comment “NHS staff's TikTok dances are feeding the hostile social media beast” DAVID OLIVER “To establish trust, we need transparency and everyday language” HELEN SALISBURY PLUS Covid’s impact on defensive medicine; a child’s right not to be hit

CRITICAL THINKING Matt Morgan Covid and that other pandemic—lies t’s been a long weekend. The growing number must also speak no evil. Instead, they scream it at of my colleagues self-isolating has led to the top of their lungs. Half of the profi les pushing the increasing gaps in our rota. Combined with the unethical, dangerous, and discredited case for herd unwelcome return of covid-19 to intensive care immunity through the Great Barrington Declaration Iunits throughout Europe, the long hard summer were artifi cial, bot-like accounts, amplifi ed by social is morphing into the longer, harder winter. I let out a media above the consensus view. slow exhale as I sink into my sofa after arriving home As doctors, nurses, and patients, we must move late on a Sunday night. Time to recharge, relax, and beyond blaming individuals who respond to these refl ect—but a million voices are shouting at me. bad ideas and bad incentives: instead, let us task A video on YouTube tells me that the covid tests I the companies with taking responsibility for their ordered were false. A Facebook post proclaims that output. If not, they can fund the intensive care masks are simply a tool of government oppression. beds, the staff sickness gaps, and the tissues Twitter advises me that those death certifi cates I’ve to wipe away tears when their broadcast written were lies. The hardest part of my day should untruths result in real world harms. be the time I spend at work, not the time at home. Matt Morgan, intensive care consultant, With so many voices screaming, it’s hard to hear the University Hospital of Wales whispers that really matter. “Thank you” is always [email protected] quieter than “F**k you.” Twitter @dr_mattmorgan Yet the clamour of social media—what Sacha Baron Cite this as: BMJ 2020;371:m4516 Cohen has called “the biggest propaganda machine in history”—is alive and well. We’re battling two pandemics, not one. Fake news outperforms real news. Lies spread more quickly than truth. And the Likes can results aren’t just likes or retweets. Likes can quickly quickly turn to hate. This results in real harm to patients, to turn to hate, families, and to the staff trying their damnedest to care for them no matter what their beliefs. resulting in I strongly believe that there are very few bad real harm people in the world. But there are plenty of bad to patients ideas and bad incentives. A publisher that can’t take responsibility for its content is like a restaurant that can’t safely cook chicken. The restaurant would be shut down, but social media platforms continue to thrive on their digital currency of empty gestures and polarising incentives. Now, more than ever, the big social media companies should stand up or shut up. It’s fi ne if they want to see no evil or hear no evil, but then they the bmj | 28 November 2020 359 PERSONAL VIEW Minna Johansson and Iona Heath Can covid help end the rise of defensive medicine? The threat of the virus has made us take a step back and critically refl ect on our priorities and our actions K, let’s leave it at that disability? Would the woman who avoided a Much too seldom do we consider then”—an unexpected CT scan have had an incidental fi nding with the potential harm of those response from a man who subsequent cascades of interventions with investigations we do “just in case” has just been told his chest doubtful benefi t and possible harm? Would “O pain is unlikely to come the man who was not sent to the emergency bring direct harm to people through adverse from his heart. Before the pandemic, it was department have undergone unnecessary eff ects, psychosocial impacts of labelling, more common to hear, “I still want to know for explorative laparoscopy? Probably not in and overwhelming burden of treatment. sure.” A few hours later, another unexpected these cases—but certainly in some. Overuse and overdiagnosis also consume response from a radiologist about an We have also seen cases when patients have scarce resources, leading to underuse incidental fi nding on a computed tomography not received essential care: a man waiting an and underdiagnosis in other areas, which scan, “very unlikely to be signifi cant—you unacceptably long time for a colonoscopy for lead to increased inequity. Healthcare don’t have to do a control CT.” A comment symptoms indicating cancer; a woman waiting spending grows all over the world, with poor rarely heard from a radiologist before covid. too long to see a psychiatrist for grievous correlation between increased costs and We have seen many examples of when psychotic symptoms; a woman with dementia improved health in high income countries. such hands-off approaches, as a direct result fading and eventually dying from “depression” The reasons behind this development of the pandemic, have been benefi cial to our caused by nursing home visiting rules. are multifaceted with vested interests patients: a man whose knee replacement playing a crucial role. But we should not surgery was postponed and who got so Hospitals can be dangerous places underestimate the power of culture; all the much better he no longer needed surgery; a The strong focus on covid has indeed had high way from medical school, to the consultation, woman whose headache improved during costs. But we argue that covid-19 has helped to informal collegial discussions, to the the prolonged waiting time for a CT scan doctors, patients, policy makers, and the science underpinning our eff orts—medicine is that could thus be cancelled; a man with public to understand, more clearly than ever, permeated by a bias towards doing something abdominal pain who would have been that hospitals can sometimes be dangerous rather than nothing, even when it may do referred to the emergency department but places, and not a resource to use lightly. more harm than good to our patients. was not because of the fear of covid-19 There is an increasing recognition that Doctors failing to diagnose are resented and then recovered spontaneously. Would defensive medicine threatens people’s health and sometimes punished, while doctors the man who avoided knee surgery have and the sustainability of health systems. who cause suff ering through overdiagnosis had a serious complication with lifelong Unnecessary tests, treatments, and diagnoses and overtreatment are not. Much too seldom

