comment‘ Care was arguably more regimented and ‘paternalistic, and patients more deferential ACUTE PERSPECTIVE David Oliver Rose tinted lenses and the NHS he NHS turned 70 this year and On the other hand, back in the day faces numerous challenges. many senior registrars, long qualified to This has prompted many to become consultants, waited endlessly debate current and future for consultant posts to become vacant. Thealthcare services and to look And not for nothing were senior house back at the NHS’s journey since 1948. officers called “the lost tribe,” as so many A fond nostalgia has its place. But doctors were drifting at that grade. Nor one step beyond is “rosy retrospection.” did we have today’s transparency and Excessively positive retrospective scrutiny around preferential selection narratives sometimes come from people based on sex, race, or patronage. who weren’t there but speak confidently about Another example of la vie en rose is those imagined golden eras. I’ve doubtless donned rose yearnings in sections of the media for golden tinted lenses myself but, as I enter my 30th year ages of nursing—where A levels, let alone degrees, as an NHS doctor, I’d prefer to avoid them when weren’t required, and where fearsome matrons discussing present and future healthcare. ruled wards with a rod of iron, insisting on shipshape Before the EU Working Time Directive placed ward cleanliness. Yet patient case mix and healthcare restrictions on junior doctors' working hours brutal were far less acute and complex; pressure and on-call rotas were common, including continuous throughput on beds was lower; and a far more limited 80 hour weekend and 36 hour weekday blocks, with range of interventions was available for nurses no guarantee of sleep. Tired doctors put patients’ to carry out, let alone as independent advanced and their own health at risk. On the other hand, practitioners or prescribers. Care was arguably far the exhaustion came with free (if basic) onsite more regimented, institutional and paternalistic, accommodation, peer support, and the continuity of and patients more deferential. Besides, the research a firm structure, and we quickly gained vast amounts evidence tells us that graduate nurses improve of experience. The loss of those hours is still lamented patient outcomes. in surgical specialties, but—with minimal induction, Nostalgia makes us forget just how far healthcare far less senior supervision, a “see one, do one, teach has come in terms of evidence, interventions, one” approach to many quite risky procedures, and far safety, and outcomes. Clinical staff may formerly less scrutiny on safety and preventable harm—the rosy have had more professional autonomy, a filter effect starts to diminish. greater sense of belonging, less managerial and The historical switch, in Modernising Medical political interference, and a far lower burden of Careers, to run through higher specialty medical documentation and public scrutiny; but some of training from more meandering routes has also that burden came about precisely because, when the attracted adverse comment, as has the botched professionals ran their own show, not everything introduction of the Medical Training Application was rosy. Service or more recent findings that junior doctors David Oliver is a consultant in geriatrics and acute general medicine, often feel rushed or pressurised to decide on a Berkshire [email protected] specialty stem too early in their career. Cite this as: BMJ 2018;362:k3866
the bmj | 22 September 2018 357 PERSONAL VIEW Tom Nolan The heart age test will put yet more pressure on overworked GPs Providing tools that don’t acknowledge uncertainty can only erode the public’s trust in the health service
hy are so do—and perhaps this is the point: it’s Lumping GPs are predictably cross about it. many of us good to know your heart age because everyone I’m sure I wasn’t the only one fielding heading it’s good to take more control of your in an area calls from people worried that their for an early health. The problem is that the NHS together and cholesterol might be high. But will grave?” heart age tool isn’t up to scratch. using the there be a spike in cholesterol testing? “Wasked the Guardian earlier this One of its major flaws is its And if so, what will the consequences average for month. The NHS online heart age test obsession with cholesterol. It tells of this be? made headlines when Public Health everyone from the age of 30 to get heart age England revealed that 81% of the 1.9 their cholesterol checked (in large estimates Socioeconomic factors million people who have taken the red capital letters), despite there doesn’t The use of postcodes is also a test had a heart age above their real being no national guidelines to this make sense problem. Socioeconomic factors have age. If only the public would exercise, effect. And it seems that anyone who a far greater effect on our health than eat well, and stop