight can be lost purely by energy production “raised metabolic rates” without a net excretion of heavy atoms but this is a conventional wisdom that is only correct in nuclear reactors in which E=mc2.

    Of course self –reporting of food intake is notoriously unreliable. But do we condemn as recidivists3 all those whose weigh loss plateaus on a diet? The same paper suggested a metabolic resistance to the maintenance of a reduced body weight. I merely provided a possible mechanism for this.

    We agree that “diets only succeed when the age-old advice to eat less and mov...

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  • Fake peer review: many faces

    Fake peer review: the many faces
    Viroj Wiwanitkit1
    1. Honorary Professor, Dr Dy Patil University, Pune Inida
    Email: wviroj@yahoo.com

    I read the recent publication by Cheung BMY with a great interest [1]. In fact, this problem is not uncommon and can be seen elsewhere.

    Reviews that seem overtly positive can be a clue for suspicious fake reviewing. It is the role of the journal editor to select the reviewer and consider the quality of the review. The fake reviewing might be by a non-existent (totally fake) person or a disguised reviewer. Sometimes, it can be a totally biased reviewer who is recommended by the submitting author.

    In addition, a similar problem can also be seen in academic presentations, proposal decisions, funding decisions, as well as academic position appointment decisions. In some underdeveloped countries, it is surprising that non-scientific reviewers can act as academic reviewers when academic work is under consideration. This reflects a poor standard and should be considered as an unacceptable misconduct.

    conflict of interest

    1. Cheung BMY. Fake peer review - too good to be true. Postgrad Med J. 2017 Jun 7. pii: postgradmedj-2016-134506.
    Conflict of Interest
    None declared

  • Re: [Verification and feedback for medical students: an observational study during general practice rotations]

    Dear Editor,

    It was with great pleasure that we read the observational study by Bosner et al [1] which centres on an aspect salient to all medical students: clinical teacher feedback [2][3][4]. A factor highlighted by Lempp et al, found that students were most pleased with teachers who were approachable and provided them with constructive criticism [4].

    As undergraduate medical students at the largest centre for healthcare education in Europe [5], we benefit from experiences in varied teaching settings; ranging from one-to-one sessions to class sizes of up to 450 students. Our clinical curriculum places strong emphasis in the primary health care setting - where we have accumulated nearly 300 hours between us in around 40 practices, both in and around London.

    Whilst Bosner et al [1] have presented a well-organised and structured study; we challenge some of the intricacies affecting its overall validity and subsequent conclusions, and therefore propose suggestions for improvements. There is an absence of information pertaining to whether the observers (fifth year medical students) were appropriately trained to effectively judge the quality of feedback given by their seniors (clinical teachers). This is then coupled with no mention of any guidelines or reference used as a “benchmark” for this assessment. Both present issues regarding quality assurance - the necessity and impact of which has been highlighted by Lievens [6].

    The presence of the ob...

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