BMJ OPINION Tamasin Knight Scotland is right: With the Children (Scotland) Act coming into That some children escape harm is force on 7 November, all physical punishment no reason to fail to protect the rest children need of children is now unlawful. This is a significant moment for children’s rights, and mean is hitting children. The UN Committee legal protection in improving the health and wellbeing of the on the Rights of the Child is clear that any from assault population of Scotland. form of physical punishment is a breach of Similar legislation will come into force in children’s human rights. Wales in 2022—but there are no plans to give The evidence regarding the harmful effects children in England or Northern Ireland this of using physical pain to discipline children same protection. is strong and consistent—it can damage It isn’t right that a child in the north of children’s health and wellbeing. It is linked England is denied the rights and protection with a range of adverse outcomes including that a child living a few miles north in increased aggression and antisocial Scotland now enjoys. Article 19 of the UN behaviour, and with depression and anxiety. Convention on the Rights of the Child is If we want to give children the best start in life the right to be protected from all forms of they need to be protected from experiencing violence. Violence exists on a continuum; and physical punishment. it’s important to call things what they are— It is perhaps no surprise then that the Equal when we talk of “smacking” what we actually Protection from Assault Bill (now Act) was

360 28 November 2020 | the bmj ACUTE PERSPECTIVE David Oliver Time for social media acts to bow out?

hould anyone care if NHS nothing specifi cally covers this stuff , so staff post a few loosely we’re in the clear, right? On refl ection, I’m choreographed dances on not so sure. TikTok, a healthcare themed I know how hard my colleagues work, choral routine on YouTube, or how much they care, and how tough their

PAUL BOSTON PAUL S an unburdening rant on Facebook? jobs can be. But TikTok dances by staff in do we consider the potential harm for our NHS shop fl oor clinical teams have uniform last spring are used in columns patients of those investigations that we do always laughed together, drunk together, hostile to the NHS and those that trivialise “just in case.” Expectations from patients and shared their frustrations in rest areas, the pandemic. This invites comments and a fear of being sued are reasons often accommodation blocks, and messes. But, along the lines of: “See! They’re all sitting given as excuses. This may be true, but the until social media, we kept them among around because hospitals are empty and anxiety of the doctor as a driver of defensive ourselves. The pandemic has led to plenty GP surgeries are closed and have time for medicine should not be underestimated. of pressures on teams, so a desire to dances!” We’re feeding the beast. Central to this culture is a failure to manage de-stress or unburden is understandable— I’ve also seen pandemic era criticism uncertainty wisely. Uncertainty will always but have we taken it too far? suggesting that self-recorded videos of be inherent to the practice of medicine. Yet My immediate feeling is that it’s nobody’s tearful clinical staff , or photos of trolley the sudden shift in culture during these business how frontline staff in demanding strewn corridors, or ICU staff in full past months is apparent. We have begun to roles let off steam, so long as we continue protective gear, have encouraged some enact what we have known for a long time to do our jobs to the best of our abilities. patients to stay away from hospital. These from experiences in palliative medicine: Post what you like; ignore the haters. clips could fuel a desire to protect the NHS the importance of carefully considering the Health professionals already have clear and unwittingly add to people’s fears of benefi ts and harms of every intervention and guidelines from regulators, unions, and hospital acquired covid-19. diagnosis—not just in terms of biomedical defence organisations on social media I very much distinguish between such outcomes but also in the patient’s social, use. These focus on issues such as patient performances and doctors legitimately psychological, and existential experience. confi dentiality, respectful treatment sharing their views, data, clinical care Every intervention and diagnosis should of colleagues, and non-discriminatory experience, or research evidence, and bring something meaningful to the patient. language. They say nothing about a lunch joining in the policy debate. We’re private This pandemic has caused brutal suff ering— break fl ash mob dancing in a corridor or citizens too, and advocacy is part of our but it may also help improve our unsettled an end-of-day chat to a camera phone. professional duty. But on balance, when relationship with uncertainty. Of course, general guidelines from the it comes to song and dance routines or Minna Johansson , director , Cochrane Sustainable GMC or the Nursing and Midwifery Council emotive videos when in work clothes or Healthcare [email protected] discuss not harming the profession’s on site, we should be more cautious—and Iona Heath , retired general practitioner, London reputation. Individual employers have perhaps, if in doubt, not post at all. Cite this as: BMJ 2020;371:m4544 guidance on social media, and David Oliver, consultant in geriatrics and acute doctors’ employment contracts general medicine, Berkshire provide some protections [email protected] for work away from clinical Twitter @mancunianmedic supported by the BMA Public Health Medicine care, including media. But Cite this as: BMJ 2020;371:m4497 Committee as well as the wider medical community, including royal colleges. Some adults may remember being hit by TikTok dances their parents and feel this did them no harm. The fact that some children escape harm is by staff in not a reason to fail to protect the rest. As a uniform child I travelled hundreds of miles in a car with are used to no seat belt and it did me no harm, yet some trivialise the children were harmed because they were not pandemic required to wear a seat belt. So we now have legislation to protect all children in cars. It is not legally justifiable to hit a partner, elderly relative, or adult with learning disabilities. Children—across the UK—should have the same protection from the law. Tamasin Knight is a consultant in public health medicine at NHS Tayside and co-deputy chair of the BMA Public Health Medicine Committee the bmj | 28 November 2020 361 PRIMARY COLOUR Helen Salisbury LATEST PODCAST S Careless communication costs lives