smoking. If more doesn’t know their cholesterol or cholesterol being a bit high. people knew their heart age, perhaps blood pressure gets a high heart age A baby girl born in Richmond they would? calculation. upon Thames is likely to live 17.8 Unfortunately, the evidence to As Ben Goldacre pointed out years more in good health than a support risk calculators being used on Twitter, if everyone in their 30s baby girl born in Manchester. But as standalone tools for behaviour checked their cholesterol, that would that doesn’t mean that a woman change is lacking. In my own be 8.7 million visits to the GP for a living in Richmond will have a qualitative research on this subject blood test. If even a fraction of these younger heart age than one living I was struck by how differently tried to book an appointment in the in Manchester. There can be huge people responded to seeing their wake of this publicity it could cripple differences in wealth, education, heart age on a screen. But even general practice—anyone with actual and opportunity within postcodes: those who didn’t like what they symptoms of a heart problem could lumping everyone in an area saw thought it was a good thing to be waiting months to see their GP. together and using the average for
BMJ OPINION Mark Taylor Why doctors’ letters should be addressed to patients “What am I, chopped liver?”—I’ve And yet, over the years, I have been obstetrician from The Meaning of always loved this old Yiddish saying, copied in to a number of letters Life, “we’re not qualified.” chopped liver being just the side between medical professionals But, let’s take a step back. The dish, not the main course. I often where my various chronic Academy of Medical Sciences quote it when I feel I am being conditions have been described recently published a report on the spoken about, but not to. in great, and occasionally challenges healthcare systems Recently the Academy of Medical obscure, detail. face in managing patients with Royal Colleges released guidance From a patient perspective, multimorbidity. We know that the calling for hospital doctors to write The only aside from the structural number of these patients is on the outpatient clinic letters directly to constant and paternalism of treating a patient rise and we know the system is not patients, free of jargon or confusing permanently as a spectator of his or her own designed to treat them. I should language. The push for doctors engaged point treatment, does it matter that know. I am one of those patients. to communicate effectively and letters between consultants and It may be that the GP is meant to is the patient directly with their patients feels GPs are not addressed to us? coordinate my various treatments, like such an obvious point to make. Surely, to paraphrase John Cleese’s my various pathways. Perhaps
358 22 September 2018 | the bmj
BMJ OPINION Trish Greenhalgh Cochrane—what crisis?
Last week the governing board of Cochrane voted to expel one of its members, Peter Gøtzsche, for activities that allegedly threatened to bring the organisation into disrepute. Four of the 13 members resigned in solidarity with Gøtzsche, and two appointed trustees volunteered to step down. In a single day the organisation lost over half its board. Is there a crisis—and, if so, of what nature? Gøtzsche’s three page statement did not name a heart age estimates doesn’t “a month older than me. Must do specific incident. Rather, it appears that his overall make sense. more exercise!” approach to overseeing and commenting on Cochrane Take the calculator at face value What is the chance that the reviews was deemed (by some but not all board and it’s an incredible thing: answer calculation will be inaccurate? What members) unacceptable. Gøtzsche might be classified 16 questions, and the programme is the 95% confidence interval? as an evidence based medicine purist. But why would will work out your heart age. This I’ve looked at the supporting he be asked to leave Cochrane, whose mission so is presented with great confidence: documents and can’t find any closely reflects his own? “your heart age is 38.” Not “38, based answers. Perhaps they’re there if The philosophical explanation is that facts are not on what you’ve told us,” or “38, plus you dig deep enough—but if I can’t self interpreting: they are value laden. Even when or minus a couple of years because, find the answer after 20 minutes of there are agreed criteria for including or excluding you know, this is just a clever bit of looking, who else is going to bother? a study in a review, multiple subjective judgments programming and we can’t really look The public deserves to know how need to be made. Because of Maintaining at your heart or see the future.” It’s a accurate these estimates are. the need for judgment on such fact: my heart age is 38. Presenting uncertainty as fact is not questions, two systematic review the “view from what the public wants or needs. Are