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 I ona 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.