ost patients want to wouldn’t be raging now. As it stands, with know “What have so many people infected, we have to take I got? Why? What drastic measures to prevent new fi res and next?”—and doctors hope limited interactions mean the sparks M spend a lot of time die out before new fl ames are kindled. (As explaining diagnosis, cause, treatment, a side note, the impossibility of allowing and prognosis. An important part of the general population to carry on as our training is learning to translate our normal while shielding only vulnerable technical knowledge into language that people is like trying to keep fl uids apart will mean something to our patient. in a public recreation facility: “There’s no Vaccines: how ready is the One tool we use is analogy—comparing piss-free lane in the swimming pool.”) needle to hit the arm? atherosclerotic arteries to furred-up pipes, Given the huge amount of money that or conjuring images of battles between has reportedly been spent on consultancy, The latest podcast in the Second Wave series immune defences and invading pathogens. it’s surprising communication remains focuses on what we know so far about the Analogies are useful, but not if they so poor. Johnson’s address to the nation vaccine contenders for covid-19. Here, Katrina are stretched too far. Comparing statins announcing the second lockdown Pollock, a senior clinical research fellow in to limescale remover, or antimicrobial involved graphs that were complex vaccinology, discusses what data she would like drugs to cleaning products, can lead to and illegible. The rules are often so to see before these vaccines are approved and dangerous misunderstandings. And complicated that ministers contradict rolled out for public use: many people fi nd military metaphors each other or can’t explain them. “The first thing I want to see is the safety unhelpful in illness and healthcare. We face many obstacles in this struggle, data; that’s absolutely paramount. I want to This pandemic has been marked and a vital fi rst step is convincing people know how well the vaccines were tolerated and by poor communication from our that restrictions are necessary. A basic whether there have been any severe adverse government and its spokespeople. At one understanding of exponential growth is reactions. We need to see all of that so that we stage Boris Johnson talked about local helpful: it may not look like a problem can predict how the vaccine might behave when lockdowns as a “whack-a-mole” strategy. if two patients are in intensive care it’s given to millions of people. At the same time, Quite apart from the bizarre levity of with covid in early November, but if the we want to know which part of the infection comparing control of a lethal infection number doubles every two weeks, we’ll disease cycle the vaccine is actually modifying, to a children’s game, this implied that run out of space before Christmas. and that’s not a straightforward question.” suppressing the virus in one place means To establish trust, we need transparency it will inevitably pop up elsewhere. around the data behind these decisions— What we’ve learnt from More helpfully, the Welsh government and we need them to be translated into treating doctors implemented a metaphorical “fi re break” easily understood language so that people GPs Clare Gerada and Zaid Al-Najjar have been to reduce transmission. This is apt, know what they need to do, and why. treating doctors through the NHS Practitioner because if we’d managed to put out Helen Salisbury , GP, Oxford Programme. In this Wellbeing podcast, they the embers over the summer by [email protected] reflect on what they’ve learnt about the using an adequate test, track, Twitter @HelenRSalisbury problems that affect doctors and how covid-19 and trace system, the fi re Cite this as: BMJ 2020;371:m4383 has exacerbated some of them, with Gerada speaking about the broader context here: A vital first step “For doctors, the way we’re trained is to deny our own needs. That’s fine when the system is convincing around you protects you—if the system puts people that limits on the amount of hours you can work, restrictions or puts limits on your own internalised sense of failure. But, unfortunately, the system pre- are necessary pandemic didn’t do that and, other than a very few places, it certainly didn’t do that during the first wave. So what we had were doctors doing back-to-back 12 hour shifts, feeling guilty for not having PPE, or feeling guilty for letting their colleagues down because they were shielding.”

Listen and subscribe to The BMJ podcast on Apple Podcasts, Spotify, and other major podcast apps Edited by Kelly Brendel, deputy digital content editor, The BMJ

362 28 November 2020 | the bmj ANALYSIS Have increases in fast track referrals improved UK bowel cancer outcomes? More precise risk stratifi cation is required to enable timely diagnosis of bowel cancer while avoiding unnecessary investigation, argue Michael Thompson and colleagues