teams can produce different nowhere” How accurate are the estimates? we scared that if we share uncertainty, findings. Meticulous application requires delicate It certainly has more impact to use people won’t do what we want them of the Cochrane handbook is thus navigation this wording, but at what cost? For to? Providing tools that lack credibility likely to generate new kinds of disagreements rather those already suspicious that their and don’t acknowledge uncertainty than a single, uncontested truth. Some methodological calculation is wrong, this is the will erode people’s trust in the health hardliners view such disagreements as errors to be final straw. For those who believe service and stop important public corrected rather than as a philosophical inevitability. it, they are being misled about the health messages getting through. And this, I think, is the stone in Cochrane’s shoe. accuracy of the estimate—like the Tom Nolan is a GP in south London The political explanation for Cochrane’s crisis health secretary, Matt Hancock, [email protected] relates to the tension between governing an who tweeted that his heart age is Cite this as: BMJ 2018;362:k3930 organisation and respecting individual members’ academic freedom to express dissent. In the 26 BMJ OPINION Mark Taylor years since its inception Cochrane has grown from a tiny academic network to a sprawling transnational Why doctors’ letters should be addressed to patients consultants across disciplines If multimorbidity is one of the bureaucracy. Maintaining—and funding—the “view should be linking up in more challenges for the NHS, and if from nowhere” requires delicate navigation of tricky productive ways. Reality suggests we believe society has a greater political spaces and sometimes accepting hard this doesn’t happen. responsibility for its own health, then won compromises. Board members are presumably In the age of multimorbidity, letters sent out after a consultation expected not to spit in the soup (especially when the only constant and permanently need to come to us as patients and using Cochrane letterhead). engaged point is the patient. We be copied to the relevant healthcare At this stage in a fast unfolding story, I am not are the centre of it all. So, tell professional. It reminds us that we convinced that Cochrane is experiencing a crisis of me again why letters about me are not passive; rather, we are the either morality or democracy. Its brand, now as ever, are not written to me, with a point of the entire exercise. It nudges stands for rigour, independence, and a commitment to plain English summary? Explain us to take more interest, and to feel using science to achieve high quality patient care and to me why such an obvious act empowered to ask more questions. social justice. We should cut it some slack while it gets of disempowerment is likely to Most of all, it reminds us we are its house in order. galvanise the patients and their not chopped liver. ЖЖNEWS, p 342 families to manage the overall Mark Taylor, head of impact, Central Trish Greenhalgh is professor of primary care health sciences at healthcare pathway necessary to Commissioning Facility, National Institute for the University of Oxford keep them going? Health Research
the bmj | 22 September 2018 359 ANALYSIS Revisiting the timetable of tuberculosis TB has a much shorter incubation period than has widely been thought, say Marcel A Behr and colleagues, which has implications for prioritising research and public health strategies Workers have chest x-rays in 1946 to check for TB infection , London
Suggested simplified terms etween a quarter term “remote infection” to describe and a third of the infection preceding active TB by more Tuberculous reactivity—Indirect evidence of present or past world’s population than two years.) infection with Mycobacterium tuberculosis as inferred by a detectable adaptive immune response to M tuberculosis are estimated to be The natural history of TB does not antigens (on tuberculin skin test or interferon gamma release latently infected with support the many terms currently BMycobacterium tuberculosis.1 The used to describe the various phases assay) in an asymptomatic person Primary infection—Evidence of new tuberculous infection, 2018 World Health Organization of infection. These terms are not only obtained with a tuberculin skin test conversion or a new resource page for tuberculosis (TB) confusing, but even misleading. positive interferon gamma release assay, which may be states: “On average, 5-10% of those We suggest using just three simple asymptomatic or accompanied by transient fever, erythema who are infected will develop active terms—tuberculous reactivity, primary nodosum, elevated erythrocyte sedimentation rate or TB disease over their lifetime.” infection, and active TB (box). characteristic roentgenographic abnormalities Because “reactivated” TB is Active tuberculosis—Evidence of progressive disease of the