comment “The events at Gosport are probably less likely two decades on” DAVID OLIVER “There's always a third presence in the consultation—my computer” HELEN SALISBURY PLUS Sugar tax and lobbying by fizzy drink companies; hospital patients' boredom

THE BOTTOM LINE Partha Kar Stan Lee’s lessons for the NHS ast month the world lost Stan Lee, the falter when it comes to delivery. In the X-Men series, great comic book creator. I was one of created in the 1960s to highlight prejudice against many who mourned his loss. As a child certain groups, “mutants” are accepted rather than I loved the colourful panels and stories shunned, and their capabilities are recognised. The of heroism in comic books, and as I’ve release of the Black Panther film in 2018 showed Lgrown older I’ve become aware of some important life many children that being a superhero wasn’t about lessons they’ve taught me. Those lessons—around being white—it was about their skills and qualities. management, leadership, and equality—are ever In terms of gender, studios aren’t merely paying lip more important as the NHS faces an uphill struggle to service to diversity when they give prominent female maintain staff morale. title roles to Wonder Woman or Captain Marvel: For one thing, comic books help us understand our these women are central figures who become leaders colleagues by creating vivid characters who personify because of their abilities. specific personality types. Personality types have been People say that life imitates art. The NHS would mapped, eruditely but controversially, by Myers- certainly be a better place if we could learn how to Briggs scores and other measures. But comic book work together and use the skills of the whole team, characters can help us to understand these types and like the superheroes we know and imagine how they would act in different situations. admire. We’ve all met someone who stands up for what’s Partha Kar is consultant in diabetes and right and whose reluctance to shift on principles endocrinology, Portsmouth Hospitals frustrates others, just as it does with Superman and NHS Trust [email protected] Captain America. And we’ve all met the show-off who Cite this as: BMJ 2018;363:k5037 struggles to fit into a team but still fights the good fight, just as Batman and Iron Man do. Beyond this, comic book stories are full of big egos Certain burying hatchets—people recognising their own circumstances weaknesses and collaborating for the sake of a team, need someone such as the Avengers or the Justice League. And yet, else some other how many times has integration in the NHS faltered character— at a presentation meeting, simply because different to step personalities can’t work together? Thinking about how fictional characters overcome forward their differences has helped me in my work. When and take the creating a model of integrated care in Portsmouth and lead building consensus in my role at NHS England I was aware that certain circumstances needed someone else—some other character—to step forward and take the lead. It was about the team achieving the goal. Similarly, the NHS may have introduced mandatory courses on equality and diversity, but these often the bmj | 8 December 2018 399 OBSERVATIONS Douglas Kamerow The shopping trolley attack: how industry is fighting against sugar taxes Lobbying by US fizzy drink makers to ban city levies on all groceries—not just on sweetened drinks—has had mixed results

ugar sweetened beverages waging successful campaigns against Financial support provide empty calories that cities that proposed taxes on sugar Laws prohibiting taxes on groceries of any succeed in two ways: they make sweetened drinks, blocking the passage kind have already been passed in Michigan, great profits for manufacturers, of such laws. Since then, however, cities Arizona, and California. And referendums and they fatten adults and such as Philadelphia, San Francisco, and against taxes on sugary drinks took place in Schildren who drink them. Seattle have passed laws despite industry November in Washington and Oregon. These Dozens of countries around the world opposition. ballot initiatives had solid financial support and a few US cities have instituted taxes Manufacturers needed a new strategy, from the grocery and fizzy drink industries. on sales of such drinks to discourage and they came up with an aggressive plan: One committee that was registered to support consumption and to raise funds for lobby for statewide legislation or ballot Washington’s initiative—benignly named government health initiatives. Research initiatives forbidding cities and counties “Yes! To Affordable Groceries”—raised and is starting to accumulate showing that from taxing any grocery items at all. No need spent $20m (£15.6m) on the campaign, more these excise taxes (often the equivalent of to mention sugary drinks; instead, market than 99% of which was from four donors: a penny or two per ounce at the wholesale these initiatives to consumers as checks on Coca-Cola, PepsiCo, Keurig-Dr Pepper, and level) reduce sales of sugary drinks and “tax-happy politicians.” Everyone is against Red Bull. Their opponents, the Healthy Kids increase sales of those without sugar, such higher taxes, right? Who would want their Coalition, spent less than $16 000. as bottled water. groceries taxed—even if there were actually What did $20m buy in Washington? When I last wrote about this, in 2010, no plans to tax any groceries except those Television advertisements with plaintive three US beverage manufacturers were containing a sugary beverage? shoppers saying, “We should not be taxed on