epartment of Health predictive value for cancer decreased The 3% risk Effect on general practice policies to improve from 14% to 8%3 - 7 (table). threshold survival from bowel Because survival from cancer means that a Public awareness campaigns, by not cancer through GP was still lower in the UK than in clinician would fully taking into account the concept of 11 17 D referral guidelines and most developed countries, public need to see the “symptom iceberg,” have greatly public awareness campaigns have awareness campaigns were introduced increased the numbers of the worried 12 32 patients 18 increased urgent referrals to hospitals. in 2011 and NICE issued new to diagnose well seeing their GPs in primary care. This has led to an unsustainable guidelines in 2015,13 liberalising the The number of people seeing their GP one cancer demand for colonoscopy and CT referral criteria with a 3% threshold with bowel related symptoms is only colonography without evidence of for risk of cancer. These changes a small fraction of all those who have signifi cant clinical benefi t. These were applied to bowel cancer, even these symptoms. Thus even small policies could be improved by more though a review,1 15 published before increases in the proportion of people precise stratifi cation of the risk of the introduction of the original seeking advice could result in a greatly having bowel cancer to achieve guidelines, had found little evidence increased workload for GPs. prompt, rather than earlier, diagnosis of benefi t from earlier diagnosis while avoiding over-referral and of symptomatic bowel cancer. The Effect on hospital services investigation of patients with public awareness campaigns resulted transient symptoms from benign in a 62-77% increase in referrals,5 - 7 To cope with the increase in fast track conditions. and falls in predictive values for referrals, hospitals initially provided cancer to 4-9%5 - 9 (table). The new additional outpatient clinics. However, Development of GP NICE referral criteria resulted in a capacity was soon overwhelmed, referral guidelines further 78-100% rise in referrals8 9 leading to strategies designed to and fast track clinics with reductions in positive predictive reduce face-to-face consultations, values8 - 10 to 3% (table). including telephone triage, nurse led The fi rst UK cancer plan was Some subgroups of patients who clinics, and booking people straight developed in 2000 to improve are referred have a risk of cancer well to test.8 21 Such approaches only outcomes for patients. The plan below the 3% threshold, including transferred the increased workload introduced the concept of the “two those whose symptoms have resolved from clinics to radiology and week wait,” from urgent GP referral or have had a previously normal endoscopy departments. 9 Increases in to the fi rst outpatient appointment. colonic investigation.10 requests for CT colonography, which In 2000, the committee developing now exceed requests for colonoscopy the referral criteria for bowel KEY MESSAGES (2:1 ratio in Portsmouth), require cancer1 advised that only those outsourcing and training of advanced • The increase in referrals 22 with symptoms persisting for six to fast track bowel cancer practitioner radiographers. weeks should be referred. The 2005 clinics and requests for whole The 3% risk threshold means that a National Institute for Health and colonic imaging are becoming clinician would need to see 32 patients Care Excellence ( NICE) review of unsustainable to diagnose one cancer. A standard of the guidelines largely endorsed the • Evidence that fast track clinics lead to diagnosis eight patients per clinic would require referral criteria, which identifi ed of earlier stage bowel cancer and improve survival four clinics taking a clinician 20 hours, nine out of 10 bowel cancers and is weak not including the time needed for had a 9-14% predictive value for Many people without bowel cancer worry patients having whole colonic imaging. 3 4 • cancer (table). Fast track clinics unnecessarily and have potentially harmful Numerous audits presented at the reduced time to diagnosis but not investigations British Society of Gastroenterology 3 4 to treatment. Over the following • Improved stratifi cation of the risk of having bowel and Association of Coloproctology of nine years the number of referrals cancer could help to solve these problems Great Britain and Ireland attest to a increased by 45% (table) while the worsening of these problems. the bmj | 28 November 2020 363 Effect on bowel cancer 2015 NICE guidelines showed no improvement in the stage of cancer. 28 outcomes 15 The review undertaken in 2000, The 2000 and 2005 NICE guidelines before the introduction of two week increased referrals but did not lead clinics, included a prospective study to signifi cant improvements in of 5173 patients, which showed cancer stage3 - 23 or survival.6 24 The that almost half of all deaths from 2015 NICE 3% risk threshold was bowel cancer occurred in those introduced for a range of cancers to treated without delay, and of the 60% widen the net, on the basis that this who survived, many had had long would lead to a greater number of delays. This suggests that the critical early referrals and facilitate diagnosis point at which most bowel cancers of cancer at an earlier, more curable, become incurable is either before, or stage.13 - 25 long after, the onset of symptoms.27 The new guidance was mainly Thirty nine other studies were also based on observational studies, 25 reviewed,15 of which 16 showed worse which suggested that reducing survival after earlier diagnosis, fi ve diagnostic delay in primary care better survival, and 18 no diff erence. Delays to Effective and efficient improved survival. The evidence for The review also noted that delays treatment management of bowel cancer compared with breast to treatment are the same in the UK are the same symptomatic patients and lung cancer was less clear,19 25 as in countries reporting better fi ve in the UK as however, and there was no evidence year survival,15 making it unlikely in countries Diagnosis of symptomatic bowel that improvements in survival would that delay is a major cause of worse reporting cancer must be effi cient as well as be cost eff ective.25 survival in the UK. Delay from the better five year eff ective.34 Precise stratifi cation of Bowel cancer screening in the UK onset of symptoms to treatment is survival the risk of bowel cancer is essential to by faecal occult blood testing26 and shorter in patients with bowel cancer identify those at higher risk, with one fl exible sigmoidoscopy is off ered who are referred as an emergency of its seven typical characteristics for to patients aged between 50 and rather than to outpatient departments prompt referral and investigation. It 74. A positive test in bowel cancer (2.1 v 7.2 months),15 which supports is also as important to identify people screening, with a 10% yield of cancer the view that the biological behaviour at low risk for longer treatment in achieves a relatively small 15% cost of a cancer is the major factor in primary care, with later referral if eff ective improvement in survival.26 It determining time to diagnosis19 29 and symptoms persist. is unlikely that investigation of more survival.29 30 Although there has been Many studies have identifi ed the patients with a 3% risk of having an overall reduction in emergency typical presentations of symptomatic cancer at later stages in their natural admissions since 2013,31 the 36% bowel cancer, which have not changed history,27 when more will have become also requiring emergency surgery32 over many years. 1 Combinations of incurable, will result in similar has not decreased, and as most other symptoms have greater predictive benefi ts. patients already have shorter delays to value than a single symptom.1 35 Five years after broadening the treatment15 it is unlikely that diverting Studies in primary16 36 and secondary guidelines, a study on 14 026 patients these patients to two week clinics will care,2 based on a structured history, seen in fast track clinics before signifi cantly improve their chance of show that over 85% of bowel cancers and after the introduction of the survival. 33 present with one of four age/symptom combinations (box, p 365). Fifty per Increase in number of patients referred to UK two week clinics and decrease in predictive values cent present with a combination of Year of study Reference No of participants Increase in referral (%) Predictive values (%)* rectal bleeding and a persistent change Introduction of GP referral guidelines: in bowel habit to increased frequency 3 2000 to 2005 Thorne (review) 2006 2440 — 10.3 (9-14)† of defecation and looser stools.2 - 36 v 4v v v 2000 2010§ Flashman 2004 2010§ 695 1010 45 9.4† 10.9† Over 90% of patients present with one of three age/symptom combinations Introduction of the public awareness campaigns in 2011: 2010§ v 2014 Flashman 20155 1010 v 1636 62 10.9† v 4.1 ‡ and an abdominal or rectal mass or 2 2005-09 v 2011-12 Aslam 20176 1676 v 2972 77 8.3† v 5.2 ‡ iron defi ciency anaemia. Only 135 2009 v 2014 Vulliamy 2016 7 1706 v 2874 68 7.9† v 4.7 ‡ (1%) of 12 605 patients referred to hospital without these characteristics Introduction of NICE 2015 revision of GP referral guidelines: had bowel cancer.2 These studies show 2015-17 Christopher 20178 702 v 1251 78 8.5 ‡v 3.5 ¶ it is now possible to stratify patients 2014-18 Maclean 2020 9 709 v 1414 100 7.5 ‡v 3.7 ¶ according to risk simply on the 10 2018 Flashman 2019 866 — 3.1¶ basis of a structured history, clinical *Percentage predictive values for three time periods: †After the introduction of GP referral guidelines until the introduction of public awareness campaigns: 2000-11; ‡After the introduction of the examination, and the results of a blood public awareness campaigns but before the introduction of 2015 NICE guidelines: 2011-15; ¶After the introduction of the 2015 NICE guidelines test for iron defi ciency anaemia, in 2015-19. §Flashman personal data for 2010. both primary16 36 and secondary care.2