contagious, eradicating latent Pre-antibiotic incubation studies lung and/or other organs generally accompanied by a positive infection is a cornerstone of global Three longitudinal studies of TB culture for M tuberculosis and/or roentgenographic findings TB control2 and achieving a better acquisition and progression were and/or histopathology consistent with TB understanding of latent infection is conducted before the widespread deemed a research priority.3 4 The use of antibiotics in Norway and KEY MESSAGES word latent has both biological and Sweden.8‑10 Careful monitoring medical definitions. The biological by astute clinicians allowed for a The current thought is that concept of latency is that of a resting reproducible timeline from acquiring Mycobacterium tuberculosis stage, hidden until circumstances are the primary infection to developing frequently establishes a latent infection following which there suitable for development. The medical active TB. is a reactivation process that definition is simply a pathological Poulsen, while working at the TB leads to active TB disease, after process in which symptoms are not station in the Faroe Islands from 1939 a long and variable incubation yet manifest. The TB clinical to 1947, was able to pinpoint the time period community has long used the of exposure to TB to a two week period 9 Rather, the incubation period apposition of latent TB infection and and often to a single day. Thus, he of TB is typically several months to two years, and reactivation, clearly applying the determined the incubation period of after that, disease is relatively infrequent biological definition. primary infection—new tuberculous There is no evidence for a bimodal distribution of The importance attached to reactivity often accompanied by TB that distinguishes primary progressive TB from latency is reflected in a major push characteristic clinical features—to be reactivation TB from research funding agencies under six weeks. In this same cohort, to understand the biology and the incubation period of active TB Immunoreactivity to TB does not necessarily indicate the presence of live bacteria, as reactivity can persist epidemiology of latent TB infection was typically 3-9 months and almost after infection has been cleared and to develop drugs that specifically always under two years. treat latent infection, aiming for global Wallgren, working in Stockholm, Classifying two billion people with evidence of TB eradication. Multiple longitudinal similarly found that active pulmonary immunoreactivity as having latent TB infection epidemiological studies, however, TB generally developed within may divert fundamental research and public health 10 interventions away from transmissible active TB show that the majority of TB disease 1-2 years of exposure. Finally, disease and newly infected people at highest risk of manifests soon after infection, with Gedde-Dahl, who monitored people progression to disease disease rarely occurring more than regularly for tuberculin skin test (TST) two years after infection. (We use the conversion (that is, the point at which
360 22 September 2018 | the bmj results of the test switch from negative for 10 years (2002-11).20 They found to positive) and then for development that 75% of active TB cases in contacts of active disease, found a similar occurred within one year of diagnosis incubation period for the development of in the index case and 97% within two active TB, usually 3-9 months and rarely years. The study confirmed that children beyond two years of newly documented and adolescents were at greater risk of tuberculous reactivity.8 developing active TB, but the timeline of developing TB was the same in all age Post-antibiotic incubation studies groups—predominantly in the first year. When isoniazid became available in The other two studies combined 1952, clinicians were interested in molecular fingerprinting with using it to treat TB disease and as a epidemiological methods to assess the Streptomycin production in 1946, England chemoprophylaxis agent to prevent the incubation period more accurately. development of TB disease after infection In summary, the typical incubation was diagnosed. period of TB disease has not changed INH In 1970, Ferebee published a and remains a few months to two Placebo review of the controlled isoniazid years. The importance of recent chemoprophylaxis trials conducted in infection as a risk factor for active TB