BMJ OPINION Jeremy Smith For doctors and nurses, and far between, and What’s so frustrating is hospital wards must surely those available quickly that the distractions I sought The malady of boredom feel like intense microcosms lost their sheen. Even are so obvious: books; bright of the life-death experience. getting visitors becomes walls (instead of municipal I came Yet for patients enduring stressful as you rack your greens or yellows); and to know long term stays in hospital, mind for something, the absolute necessity of boredom the gruelling cocktail of pain anything at all, to recount of having cards, letters, and on an and boredom, loneliness your endless inactivity. photographs from family intimate basis and fear, and the numbing Bafflingly, the mental and friends to put up on minutiae of ward routine can health professionals walls. Too often, hospitals strip a mind of all but its most (psychotherapists, make no provisions for these primal functions. counsellors) assigned to preoccupations, or even Jeremy Smith is Three years ago I spent oversee the wellbeing of actively strip them away. an Oxford based almost 11 months in hospital those enduring long term One patient I knew had a journalist and because of a spinal injury hospital stays never seemed hand drawn card made by broadcaster. In and, consequently, I came willing to ask, “Are you his young daughter removed 2015, he suffered a to know boredom on an bored?” It’s as if being bored without warning from his spinal injury and was intimate basis. was somehow unworthy of bedside while he was in hospital for 11 months Distractions were few clinical appraisal. awaiting an x ray; needless to

400 8 December 2018 | the bmj what we eat. We need to eat to survive, and if we have to cut back on what we eat, that’s not ACUTE PERSPECTIVE David Oliver going to be good—especially for the elderly.” Other spots starred farmers and housewives Preventing a repeat of Gosport urging the viewer to vote for the tax ban “before local governments can put taxes on n the wake of this June’s or measurement of their any of our groceries.” Cynical, but effective. inquiry report on the performance. In Oregon, opponents of the ballot initiative sometimes preventable Jane Barton, the doctor who raised more money than in Washington, or needlessly distressing featured most prominently in thanks in part to a $1.5m contribution deaths of 451 patients at the Gosport inquiry, worked as from former New York City mayor Michael IGosport War Memorial Hospital in a clinical assistant. Her case Bloomberg. They were still outspent by the the 1990s, a Commons statement raises an issue of training and group backing the measure, “Yes! Keep Our in November by the health supervision for doctors in such Groceries Tax Free,” supported by the soda secretary set out policies aiming roles, and accountabilities for the companies and supermarket chains. to prevent a repeat and to improve supervising consultants if based How did the elections turn out? Split healthcare safety. on another site. decision. Washington approved the ban on I welcome such government The inquiry also found that grocery taxes by 56% to 44%, though the attention, but the devil is in the several patients who were not ALAMY result does not overturn existing city beverage detail. Ultimately, the only way to terminally ill were labelled as Most of taxes, such as Seattle’s. Oregon voters improve safety and prevent more dying or given very large doses the £15.6m defeated the proposal, by 57% to 43%. scandals is through the culture and of opioids. This in turn raises the This issue has wider ramifications for the solutions of local organisations. issue of doctors’ confidence in spent in rights of local municipalities to tax citizens. Reports on other mass care failings accurately recognising the dying Washington Similar initiatives have worked in 43 states have shown that external regulation phase and discussing it openly came from for guns: pre-emptive laws banning gun can be late in recognising them. and sensitively with patients and Coca-Cola, control regulation. What’s next? Tobacco? Too often patients, families, local families. At Gosport it seemed PepsiCo, Electronic cigarettes? Other evils? media, and staff have had to speak that patients deemed to have little Keurig- In the end, it looks like it will be up to voters up for problems to be identified chance of recovery didn’t always Dr Pepper, and legislators in each state to determine and action taken. Gosport nurses’ know that this decision had been and Red which is more important: a pre-emptive ban concerns were ignored, dismissed, made or why. Bull on grocery taxes that have not been proposed, or suppressed in what the inquiry Much has changed since or fizzy beverage taxes that discourage sugary called an overly hierarchical Gosport, including laws to protect drink consumption and fund better access for culture. whistleblowers, the founding of working poor people to healthier foods. We need conducive systems the CQC and the Healthcare Safety

Douglas Kamerow is a senior scholar at Robert and a culture where open, Investigation Branch,a “learning Graham Center for policy studies in primary care, and candid flagging of problems is from deaths” programme, and associate editor, The BMJ [email protected] encouraged and required. This is now a requirement for healthcare Cite this as: BMJ 2018;363:k5111 now the official view among NHS safety lead in each hospital, leadership and regulators. The reporting how they’re acting on events at Gosport, where several what they learn.

say, he was distraught upon months in bed without any contributory factors aligned, But, as workload rises his return. Allowing the meaningful sensory release are probably less likely two and workforce gaps grow, patient small but important must surely hamper a decades on. But I doubt any of the complacency could kill. Let’s comforts like these creates patient’s recovery. Indeed, individual issues raised has been make sure it doesn’t. resolved in every NHS service. a vital link with loved I’m sure adults would David Oliver is a consultant in ones at home and helps benefit hugely if the same Gosport was a small community geriatrics and acute general maintain a psychological attention paid to keeping hospital, away from the main medicine, Berkshire bulwark against tedium. younger patients distracted district hospital and without its davidoliver372@ Staff and hospitals can and entertained was senior specialist doctors. This googlemail.com help support patients in equally applied to them. isn’t inherently bad: hundreds of Cite this as: BMJ 2018;363:k5038 other ways; for example, If I now had to return UK community hospitals provide through access to a garden to hospital for a stay of care for patients who don’t need or outdoor space. For those four weeks or, God forbid, the full facilities of a general I doubt any of confined to wards, myriad longer, it wouldn’t be the hospital. Patient outcomes and the individual low maintenance activities pain or inconvenience of experience can be good and care issues raised in such as board games; pens the treatment that would more personalised. However, Gosport has and paper; or even origami terrify me, but the endless, community hospitals, operated by could help enormously. almost palpable vacuum of a wide variety of providers, have been resolved Lying for hours, days, and its monotony. had comparatively little regulatory in every scrutiny, standardisation, NHS service