364 28 November 2020 | the bmj Diagnosis of asymptomatic cancers

Bowel cancer typically has a long asymptomatic phase. Many cancers become incurable before the patient develops any symptoms.27 By contrast, diagnosis of cancers by screening 26 has been shown to detect early stage, more curable cancers. If the relatively poor uptake of screening and the sensitivity of the test could be increased—for example, by the faecal immunochemical Public awareness campaigns test, this could greatly reduce death for bowel cancer were introduced in the UK in 2011 from bowel cancer. Conclusion Investigations must be used of their symptoms. Giving written Seven typical appropriately. The ideal investigation information to patients may UK public awareness campaigns in characteristics of is whole colonic imaging. Outpatient reinforce messages about provision bowel cancer2 2011, and revision of the NICE GP fl exible sigmoidoscopy identifi es of a safety net20 and make clear the referral guidelines in 2015, have around 85% of bowel cancers 37 and need to seek further advice if their • >50% of all substantially increased referrals to patients with as most of the remaining 15% of symptoms persist or recur. fast track clinics. These referrals are bowel cancer cancers have an abdominal mass, Another approach to overwhelming hospital resources present with iron defi ciency anaemia, or early stratifi cation for risk in rectal bleeding without producing the expected symptoms of colonic obstruction, symptomatic patients, which in combination increases in survival. The policies the diagnostic yield of whole colonic is rapidly becoming more with a persistent did not take into account the high imaging in patients without these accepted, is the use of the faecal and unremitting prevalence of bowel symptoms in the characteristics can be as low as 0.1% immunochemical test. NICE change in bowel absence of underlying cancer, and (6/4132).2 Flexible sigmoidoscopy, recommends the use of the habit to increased failed to ensure that only those with with highly selective whole colonic faecal immunochemical test for frequency of persistently higher risk symptoms imaging and later referral only if patients without rectal bleeding defecation and and signs were fast tracked for urgent looser stools symptoms persist, could safely reduce and unexplained symptoms investigation in hospital. the need for these investigations. who do not meet the criteria for • >20% have a Improved risk strafi cation and Many people in the community referral for suspected cancer.39 similar change internet decision support for the in bowel habit with symptoms associated with Recent work suggests that the public and doctors could avoid without rectal cancer may benefi t from more faecal immunochemical test can excessive delays in diagnosis while bleeding nuanced information, which can eff ectively rule out cancer, even in safely reducing the number of • >12% have only be given by internet decision patients with higher risk symptoms people without cancer undergoing persistent rectal support tools. In primary and who do meet referral criteria.40 unnecessary investigations. In the bleeding without secondary care, internet decision A large observational study anal symptoms future faecal immunochemical testing support based on referral guidelines showed a reduction in referrals without a change may further improve patient selection. that aim to identify or exclude the to secondary care of 15% in the in bowel habit Screening identifi es patients with seven red fl ag symptoms and signs fi rst year of triaging with a faecal • <2% have bowel cancer before they develop of bowel cancer, could help health immunochemical test, with a abdominal symptoms and represents higher value professionals to confi dently identify sensitivity for cancer of 90.5% and pain as a single clinical activity. and advise patients at low risk of a specifi city of 48.6%.41 As a small symptom, Forty eight years ago Cochrane 34 having cancer that it is safer to “treat, number of patients with cancer which is always pointed out the importance of effi cient watch, and wait” and accept some have a false negative test, it is still provoked by as well as eff ective healthcare. Now degree of uncertainty38 rather than to necessary to provide a safety net for eating, causing more than ever, the right test for the have immediate referral for invasive these patients.20 weight loss right patient at the right time is an investigations that might cause harm. It is important that patients • 25% have a rectal important goal for all. Many patients’ symptoms resolve and the public are involved mass Michael Thompson, consultant colorectal within six weeks.1 If symptoms do not in developing safe diagnostic • 12% have an surgeon, Queen Alexandra Hospital, resolve and remain low risk, patients, strategies for those at low risk of abdominal mass Portsmouth [email protected] particularly those having previous having cancer. People, particularly • 8% have an On behalf of Daniel O’Leary, Iona Heath, Lynn normal colonic imaging,10 should be those who have had bowel cancer, iron deficiency Faulds Wood, Brian Ellis, Karen Flashman , Neil Smart, John Nicholls, Neil Mortensen, referred to routine gastroenterological can contribute to the development anaemia with or Paul Finan, Asha Senapati, Robert Steele, or surgical clinics for reassurance and of referral guidelines and internet without bowel symptoms Peter Dawson, James Hill, Brendan M oran specialist advice on the treatment decision support. Cite this as: BMJ 2020;370:m3273 the bmj | 28 November 2020 365 LETTERS Selected from rapid responses on bmj.com