11 Rate (per ) the US between 1956 and 1966 (fig 1). was emphasised recently by Houben Examination of the placebo recipients and Dodd in a modelling paper that shows that, as in the older studies, the provided both overall estimates of likelihood of developing TB disease after latent TB infection and the subset 1 infection dropped precipitously after the infected within two years. Study year first year, leaving a tail of what might be Fig 1 | Rates and incubation period of active TB in tuberculin considered “reactivation” TB. Is there a late spike of disease? positive (induration ≥5 mm) household contacts of patients Examining those who received Reactivation TB is thought to occur with recently diagnosed TB. Data from Ferebee.11 isoniazid provides further insights into most frequently later in life when A this tail. Isoniazid was given for 12 immunity wanes or intercurrent months after infection, and its efficacy illness occurs. If this were the in preventing TB disease is reflected in case, we would expect a rise in TB % with TB a fivefold reduction at year one. After incidence decades after infection, year one, the rates of TB disease were no and this would have been missed different between placebo and isoniazid by the above studies that monitored arms, indicating that newly acquired people up to 10 years at most. infections, rather than reactivation of To examine this more rigorously, we the original infection, were substantial looked at longer term epidemiological contributors to this tail. studies. A 20 year study followed TST B Several other studies support positive and TST negative adolescents the inference that TB occurring in England and Wales assigned to the remotely after primary infection can be control arm of a BCG vaccine trial.21 % with TB due to newly acquired infection rather This study was carried out from 1951 than reactivation. to 1970, a period of a sharp decline in In sum, both histopathological and TB incidence. Importantly, the study epidemiological approaches indicate a showed that the fall was the same for far greater role for exogenous infection both TST positive and TST negative than reactivation of primary TB. people, with no late spike in disease. In another revealing study, C Has the incubation period changed? McCarthy followed people who had Could the natural history of TB have migrated from Asia to London for more
changed since the earlier studies were than 20 years, stratified by whether % with TB performed so that the median incubation they had remained in the UK or had period is now longer? returned to Asia to visit friends or Three studies (two from the relatives (fig 2).22 In those who never Netherlands and one from Canada) show returned to Asia, the majority of TB that the incubation period of TB remains cases occurred in the first two years unchanged in the 21st century.18‑20 Sloot after arrival, with a steady steep > and colleagues identified patients with decline thereafter and no late peaks Time since UK entry (years) recent active TB in Amsterdam and (fig 2A). Fig 2 | Time of onset of active TB in Asian immigrants to the monitored their TST positive contacts By contrast, those who visited their UK, some of whom went to their home country and back to who did not take isoniazid prophylaxis country of origin after initial arrival in the UK before their onset of TB. Data from McCarthy.22 the bmj | 22 September 2018 361 the UK had an apparently steady rate identical findings.25 Almost all people As clinicians caring for patients of TB disease over the study period who had been TST positive for only in low transmission countries, (fig 2B). When the time of re-entry was a few weeks at the start of isoniazid we predominantly see TB disease considered, however, disease occurred treatment reverted within three in elderly people who were predominantly early (fig 2C). months; all who had been positive for infected at a time when TB was Finally, Wiker and colleagues more than one year remained positive widespread (remote infection) and in specifically tested the hypothesis at the end of the year’s treatment. immigrants from high transmission that TB incidence increases with These findings are consistent with areas and their contacts (recent or age by analysing the incidence of TB immunoreactivity being retained remote infection).6‑33 TB over 20-30 years in Norwegian well after infection is cleared. The The terms In such low burden areas, men stratified into 10 year birth more stable immunoreactivity of currently used screening contacts of patients with cohorts, from 1879-88 to 1959-68.23 people with long term TST positivity TB and others known, or likely, to to describe Surprisingly, they saw a decreased is consistent with immunological be recently infected is important to incidence over the 10 year observation memory being more robust and long the various prevent outbreaks. Biomarkers that periods in all age cohorts.8‑20 lasting when the infection lingered phases of distinguish newly acquired infection In sum, these studies show that, longer before being cleared. infection from remote infection could help to contrary to the prevailing view, TB Together, these studies indicate are not only prioritise interventions.34 35 But in high does not have a bimodal distribution that the reported burden of latent confusing, transmission countries, preventive separating primary progressive TB infection is overestimated, as it but even therapy for contacts is of limited