the bmj | 8 December 2018 401

PRIMARY COLOUR Helen Salisbury NEW BMJ PODCASTS The third presence God is in Operating Room 4 “Given the environment in s students we’re taught Occasionally the computers go down, which surgeons practise—a not only scientific and and I’m taken back to that original very high risk, high stakes, clinical facts but also format: finding out why the patient is high stress environment— how to consult with here and attending wholly to his or her you can imagine that even Apatients: how to build a agenda because, for a brief moment, the best may have moments rapport, how to listen so that patients I don’t have one of my own. It’s very where they exhibit ego know that they’re heard, how to refreshing, even if a little frustrating. driven behaviour that explain and be understood, and how borders on inappropriate. to share decisions. Things left unsaid However, the advent of In the classroom, teaching On other occasions, if I’m not checklists and team training has begun to take scenarios usually involve one doctor careful, technology can take over hold over some hospitals and has contributed to and one patient (often an actor). the consultation so that the codes, an improvement of the culture. In reality, consulting is often more templates, and defensive documentation “While the surgeon by proxy has the patient’s complicated: the wife who keeps take more time than the listening and life in their hands to some degree, we have interrupting to speak for her husband; the talking. Worse still is when I try to begun to recognise and acknowledge verbally the the toddlers intent on emptying do both at once—listening a bit but not importance of everybody in the operating room.” your cupboards while you try to enough, hands already typing, eyes In this conversation, three surgeons and consult with their parent. But even in on the screen. There’s nothing like not an organisational psychologist talk about consultations that are ostensibly one listening to encourage not talking: it surgeons who behave badly in theatre and why to one, a third presence is always in the undoubtedly speeds up the clinic, but it that behaviour has persisted. room, distracting me if I’m not careful, may also mean that important things are stealing my attention and eye contact: left unsaid and problems aren’t resolved. The bone crushing my computer. Few doctors have received anything nausea of hyperemesis other than technical training in how “For me the horror came when I started going to Half in love with my computer to use an electronic patient record, so ask for help and was just met with barriers. For I’m no Luddite—in fact, I admit to we’ve had to work out for ourselves how women with hyperemesis, the nausea is so all being half in love with my computer. to manage this tricky triad of doctor, consuming that you can’t focus on anything else At the click of a mouse I can find patient, and computer. Ignoring the because it's like it's in every cell of your body. To out diagnoses, investigations, and computer for the first few minutes and be in that position and to be asking for help and treatments. How long ago was her focusing my whole attention on the being told that you're not sick enough to warrant diabetes diagnosed? How regularly patient, and then sharing the screen it, or that you're selfish to want to take drugs and has she been ordering her medicine? when looking at results or writing up the you should think about your baby, that's where

What’s the trend in her HbA1c and renal consultation, works for me. the battle really lies.” function? I can check the latest We assume that our students and Listen to this podcast to hear what hyperemesis NICE guidelines or local younger colleagues, being natives of the gravidarum is like and what treatment options prescribing advice. digital world, will do all of this naturally. are available. See also p 410. And my computer is Alas, it’s not true. Holding on to your packed with useful consultation skills while using a Catch up on all of The BMJ’s latest podcasts at bmj.com/podcasts reminders: check computer isn’t rocket science and smoking status, can be taught quite easily. But it update BMI, take a does need to be discussed and MOST READ ONLINE BP reading, give a taught explicitly, because it can Hernia mesh complications may have affected flu jab—all of which take a surprisingly long time to up to 170 000 patients, investigation finds help me to be a more work out. ̻̻BMJ 2018;362:k4104 efficient doctor and Helen Salisbury is a GP, Oxford Helen Salisbury: What should GPs stop doing? maximise helen.salisbury ̻̻BMJ 2018;363:k4976 @phc.ox.ac.uk practice Impact of patient and public involvement on income. Cite this as: BMJ 2018;363:k5100 enrolment and retention in clinical trials ̻̻BMJ 2018;363:k4738 There’s nothing like Sixty seconds on . . . rainbow badges not listening to ̻̻BMJ 2018;363:k4988 encourage not talking Disease-modifying therapies for multiple sclerosis ̻̻BMJ 2018;363:k4674

402 8 December 2018 | the bmj ANALYSIS The bn a year scandal of wasted medical research that distorts clinical practice and causes harm to patients Progress has been made to cut the 85% of global investment that is avoidably wasted from awed study design, analyses, and interpretation—but there’s a long way still to go, say Paul Glasziou and