COVID-19: AGE AND OBESITY AS HIGH RISK FACTORS

Covid-19 risk for older people at work As age advances, the risk of death with covid-19 infection increases markedly (News Briefing, 31 October). In late 2019, men and women over 65 in employment numbered approximately 1 326 000, representing 4% of the total paid workforce. But continuing workplace engagement can be associated with increased covid-19 related risk. Problems that might occur either in the workplace or while commuting include difficulties maintaining safe LETTER OF THE WEEK social distancing and ensuring consistent mask or visor wearing by others. Can the risks be minimised? An “age stratified” approach to risk in the workplace might Covid-19: uncertainty and shared be considered. Could home based working become the universal norm for older people? decision making Nobel laureate Thomas Mann said, “Everything is politics.” The challenge for our politicians is to find a workable formula that keeps the country’s economy functioning I agree with Davey Smith and colleagues about the while minimising the personal risks of catching covid-19 for those most at risk of dying if expression of certainty in covid-19 communications they become infected. and the effects on trust and public beliefs (Editorial, Stephen T Green, honorary professor of international health and consultant physician , Sheffi eld; 31 October). Lorenzo Cladi, associate head (teaching and learning) , School of Law, Criminology, and Government, Certainty is reassuring for the general population University of Plymouth Cite this as: BMJ 2020;371:m4528 at times of crisis. Certainty around severity increases perceived susceptibility, and clarity on ETHNIC MINORITY DOCTORS’ PROGRESSION resulting required behaviours provides a sense of control. But with declining certainty, we erode that The devil is in the detail datasets and ask whether they are doing trust. This is diametrically opposed to our clinical enough to achieve a true meritocracy. The Royal College of Physicians’ finding model of shared decision making, which helps Only then can we drive change. that ethnic minority doctors are less patients weigh up the pros and cons of difficult Surash Surash, consultant neurosurgeon, likely to get consultant posts reflects health trade-offs so that decisions are made Newcastle upon Tyne the concerns raised by numerous senior through discussion of values, preferences, and Cite this as: BMJ 2020;371:m4496 trainees (This Week, 31 October). The different likely outcomes. NHS Workforce Race Equality Standard Current communication around covid-19 has led data show the same thing. These datasets History repeating itself to polarisation and dismissal of rival positions. The reinforce the subjective narrative but fail In 1912 Harold Moody was denied the evidence base usually acts as an impartial referee in to support the objective experience. And opportunity to practise medicine at King’s shared decision making, but, as the authors rightly subjective experience is easier to dismiss. College Hospital, despite qualifying point out, the evidence is uncertain for a disease in Individual employing organisations at the top of his class, because he was its infancy. The presentation of personally changed must properly scrutinise their own black. A landmark paper published in positions is a fitting end to the article. datasets. My organisation’s data show The BMJ in 1993 indicated that doctors Uncertainty is often not deemed fit for public that a white applicant to a consultant with English names were twice as likely to consumption. We recognise that clinical decision position is 1.65 times more likely to be be selected for senior house officer jobs making can be surrounded by uncertainty, so we shortlisted and 1.53 times more likely to than those with Asian names, despite discuss this with patients using a combination of be appointed. The devil is in the detail, having identical training and experience. their preferences and agreed further investigations. and our objective datasets reflect the lived Earlier this year, a study of appointments Interestingly, as new evidence on the condition subjective experience of our staff. to specialty training posts found that the comes to light, we may change our initial positions Royal colleges, Health Education chasm between ethnic minority doctors together, and this might be a worthy temperament England, and employing organisations and white doctors still exists today. in public communication. We should be much should look at their own objective Racism is present in modern day better at representing and visualising the pros and medicine, with ethnic minority doctors cons of different positions, with more debate on the being more likely to be reported to the consequences of one route or another. General Medical Council and having lower The negative effects of covid-19 on population wages. More needs to be done to ensure mental health are in part due to ongoing economic that history does not keep repeating itself and social factors and bereavement. But loss or else the shortage of doctors we already of trust in science could have even greater see may worsen, with an exodus in search effects in the long term. The short term focus on of better working conditions. communications for immediate behaviour change Lakshya Soni, Jasen Soopramanien, Kirthi will not improve that. Shamanur, Sagar Mittal, fi nal year medical Mark Cobain, director , Younger Lives student s, London Cite this as: BMJ 2020;371:m4514 Cite this as: BMJ 2020;371:m4504

366 28 November 2020 | the bmj 31 October 2020 371:169-210 No 8266 | ISSN 1759-2151 VIDEO CONSULTATIONS Beware claims of covid certainty p 179 Winter lessons from Australia p 182 Healthworkers’ risk of covid-19 p 186 Equality and research funding p 193 Health inequality likely needs privacy, which can be 1 CPD hour in the education section We can hear only half a to increase challenging for those who live in telephone consultation, and overcrowded housing. they remove the possibility of Although video consultation has Solutions are possible: HHowow ttoo mmakeake students performing a physical benefits (Practice Pointer, 31 ssureure vvideoideo healthcare teaching programmes cconsultationsonsultations examination. While the article October), it may also increase wworkork could be provided and installing explains how to examine with health inequality. free, bookable, soundproofed video, this is more appropriate Many patients cannot engage video booths in community for experienced clinicians. The with video services. Internet centres, libraries, or surgeries inability to practise physical access remains inaccessible could ensure privacy, with staff to examinations does, however, to those who can’t afford it or advise on use of technology. highlight the importance of

don’t live in areas with good 371-8266-cvr.indd 1 27/10/2020 16:13 Ashley K Mehmi, urology registrar taking a thorough history. coverage. Some 77% of people (research); David Winters, urology While the move to digital aged over 70 have low levels of registrar (research); James S A Green, medical students are seeing professor and consultant urological clinics may be a necessary step digital engagement and almost surgeon , London more frequently; unfortunately, it to reduce the spread of covid-19, 10 million people in the UK have Cite this as: BMJ 2020;371:m4498 is not included in our curriculum. this could have a detrimental poor digital skills. The cost of We have observed clinics effect on the skills of future data is another barrier to patients both before and during the doctors. on low incomes. These problems Detrimental effect on pandemic. They are an integral are especially relevant for skills of future doctors Alexander E Dalton, fi ft h year medical part of our education, providing student ; Thomas L Christensen , groups where health inequality Thank you to Car and colleagues opportunities to see clinicians fourth year medical student; is already a major concern, such for providing clear guidance for taking histories and enabling Hannah F Starling, fi nal year medical as refugees or immigrants. A digital consultations (Practice us to speak to and examine student , Manchester healthcare consultation also Pointer). It is something that patients. Cite this as: BMJ 2020;371:m4492