value disease from reactivation disease. reflects immunoreactivity to either misleading given the high continuous chance Rather, the low rate of TB disease past or present infection. Not only of re-infection from known and many years after infection continues are most TST positive people not at unknown contacts. The latest WHO to dwindle with time. higher risk of TB, but multiple studies guidelines recognise this.36 have shown they may be protected Although the biology of latency is What does immunoreactivity mean? against the disease on subsequent tantalising, the importance of this In light of the findings that the risk exposure to infection.27‑29 phenomenon for global TB control of TB drops precipitously after the and for prioritising research is less first couple of years and continues Summary and implications convincing. That approximately to drop further, we revisited the Asymptomatic M tuberculosis 10 million new cases of TB disease assertion that a quarter of the world’s infection can result in disease decades are diagnosed each year is well cited, population is latently infected with M later, the most dramatic known but we cannot find a published tuberculosis. This statistic is derived example being a case of father to son estimate of the number of people from the finding that about a quarter transmission in Denmark with a 33 who are newly infected each year, of the world’s population exhibits year interval between infection and even though these people are at the immunoreactivity to TB, as shown by disease, which was confirmed on highest risk of developing disease. a positive TST or interferon gamma genome sequencing.30 Based on the number of contagious release assay. But the longitudinal studies cases worldwide, we can confidently The basis of adaptive immunity that we have examined support a assume there are tens of millions of is that a memory response does median incubation period of a few new infections per year, if not more. not require the inciting pathogen months to two years, with only a WHO has pledged to eliminate TB to remain present. Therefore, TB small proportion of people getting by 2035 through its End TB Strategy.37 reactivity must encompass both disease later. There is no evidence or Its staged implementation plan Marcel A Behr, current and past infections. But is epidemiological basis for a bimodal professor of includes “new tools: a vaccine, new there evidence that TB reactivity curve differentiating primary medicine, McGill drugs, and treatment regimens for persists afterM tuberculosis is cleared? progressive TB from reactivation TB. International TB treatment of active TB disease and Several papers suggest so. Atuk Furthermore, the epidemiological Centre, McGill latent TB infection,” which again and Hunt examined persistence of data do not support the existence University Health reflects the concern that the large TST positivity at the end of one year of of a special bacterial state (such as Centre Research reservoir of people with latent TB isoniazid treatment of asymptomatic, dormancy) during the asymptomatic Institute, Montreal infection may stymie efforts to achieve TST positive hospital employees.24 phase of TB, no matter how prolonged. Paul H Edelstein, this goal. Among recent converters (less than We must, therefore, recognise professor of We hope that the evidence that one year), only five of 20 people that the respective contribution of pathology and most TB cases occur within 18-24 laboratory medicine remained TST positive to the same recent and remote infection differs months of infection will lead to Lalita Ramakrishnan, extent; the rest became TST negative in high and low transmission reconsideration of the current professor of or positive to a smaller extent. settings.5 In high endemicity areas, strategy. If focused attention was immunology and By contrast, all 17 people who had the vast majority of disease burden infectious diseases, given to those with active TB disease been asymptomatically TST positive is accounted for by newly acquired Department of and their newly infected contacts, TB 1 for more than a year remained so after infection. As TB incidence declines, a Medicine, University elimination might be achieved sooner the year of isoniazid treatment. A greater proportion of disease is due to of Cambridge than projected. 1 5 study in naval officers had virtually a remote infection. [email protected]. Cite this as: BMJ 2018;362:k2738
362 22 September 2018 | the bmj LETTERS Selected from rapid responses on bmj.com See www.bmj.com/rapid-responses