Milestones in the recognition and n their history of the evolution through the use of inappropriate of guidelines for reporting designs, unrepresentative reduction of avoidable research waste medical research, Doug samples, small samples, incorrect Schor and Karten find 73% of research Altman (left) and Iveta Simera methods of analysis, and faulty 1966 conclusions not justified showed that poor design, interpretation.” 4 In 2015, the Iconduct, and reporting of medical journal’s readers rated the article Simes shows impact of non-publication; 1986 call for universal registration research have been concerns for the most important in The BMJ in more than a century: “The quality of the previous 20 years. 5 It has been Altman declares “scandal of poor published papers is a fair refl ection cited more than 700 times. medical research” in The BMJ 1994 of the defi ciencies of what is still the Altman was blunt: “What should CONSORT statement common type of clinical evidence. we think about researchers who 1996 published A little thought suffi ces to show that use the wrong techniques, use ClinicalTrials.gov founded, the greater part cannot be taken as the right techniques wrongly, 1997-2000 made internet accessible serious evidence at all.”1 misinterpret their results, report Indeed, more than 250 years their results selectively, cite the Altman founds EQUATOR 2006 Centre in Oxford ago, the Scottish doctor James Lind literature selectively, and draw declared in the introduction to his unjustifi ed conclusions? We should Chalmers and Glasziou publish review of reports on treating scurvy: be appalled. Yet numerous studies “Avoidable waste in research” in Lancet 2009 “Before this subject could be set have shown that all of the above National Institute for Health Research initiates in a clear and proper light it was phenomena are common. This is 2010 adding value in research programme necessary to remove a great deal surely a scandal.”4 2 Begg and Ellis fail to replicate key preclinical of rubbish.” Altman’s conclusion was that 2012 studies Quantifying the extent of poor we needed “less research, better reporting of medical research seems research, and research done for the AllTrials campaign 2013 launched not to have begun until 1966 (box). right reasons.” After assessing 295 publications in Lancet ’s five papers on 10 “most frequently read” medical Reporting was so poor avoidable waste 2014 journals, Schor (a statistician) Altman’s challenge contributed Conference in Edinburgh and and Karten (a medical student) to two important developments. 2015 the REWARD statement concluded: “In almost 73% of the Drummond Rennie, a senior Ensuring Value in Research reports . . . conclusions were drawn editor of JAMA , the journal of the 2015 (EVIR) Funders’ Forum founded when the justifi cation for these American Medical Association, was conclusions was invalid.”3 infl uential in both. -REWARD prizes to 2017 NIHR, SYRCLE, and COMET However, the title of their First, in 1989, Rennie initiated article, “Statistical evaluation of a series of congresses on peer Cochrane-REWARD Prizes to EQUATOR, medical journal manuscripts,” was review in biomedical publication, 2018 TrialsTracker, and unlikely to ignite action among an international forum in which clinicians to deal with a situation these problems could be identifi ed Paul Glasziou is a GP researcher and the founding that threatened their patients’ and confronted. director of the Centre for Research in Evidence- wellbeing. Second, he suggested that Based Practice at Bond University, Australia. He is also chair of the REWARD Alliance. The wake-up call came 30 years reporting was so poor Iain Chalmers has a longstanding interest later, in 1994, with an editorial that a reporting guideline was in biased under-reporting of research. in The BMJ by the journal’s chief needed. The resulting CONSORT He is coordinator of the James Lind Initiative. statistical adviser, Doug Altman. He (Consolidated Standards of We dedicate this article to Doug Altman, who died described as a scandal that “huge Reporting Trials) statement6 in June, and the many ways in which he strove to sums of money are spent annually prompted the development of other improve the relevance and impact of research. on research that is seriously fl awed reporting guidelines. In 2006, the bmj | 8 December 2018 403 recognising the need to compile, We need “less improve, and disseminate these research, better guidelines, Altman established the research, and first EQUATOR centre for enhancing research done the quality and transparency of for the right health research.7 reasons” Unfortunately, medical journals’ efforts to improve reporting do not Doug Altman tackle fundamental deficiencies in the design and conduct of research. Another Altman article8 suggested that journals could help to prevent poor research by promoting electronic publication of research protocols; this could occur within the emerging framework of registering trials at their inception. Subsequent reports of the registered research could be linked electronically, through to deposition of whole datasets. Better trial registration has made it possible to assess the extent of biased under-reporting of whole studies, first shown in medicine in 1986 with comparisons of analyses based on all trials registered with all those that had been reported in This staggering sum brought analysis, and faulty interpretation,” public showing that the reported attention to Altman’s scandal. One together with pervasive biased trials overestimated benefit by of England’s principal research under-reporting of research. between 10% and 15%.9 Other funders, the National Institute for What have been the drivers that studies showed biased reporting of Health Research, soon established led us to this waste? The lack of outcomes within studies.10 11 the “Adding value in research” motivation to tackle research waste Commenting on the practical programme to monitor and has been driven by the lack of consequences of these reporting tackle the problems. The Lancet awareness: funders and researchers biases, Alessandro Liberati, a health commissioned five articles with more often express surprise, or even services researcher and patient, than 40 authors, including Altman disbelief, at the scale of the problem. complained about the waste and and his former students, giving more Instead, academic and commercial suffering caused by the biased detail about sources of, solutions to, incentives in the research system under-reporting of research.12 To and recommendations for reducing reward poor research practices such tackle that concern, the AllTrials avoidable research waste (www. as reanalysing data until statistical campaign was launched in 2013, thelancet.com/series/research). significance is found (P hacking), calling for all past and present Altman’s observations and spin, incomplete reporting, and clinical trials to be registered, and critique were largely in applied withholding protocols and data. their results reported. clinical research, but similar Fortunately, both awareness and problems have become apparent in incentives seem to be changing. $100bn a year preclinical research. Most notably, To try to quantify Altman’s “huge a 2012 study failed to replicate the Where are we now? sums of money” wasted, we findings of 47 of 53 “key” preclinical At Edinburgh’s 2015 conference on estimated in 2009 that 85% of the studies, even though the attempted research waste, Altman’s keynote more than $100bn a year spent replications had mostly been done by address began, “It is my great on medical research globally was the original authors.15 pleasure to be here and make you being wasted avoidably.13 This This finding challenged feel quite sad about how bad things waste arises from the multiplicative researchers to reconsider whether are.”16 He proceeded to enthral effects at different stages of research: the research enterprise was working. and sadden us with a catalogue more than 50% of research is The causes can largely be found of editorials and research which not published; more than 50% in the issues Altman raised in pointed out the extensive and has avoidable design flaws; and 1994: “inappropriate designs, ongoing problems. more than 50% is unusable or unrepresentative samples, small However, in 2016, a report by the incompletely reported, or both.14 samples, incorrect methods of researcher David Moher