SCIENTIFIC DIVISIONS ON COVID-19 previously for dental infection with antibiotics but without extraction of the infected teeth. Given the difficulty that many patients have in Time for open debate, without the offensive accusations obtaining dental treatment, this is understandable. But infected teeth McKee and Stuckler, notable policy analysts, say that scientific splits must be extracted. on covid-19 are not what they seem (Personal View, 24 October). The covid-19 pandemic has reduced dental availability, with even But they use injudicious language to undermine those who hold emergency appointments becoming difficult to obtain, and has also opposing views. raised anxiety in patients, possibly leading them to delay seeking They refer to “well meaning” scientists and health professionals who treatment. Antibiotic treatment alone is insufficient for dental infections. support the Great Barrington Declaration. There is no evidence that Gary C Cousin, consultant oral and maxillofacial surgeon; Imran Yousaf, registered supporters are any more well meaning than those who oppose it. This dental nurse , Blackburn euphemistic term subtly casts doubt on the calibre and credibility of Cite this as: BMJ 2020;371:m4466 any signatory. They justify the chief executive of NHS England’s use of the WALKING THE GREEN FIVE MILES word “apartheid.” This term denotes systematic segregation and Empathy for those working in other disciplines discrimination, and to be accused of such is highly offensive. The intention of those proposing an alternative approach is to better Morgan’s article about his experience wearing the scrubs of a healthcare protect vulnerable people. This is not the time for closing down debate assistant for the day presents a refreshing perspective, bringing empathy or attacking the integrity of those who hold different views. It is the time into sharp focus and breaking down the hierarchical barriers engrained in for thoughtful and reasoned scientific debate. medical culture (Matt Morgan, 31 October). Empathy is often considered Thomas Scanlon, honorary senior lecturer , Brighton in the context of patient care but is often neglected when working with Cite this as: BMJ 2020;371:m4538 colleagues. This is a perilous oversight that undermines the effective leadership and teamwork required to overcome adverse challenges such A RAPIDLY ENLARGING NECK SWELLING as those we face with covid-19. The increasingly specialised approach to healthcare promotes better Infected teeth must be extracted quality of care but risks insulating people from the challenges faced in Baily and Renwick discuss the management of Ludwig’s angina of dental other disciplines. This could leave the workforce unsupported in their origin (Endgames, 24 October). The immediate treatment comprises roles, threatening professional development and fostering feelings of airway management, fluid resuscitation, and antibiotic treatment. disillusion. Sometimes surgical drainage of the swelling is needed. An effective multidisciplinary team requires an understanding of not The authors report that the incidence of Ludwig’s angina has only each other’s roles but also the barriers our own positions present. decreased since the 1940s—would that were so. The incidence of severe Only then can we move towards true patient centred care. cervicofacial infections is increasing. One common factor in almost Matthew J Kane, masters student ; Henry M J White, senior house offi cer, London all our patients with severe infections is that they have been treated Cite this as: BMJ 2020;371:m4549 the bmj | 28 November 2020 367 Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES

Birnie Winchester Duthie Elkan (Chonon) Lewis Isaac Mohamed Nuseibeh General practitioner General practitioner Consultant surgeon (b 1928; q Aberdeen 1949), (b 1931; q Liverpool 1955; and spinal injuries died from Parkinson’s DObst RCOG, FRCGP), died rehabilitation specialist disease and heart disease from frailty of old age on (b 1933; q Alexandria, on 8 February 2020 4 April 2020 Egypt, 1960; FRCS Ed), Birnie Winchester Elkan Lewis (“Chonon”) died from a ruptured aortic Duthie was called up as was a wise physician and aneurysm on 3 August 2020 a medical officer in the a fine musician. Born Isaac Mohamed Nuseibeh Royal Air Force in 1950. In October 1952 in Liverpool, he won a scholarship to study was born in Hebron, Palestine, and grew up he was demobbed but continued on the medicine at its university. After house jobs, he in Jerusalem but had to leave as a refugee in reserve for five years as a flight lieutenant. was conscripted into the Royal Army Medical 1949. He worked in Kuwait before moving On his return to Aberdeen he worked as a Corps for two years. He specialised in general to Britain in 1963. He trained in general resident on the eye ward at Aberdeen Royal practice in London and became the principal surgery, urology, and spinal cord injuries Infirmary until a GP post became available. and trainer of a surgery in Leyton. He was a and was a consultant surgeon at Stoke In March 1953, Birnie took up the position violinist with the Brent Symphony Orchestra Mandeville Hospital from 1975 to 2006. His as assistant in the Kincorth and Portlethen and a composer of 60 varied works. His interest special interests were neuro-urology and the practice, Aberdeen. He was appointed in the emerging discipline of performing arts surgical closure of pressure sores. A leading a partner in 1954. Birnie retired in 1989 medicine led to his prestigious appointment international pioneer in spinal paralysis after a busy career. He lived at Angusfield as the first honorary medical adviser to the rehabilitation, he worked tirelessly for several House Care Home, Aberdeen, for the last Philharmonia Orchestra. Also highly regarded charities. He supported many spinal injury four years of his life along with his wife, in medical hypnotherapy, he was elected a rehabilitation centres in the Middle East. He Ella, who died from Alzheimer’s disease on president of the British Society of Medical and was a great teacher and trained generations 29 May 2020. He leaves three children and Dental Hypnosis. Chonon was unmarried and of doctors. He leaves his wife, Suhair; four four grandchildren. leaves two sisters and a brother. children; and four grandchildren. Elaine MacEachern Jonathan Julius Jacobs Fadel Derry Cite this as: BMJ 2020;370:m3661 Cite this as: BMJ 2020;370:m3665 Cite this as: BMJ 2020;370:m3666 Juliusz Kessling Michael Schachter Peggy Stradling General practitioner Senior lecturer in clinical Specialist in community (b 1939; q St Andrews pharmacology Imperial medicine (child health) 1965), died from secondary College London (b 1950; Brent and Harrow Area bowel cancer on 28 August q University College Health Authority (b 1918; 2020 London 1974; FRCP UK), q London 1942; DCH, DPH, Juliusz Kessling was died suddenly on his 70th MFCM, FFPHM), died from born in Warsaw. His first birthday on 25 July 2020 old age on 6 August 2020 memories were of Nazi Michael Schachter Peggy Snow married tanks in Warsaw. Survivor of an explosion (“Mike”) left his native Budapest with his Peter Stradling in 1942 after their finals. in the Warsaw uprising, he was smuggled parents for north London in 1956. Mike arrived Peggy’s experience of attending to poor across immediate postwar frontiers by the in the department of clinical pharmacology and deprived families (before the NHS) Resistance, with his dentist mother. They at St Mary’s Hospital in October 1984. His while working in general practice spurred were reunited with his Gulag-survivor father, a breadth and depth of knowledge on many her on to a career in public health. She Polish army doctor. Juliusz arrived in England, subjects was extensive. He spent years started working in child health clinics. Over aged 7, a refugee. After graduating he worked nurturing PhD students in vascular biology, several years she gathered experience and at Kidderminster, Dover, and Canterbury many of whom remained in contact throughout additional qualifications that allowed her hospitals before spending most of his their professional lives. He was an editor of to progress from senior medical officer, professional life in general practice (with an various journals and a member and, more to principal medical officer, and finally in enduring interest in psychiatry) in Rochford, recently, chair of a regional ethics review 1974 to specialist in community medicine Essex, and, for over 20 years, in Clapham, board. Although a clinician by training, (child health). Peggy was actively engaged south London. His lifetime passion for art he never pursued an active role in clinical in containing the outbreak of smallpox that found expression in prolific, abstract painting. medicine, with the exception of outpatients. occurred in 1973. She was an impressive He was sustained by art, books, music, A private person, who very much kept himself woman, with a strong work ethic and sense and love. He died peacefully, loved and to himself, Mike will be remembered for all of public service. Predeceased by Peter mourned by many. He leaves two sons, six his marvellous qualities, his intelligence, in 2010, she leaves three children, eight grandchildren, and two great grandchildren. knowledge, integrity, and kindness. grandchildren, and eight great grandchildren. Anna M Kessling Peter Sever John Stradling Cite this as: BMJ 2020;370:m3663 Cite this as: BMJ 2020;370:m3667 Cite this as: BMJ 2020;370:m3669 the bmj | 28 November 2020 377 OBITUARIES Peter Byass Global health specialist, epidemiologist, and teacher