ALCOHOL AND DEMENTIA We have stripped liver function tests from syndromic order sets Media distort findings to avoid this sort of non-evidence of drinking study based screening and have cut Sabia and colleagues report the use of liver function tests in their finding that, starting from primary care by more than 20% in midlife, moderate drinkers have our region. A patient presenting a reduced risk of developing with a BMI of 29 for a routine dementia (Research, 4-11 health check does not need a August). Media coverage has liver function test, he needs a been extensive, with headlines review of alcohol use and help that focus on one part of the with losing weight. research to present an appealing We need to ask how patients but distorted view of its findings LETTER OF THE WEEK are entering our services. We and implications. The article’s then need better discussion more important observation Does alcohol really have health benefits? between primary care, secondary about the substantial increased The public might be confused by The BMJ’s editorial on the care, and public health about hazard posed by heavy drinking beneficial relation between moderate alcohol consumption and how we deliver what matters with was lost. Alzheimer’s disease, which was based on an observational study a finite budget. Proper support This article is part of a (Research, 4-11 August). The view that moderate drinking has of under-resourced and at-risk diverse, lively, and divisive health benefits has been criticised as a bias favouring the alcohol weight and alcohol services is debate about alcohol and industry. likely to have population benefits brain function. It should not Observational studies touting the benefits of moderate alcohol that go beyond the function of a be looked at in isolation but as consumption underpinned the “French paradox”—a low incidence single organ. part of a mosaic of findings that of coronary artery disease attributed to drinking wine despite high Tom Lewis, consultant, Barnstaple will, with additional research, levels of dietary cholesterol. The paradox was criticised as a hoax Cite this as: BMJ 2018;362:k3709 come together to create a emanating from biased studies with commercial ties to industry. complete picture. The alcohol industry is powerful and its influence far reaching. NHS lacks the resources to The findings should also be A recently discredited National Institutes of Health (NIH) trial keep re-testing viewed in the context of the was meant to measure how well the alleged health benefits of strong evidence that led the moderate drinking hold up. But it was stopped owing to revelations As others have said, routine UK’s chief medical officers to that NIH researchers had courted the alcohol industry to support screening with liver function tests advise that drinking within the the £77m trial. An investigation found that the “trial design was needs to be stopped, but after recommended limits carries a low such that it would not pick up harms, such as an increase in the result is out, what should we but present risk of harm. cancers or heart failure associated with alcohol.” Industry has also do? I found Byrne and colleagues’ Gabriel L Van Duinen, paid journalists to try and influence public opinion on the benefits article helpful, but the resources public health student, of drinking. and tests are not available in Macquarie Park Cite this as: BMJ 2018;362:k3891 The narrative that alcohol has health benefits is alluring and primary care. difficult to challenge. A new observation based global report on If I have read the infographic alcohol indicates that no level of alcohol consumption is safe. correctly, those found not to have Defining alcohol related Alain Braillon, senior consultant, Amiens, France clinically significant disease dementia Mark Wilson, bioethicist, Guelph, Canada should be re-tested every Sabia and colleagues’ study Cite this as: BMJ 2018;362:k3888 2-3 years. We know that about 62% tells us little about how drinking of UK adults are overweight and above low risk guidance not include the one diagnostic examining attribution and 28% are obese. Does this mean beyond the age of 55 affects the category that describes alcohol association. that 28% of the adult practice development of dementia. We related dementia (F10.73). Rahul Tony Rao, consultant old age population would need testing know that a third of older people Alcohol related dementia psychiatrist, London every 2-3 years (corresponding to Cite this as: BMJ 2018;362:k3894 who misuse alcohol, start doing differs from other dementias about 10% a year)? If overweight so in later life, and this group in its clinical characteristics, NAFLD people were included, it would be would not have been included. including areas of cognitive about 20% a year. The elephant in the room, impairment. Until we start Reducing use of This is a huge workload that however, is the definition of using a more valid definition liver function tests is not resourced at a time when “alcohol related dementia.” The of alcohol related dementia, Byrne and colleagues suggest things that do make a difference, study inclusion criteria were we are going to continue to be an investigation of patients with like hip replacements, are being based largely on the F and G misled by research that uses abnormal liver enzymes detected banned by the NHS. codes of the International degenerative and vascular at a routine health check Nicholas Sharvill, GP, Deal Classification of Diseases but did dementia as the basis for (Rational Testing, 14 July). Cite this as: BMJ 2018;362:k3710 the bmj | 22 September 2018 363