404 8 December 2018 | the bmj 30 research funders internationally, Based Medicine. The tracker exposes working together to reduce research the institutions and people who waste and improve value. are acquiescing in under-reporting Given their influence through of research—and it has shown that funding decisions and regulation, academia is now more culpable than research funders have a pivotal industry. role in fostering improvements. However, their potential influence What needs to happen now remains underexploited: an Initiatives such as those recognised audit of the adoption by funders by the REWARD prize are heartening, of relevant recommendations in but their work is poorly supported the Lancet series showed low levels by funders and institutions. So, of uptake, with a few influential although the pace of change in outliers.22 reporting guidance has been rapid, change in improving practice is Recognising efforts to reduce waste slow, with overall publication rates At the 2015 Edinburgh conference, remaining at about 50%, and vast the REWARD (Reduce Research other areas of medical research Waste and Reward Diligence) unobserved and unimproved. Alliance was founded to facilitate The recent evidence based work on the Lancet series medicine manifesto, citing Altman’s recommendations. It established 1994 “scandal” paper, proposes the Cochrane-REWARD prize to nine steps towards “better evidence recognise and disseminate scalable for better healthcare.”24 It links the initiatives aimed at reducing problems of poor research to poor avoidable waste in research. At the information for clinical decision 2017 World Congress on Research making. For Altman, these decision and his colleagues promoted some Funders and Integrity in Amsterdam, the first making consequences were central. optimism that practical steps could researchers prize was awarded to NIHR for its As a statistician, he was appalled 17 be taken to reduce waste. They often express initial response and ongoing work by the poor quality of the design, documented the global response surprise, or in monitoring and reducing waste. conduct, and reporting of research, to the 2014 Lancet series using even disbelief, The second prize was shared by not just for its effects on the medical examples of individual initiatives to at the scale of the Centre for knowledge base but for its “serious reduce research waste in different Laboratory Animal Experimentation consequences for clinical practice, stakeholder groups. the problem (SYRCLE), based in Nijmegen, the research, policy making, and Among the responses has been Netherlands, for reducing waste in ultimately for patients.” the establishment of the Evidence- animal research through systematic Given Altman’s pivotal role in Based Research Network (www. reviews and better regulation; raising awareness of the scandal EBRNetwork.com) in 2016 to lobby and the Core Outcome Measures of poor medical research and in for all proposals for new research for Effectiveness Trials (COMET) founding the EQUATOR centres, to be supported by references to Initiative, which promotes the it is unsurprising that in 2016 he systematic reviews of existing agreement and adoption of core received a Lifetime Achievement research.18 This is supported by the outcome measures for assessing the Award from The BMJ. To realise the call from nine coauthors, including effects of interventions, as pioneered full value of his legacy, research former and current chief in the 1990s by the rheumatologists funders, research regulators, scientific advisers to the British who created the Outcome Measures research organisations, journals, government, for information in Rheumatoid Arthritis Clinical and the many people Altman taught syntheses that are inclusive, Trials (OMERACT) Group. and inspired must act together to rigorous, transparent, and The 2018 Cochrane-REWARD design, conduct, and report better accessible for policy makers,19 a call prize was awarded to the EQUATOR research done for the right reasons. we consider long overdue.20 Network for Good Reports, and in The continuing ethical, scientific, But perhaps the most notable recognition of the considerable work and economic deficiencies of medical and potentially influential of Altman’s Oxford Centre for Medical research remain scandalous. 23 development is the Ensuring Statistics. Second prize went jointly Paul Glasziou is director, Centre for Value In Research (EVIR) Funders’ to the James Lind Alliance for its Research in Evidence-Based Practice, Bond Forum, established by the NIHR, extensive and innovative efforts to University, Gold Coast, Australia ZonMw in the Netherlands, and the improve research prioritisation and [email protected] Patient-Centred Outcomes Research to the Trials Tracker established by Iain Chalmers is coordinator, Institute in the United States.21 and his colleagues James Lind Initiative, Oxford The forum now includes more than at the Oxford Centre for Evidence Cite this as: BMJ 2018;363:k4645 the bmj | 8 December 2018 405

Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES

Benjamin Moore David Biddulph Goss Robert Jones Consultant obstetrician General practitioner General practitioner and gynaecologist Welwyn Garden City (b 1922; q Guy’s (b 1932; q Christ’s (b 1923; q Middlesex Hospital, London, 1953), College, Cambridge, Hospital 1947; MRCS Eng, died from metastatic 1969; MA, MD, FRCOG), LRCP Lond, MRCGP), died prostate cancer on died from old age on after a stroke on 25 October 2018 13 June 2018 7 November 2018 Robert Jones (“Bob”) During national service David Biddulph Goss did war service as a in Korea, Benjamin Moore (“Ben”) survived entered general practice in Welwyn Garden flight lieutenant navigator in the Royal Air a penetrating gunshot wound to the chest City in 1950. He later became a trainer Force. After house jobs at St Helier Hospital in 1952. He worked as a geologist in Brazil himself. He retired in 1985 but continued to in Carshalton, he joined a practice in and Canada before returning to Cambridge to work as an examining medical practitioner for Cranford, near Heathrow airport. For the first study medicine. Ben trained in obstetrics and the government until he retired in 1993. David half of his career, in addition to enjoying the gynaecology in Norwich, Dublin, Birmingham, was active in the BMA, served on the medical variety of general practice, the practice also and Zimbabwe. In Birmingham, he ran the staff committee at the Cottage Hospital in undertook most of its obstetrics work at the first menopause clinic in the UK. In 1981 he Welwyn Garden City, and chaired the GP unit local maternity hospital. After compulsory was appointed consultant in obstetrics and of the Queen Elizabeth II Hospital. He was retirement from the NHS at 70, Bob gynaecology at Hereford. He worked in nine medical officer to the Tewin Water School for continued for another five years as a locum different countries. Latterly, he did voluntary partially hearing children for 35 years. David in a practice in Hounslow. He was the local work in India, Tanzania, and Zambia, played tennis and squash well past his 68th Treasury medical officer for the civil service, maintaining his surgical skills right up to his birthday and was active in the charity Age and he was able to maintain an interest in retirement at age 76. Outside medicine he was Concern and the Rotary and Round Table aviation medicine with a weekly session a keen writer (of two books), walker, rower, and clubs. Predeceased by his wife, Eileen, he at British Airways. He leaves his partner, rowing coach. He leaves his wife, Veronica; leaves four children, as well as grandchildren two daughters, four grandchildren, and six four children; and five grandchildren. and great grandchildren. great grandchildren. Tom Moore, Jess Moore David Biddulph Goss Liz Bloxham, Claire Gray Cite this as: BMJ 2018;363:k5004 Cite this as: BMJ 2018;363:k5008 Cite this as: BMJ 2018;363:k4705 Margaret Costen Kirsty Paterson Krishna Somers Associate specialist Obstetrics and gynaecology Cardiologist Perth, psychiatrist Guernsey, trainee Royal London Australia (b 1926; Channel Islands (b 1947; Hospital (b 1984; q Bristol q University of the q Leeds, 1970; MBE), 2009; MRCOG), died from Witwatersrand, died from complications metastatic breast cancer on Johannesburg, South of lung cancer on 14 September 2018 Africa, 1949; FRCP 22 October 2018 Kirsty Paterson (previously Lond, FRCP Edin, FRACP, Margaret (“Maggie”) Cleverly) started her FACC, FCSANZ, DC) died Costen (née Williams) pursued an interest in obstetrics and gynaecology training in North from ischaemic heart disease, aspiration dermatology during her early postgraduate East Thames in 2011. A keen surgeon, she was pneumonia, and heart failure on 15 October years. After a move to Guernsey in 1975 passionate about fetal medicine and high risk After completing his internship in Durban, she switched to psychiatry. She took up a obstetrics, as well as medical education. Kirsty Krishna Somers trained at London’s post as an associate specialist at the Castel excelled throughout training and combined Hammersmith Hospital and the Royal Hospital. Her commitment to charity work scientific interest with a kind and caring Postgraduate Medical School from 1954. (mental health, drug and alcohol addiction, patient manner. She passed her membership He studied in the US from 1962 to 1963. Women’s Aid, and—more recently—domestic of the Royal College of Obstetricians and From 1968 to 1973 he held a personal violence) was recognised nationally in 2016, Gynaecologists with ease despite adversity. chair at Makerere University and Mulago when she was awarded an MBE. Maggie Kirsty enjoyed making gifts and baking, as well Hospital in Kampala, Uganda. His was diagnosed with lung cancer in 2017, as being an enthusiastic cyclist and traveller. cardiovascular service contributed to but—characteristically—she took it in her She was known for her indefatigable attitude, research developments in hypertension, stride. She died from bronchopneumonia at her intelligence, her style, and her dry wit, as rheumatic heart disease, and the Princess Elizabeth Hospital, Guernsey, well as the immense dignity and grace she cardiomyopathies and was funded by the surrounded by her family. She leaves two displayed while confronting her terminal British Heart Foundation. In 1973 he left children and three grandchildren (with a illness at such a young age. She leaves her Uganda and took a consultant post at the fourth arrival imminent). mother and brother. Royal Perth Hospital in Western Australia. Sarah Costen, David Costen, Jane Williams Adalina Sacco Y K Seedat Cite this as: BMJ 2018;363:k5003 Cite this as: BMJ 2018;363:k4726 Cite this as: BMJ 2018;363:k5040