Peter Byass (b 1957; BSc, died, Tedros paid tribute to apple orchard, and where he who was from a social sciences MSc, PhD), died from a heart “my dear friend and mentor later based and raised his own background, said, Byass was attack on 16 August 2020 who was a committed and family, the Medical Research interested in the idea rather talented servant of global Council took the couple and than disciplinary boundaries. Epidemiologist Peter Byass health who helped many people their young family back to The approach combined the was contributing to covid-19 shine around the world.” Africa in 1984. He took up the “how” and “why” underlying research—including for the newly created post of head of deaths when millions of deaths World Health Organization— Low and middle income countries computing and statistics at a still go unrecorded—with big right up to his sudden death Byass’s passion for Africa research site based in a remote implications for policy making from a heart attack in August. began during a whirlwind rural community in the Gambia. and resource allocation. A specialist in measuring three months in 1978, when health outcomes in low and he completed his BSc in Verbal autopsy UK and Sweden middle income countries Nottingham in July; married Armed with the early BBC After six years in the Gambia, (LMICs) in Africa and Asia, his wife, Margaret, in August; computers, Byass began Byass returned to the UK in 1990 Byass published more than and began a three year stint evangelising in support of to take up a position as a lecturer 300 papers, led work on the teaching (with Margaret) at a medical informatics among in public health at the University health impact of climate Methodist missionary school sceptical colleagues—promoting of Nottingham, where he was change, and campaigned for in Sierra Leone in September. the potential of large scale to stay for 15 years. The later the election of Tedros Adhanom Religion played a central part verbal autopsy projects. years of that period overlapped Ghebreyesus as WHO director throughout his life, and Byass As an eager supporter of with the fi rst years of a 22 year general in 2017. He had kept became a minister in 1997. One verbal autopsy—he became relationship with the University in touch with Tedros since colleague described him as a a member of WHO’s verbal of Umea in northern Sweden. supervising the Ethiopian’s humanist who happened to autopsy reference group— He worked at Umea’s doctoral degree when the latter have a very deep faith. Byass developed InterVA, an emerging Centre for Global was a student at the University After three years lecturing algorithm that allowed for more Health Research, becoming of Nottingham 17 years earlier. at a college in Bedfordshire, standardised reporting of verbal professor of global health At the daily WHO covid-19 where Byass had been raised autopsies and identifi cation of in 2008 and building the media briefi ng, days after Byass and his parents owned an probable cause of death. centre into a world leader of The use and status of the development research as its verbal autopsy approach grew director from 2010. In recent Byass was during the 1990s. It involves years he began to reduce his “a committed interviews with close relatives of work with Umea as he spent servant of people—particularly children— more time with his family in the global health who have died in areas with few UK. Much of his working time, who helped health services or clinicians. however, continued to be spent people shine Although his innovations have in LMICs. around the subsequently been refi ned, the As colleagues at Umea world”orld algorithm allowed for larger increased their focus on the scale and more rapid studies by impact of climate change reducing the need for several and health, Byass was drawn clinicians to study the notes for into their work and became a each death before deciding on senior fi gure in the Lancet ’s cause. Commission on Health and Byass’s work with a Climate Change and Countdown multidisciplinary research on Health and Climate Change. team studying maternal He was appointed chief editor mortality in Burkina Faso, of the journal Global Health Ghana, and Indonesia led Action in 2018. WHO to incorporate social Peter Byass leaves his wife, factors contributing to the Margaret; three children; and biomedical cause of death fi ve grandchildren. into the International VA Chris Mahony , London Standard in 2012. As one [email protected] collaborator on that project, Cite this as: BMJ 2020;370:m3530

378 28 November 2020 | the bmj