Warner Slack Physician who believed that patients are the most underused resource in healthcare
Warner Slack (b 1933; q College of system is inversely related to the size Physicians and Surgeons, Columbia of its manual,” a lesson that many University, New York, 1959), died from wish would be heeded by today’s pulmonary fibrosis on 23 June 2018 electronic medical records. Noting that physicians are facultative (at Warner Slack, the visionary will) users, not obligate, he saw that physician who wrote that the patient functionality and user experience is the “largest and least utilised would be critical factors for success. resource in healthcare,” has died at How many doctors and nurses the age of 85. Accolades have come today wish their current “death by a in from scores of people who, like the thousand clicks” electronic health authors, benefited from his wisdom records were held to the standard of and generous mentoring. being worth the effort? Slack foresaw, with remarkable A key success metric for any clarity, both the extent and the new application we implemented limitations of what computers could was how much it was used by contribute to medicine. His 1997 physicians, even without publicity book Cybermedicine: How Computing about its existence: an app’s survival Empowers Doctors and Patients depended on word of mouth among for Better Care encapsulated his satisfied users. While this is rarely steadfast belief that information tracked in clinical settings today, Slack looked at each patient’s record technology, “implemented wisely it is a cherished metric among believed that and what they looked at. Later he and well,” can empower both smartphone app developers. information collaborated with Jonathan Wald, physicians and patients. technology adding a feature to require those Patients and physicians can empower viewing a record to choose their Cybermedicine The patient-clinician partnership physicians reason for viewing it. Technology was a lifelong aspect aspect of his vision foretold He believed patients had of Slack’s work. In 1966 he created The BMJ’s Patient and Public and patients every right to view their software to take a patient’s medical Involvement campaign and its clinical information, which history, saving physician time and status as the first journal to earn anticipated patient portals, future improving accuracy. In the 1970s #PatientsIncluded accreditation in government policy, and eventually Slack and Howard Bleich created 2012. Not incidentally, in the 1990s the OpenNotes movement. the Center for Clinical Computing he introduced me [DZS] to “Doc Tom” Warner Slack graduated from (CCC) at Harvard Medical School, Ferguson, who wrote in The BMJ in Princeton in 1955, and from now Division of Clinical Informatics 2000 about online patient helpers Columbia University’s College at Beth Israel Deaconess Medical and physicians working together. of Physicians and Surgeons in Center (DCI). They soon conceived Slack was one of the first board 1959. His many honours include a computerised librarian function, members of ACOR, a network the 2002 Morris F Collen Award PaperChase, which was so widely of cancer patient listservs. My from the American Medical adopted that it foreshadowed oncologist [writes Dave de Bronkart] Informatics Association, received subsequent literature search engines. said that ACOR helped save my life jointly with Bleich. Slack continued in DCI leadership from a near fatal renal cell carcinoma Slack died in the arms of his wife, until his death. because of practical unpublished Carolyn, on the morning of their With Bleich he co-created one information that patients had 62nd wedding anniversary. He leaves of the earliest hospital information accumulated. This partnership vision Carolyn, three children, and seven systems, for both clinical and is today expressed in the Society for grandchildren. administrative use. It included Participatory Medicine, whose 13 Dave de Bronkart, BMJ Patient Panel perhaps the first hospital email co-founders include the authors and member, and chair emeritus, Society for system. But technology was not an ACOR founder Gilles Frydman. Participatory Medicine end in itself—Slack insisted it be Slack said that privacy of patient [email protected] useful to the physician. data must be a core value, because Daniel Z Sands, assistant clinical During my fellowship [writes Daniel trust is essential in the clinical professor of medicine, Harvard Medical Z Sands] at CCC he taught me that relationship. He insisted that CCC School, Boston the “utility of a clinical information store a complete audit trail of who Cite this as: BMJ 2018;363:k3194
364 22 September 2018 | the bmj