406 8 December 2018 | the bmj

Maria Bitner-Glindzicz Clinical and molecular geneticist

Maria Bitner-Glindzicz (b 1963; “Bitner- q University College London, Glindzicz’s 1987), died after a collision with a drive and vehicle while cycling in Clerkenwell, passion for London, on 20 September 2018 research was both Maria Bitner-Glindzicz was born in 1963 in Fleetwood, Lancashire, to inspiring and a Polish father and Irish mother, infectious” who had both come to live in the UK. A renowned clinician and research scientist who made her mark in the specialism of deafness, Bitner-Glindzicz finished her training with first class honours at University College London (UCL) in 1987, aim of bringing the revolution in shifting towards the potential of having undertaken an intercalated genomic medicine to the NHS and prevention and curing patients using BSc in genetics. its patients. She was a key member gene therapy. Bitner-Glindzicz and of the national team defining testing colleagues developed and evaluated Focus on deafness and blindness criteria for the project and was bedside tests, now in regular use, to After gaining her PhD in genetics the rare disease lead for the North identify newborns with infections at UCL’s Institute of Child Health in Thames Genomic Medicine Centre, at risk of deafness in response to a 1996, she went on to become one where she encouraged colleagues particular antibiotic. of the world’s leading specialist across the region to enrol more than Most recently, Bitner-Glindzicz and academic consultants in clinical 16 000 patients and their relatives her colleague Jane Sowden had been genetics with a key focus on deafness into the programme. More recently, successful in securing funding to and blindness. She was promoted to as the project has come to its close, increase understanding and develop professor of clinical and molecular she was instrumental in building a treatment for Norrie disease, a rare genetics at UCL in 2012. the teams needed to interpret and genetic disorder with childhood Appointed in 2000 as a consultant return results to families, and in onset of progressive hearing loss and clinical geneticist at Great Ormond establishing a new breed of clinician eventual blindness. Street Children’s Hospital (GOSH), needed to embed genomic medicine In addition to her research, Maria established the UK’s first in clinical care. Bitner-Glindzicz was instrumental and only clinical service to provide Colleague David Goldblatt, in securing funding for the comprehensive diagnostics and consultant paediatric immunologist establishment of an experimental follow-up care for children with and director of research and biomedical research centre at GOSH genetic forms of deafness. development at GOSH, says: “As a and UCL, funded by the government Subsequently, she went on to colleague she was wise, kind, clever, since 2007. GOSH issued a statement establish a dual sensory (eyes and and energetic; her drive and passion saying: “Maria was a true leader in ears) clinic at the National Hospital for research that translated into her area, a very valued colleague, and for Neurology and Neurosurgery patient benefit was both inspiring internationally recognised for her in London, for the specialist care and infectious.” contributions to genetics. of children with diseases of both In addition to her clinical work, hearing and sight, helping to Tackling rare disorders Bitner-Glindzicz’s family say that she transform the lives of deaf and blind As well as helping families coping valued her free time, which she shared children and their families. with serious and rare disorders of with family and friends. She loved Bitner-Glindzicz’s main roles were deafness and blindness, Bitner- her life in Suffolk, spending as many as a clinical geneticist at GOSH and as Glindzicz also led an international weekends there as possible; walking, professor of clinical genetics at UCL’s team of scientists and clinicians, gardening, and sharing her dinner Great Ormond Street Institute of Child focusing on the discovery of genes for table with characteristic generosity. Health (GOSICH). these rare disorders, with the intention She leaves her husband, David; two Bitner-Glindzicz was perhaps best of improving diagnosis and treatment. children; and her mother. known for being central to the UK With increasing success over 25 years Adrian O’Dowd, Herne Bay, Kent government’s 100 000 Genomes of research and numerous research [email protected] Project, launched in 2012 with the publications, her recent focus was Cite this as: BMJ 2018;363:k4233 the bmj | 8 December 2018 407 LETTERS Selected from rapid responses on bmj.com See www.bmj.com/rapid-responses

PROFESSIONAL HIERARCHIES would be prevented by informed pre-emptive discussions and Disproportionate privilege shared decision making. But at medical school across Europe >80% of patients in The “doctor-nurse game” intensive care lack the capacity to remains an endemic part of participate in such discussions. healthcare culture (Cover Story, The Faculty of Intensive Care NEIL WEBB NEIL 27 October). The authors’ LETTER OF THE WEEK Medicine has established a suggestions for changing the multidisciplinary group to culture are all very well, but there The doctor-nurse game: who has the power? provide guidance for clinical are some elephants in the room. Darbyshire and Thompson make a powerful case for flattening teams delivering care at the First, the cultural influence hierarchies across the health service (Cover Story, 27 October). They end of life, to guide decision of wider society continues to present the “doctor-nurse game” as one of power dynamics, where making, and to increase public reinforce the hierarchical status doctors have the power. But the dynamic may be reversed between awareness of the benefits and of nurses as subordinate to transient junior doctors and senior nursing staff. burdens of intensive care. Key doctors. Second, persisting I teach final year medical students, and many are anxious about themes will be the need for good power divides determine how they will be perceived by nursing staff when they start work. The multidisciplinary interactions, medical school applications and annual #tipsfornewdocs advice on Twitter yields plenty of tweets promoting patient involvement, acceptance, perpetuating the that caution new foundation doctors to respect the experience of and determining patients’ values over-representation of privileged, nursing colleagues. Many are accompanied by the jokey phrase, and preferences, emphasising privately schooled children “Otherwise they’ll make your life hell.” Perhaps this is good that life has both physiological of professional parents. Until humoured punching up, but the ubiquity of the joke hints at an and philosophical components. medical school applications underlying power imbalance. The group is now presenting its stop being vetted by the Short rotations lead to junior doctors often becoming the most proposals to a wider stakeholder disproportionately privileged, a transient members of a clinical team. A few months is long enough audience and will publish its social and professional power to experience the negative effects of the culture but also short recommendations in June 2019. divide between doctors and enough to see the light at the end of the tunnel. Transience can Joseph F Cosgrove, consultant, nurses will remain. Newcastle upon Tyne; Christopher be an important protective factor, and raising concerns can feel Bassford, consultant, Coventry, on Catherine Welch, island physician, like more trouble than escaping unscathed. You move on, but the behalf of the End of Life Working Party, Isle of Arran culture remains for someone else to endure. Faculty of Intensive Care Medicine Cite this as: BMJ 2018;363:k5085 For meaningful progress, junior doctors must feel supported and Cite this as: BMJ 2018;363:k5090 Subservient nurse heard in raising concerns about culture and hierarchy. Otherwise Intensive care staff are we’ll just carry on playing the game. stereotype is old fashioned susceptible to burnout George C Greenlees, clinical teaching fellow, Wolverhampton It seems simplistic—even Cite this as: BMJ 2018;363:k5058 Gross and colleagues describe old fashioned—to attribute the often underappreciated dysfunctional work cultures to personalities, rather than from the costs of admitting patients with the persistence of the arrogant Hierarchies serve us well structure. This is not an easy thing established frailty and chronic doctor-subservient nurse Is this article a political polemic to remedy. illness into intensive care units. stereotype. It is not helpful for or a rhetorical essay? We seem Have many of the politically Another adverse consequence one occupational group to blame to be guided into the untenable inspired changes made in the of these admissions is the effect another for dysfunctional work and ideological position that NHS been anything other than on the wellbeing and mental cultures in clinical environments. hierarchies are malign. counterproductive? Hierarchies health of staff. Those who work Nursing is a recognised In all life, hierarchies evolve are here to stay and continue to in intensive care are particularly pathway to a career in NHS naturally. In professional life, serve us well. susceptible to burnout, which management; my impression hierarchies are usually based David M Bowker, retired consultant may have a detrimental effect on is that general NHS managers on individual knowledge, psychiatrist, Manchester patient care and safety. are far more likely to be nurses experience, and skills (three words Cite this as: BMJ 2018;363:k5087 Perceiving non-beneficial than doctors. There seem to be not mentioned by the authors), INTENSIVE CARE treatment is stressful, as is as many reports of individual coupled with taking responsibility dealing with limitations in the nurses, or groups of nurses, for decisions, made jointly or Multidisciplinary group to capacity of intensive care units, fostering a dysfunctional, often otherwise. A patient does not want tackle end of life care exacerbated by the admission bullying, work culture, as there to hear that a multidisciplinary Gross and colleagues discuss the of patients that are unlikely to are of doctors—both anecdotally team was responsible for a need to balance the benefits and benefit. Staff retention should and in official reports. mistake. potential burdens of intensive also be considered. Katherine M Venables, medical Perhaps the occasional, malign care (Analysis, 27 October). Paul J Frost, intensive care academic, Oxford effects of hierarchies arise from Ideally the delivery of consultant, Cardiff Cite this as: BMJ 2018;363:k5086 the characteristics of particular disproportionate treatments Cite this as: BMJ 2018;363:k5088

408 8 December 2018 | the bmj