The BMJ

A man wakes up in a city consisting of humans. No streets, buildings or cars...ONLY HUMANS!

Editor—I assume that I am one of the few medical practitioners in this country who self manages his own oral anticoagulation and would like to comment on the paper by Fitzmaurice and Machin on patients undertaking self management of oral anticoagulation.1 Firstly, the suggestion that patient demand for self management is partly fuelled by a national media advertising campaign for CoaguChek is disingenuous. I wonder how much of an NHS hospital trust haematology department budget is derived from patients attending their warfarin clinic? Secondly, routine performance in anticoagulation clinics in the United Kingdom may compare favourably with that in other countries, but at what hidden costs to the patients? As I have noted before, attending the warfarin clinic at my local hospital every two to three weeks would occupy 150 working days over 25 years, over half a year.2 Thirdly, testing is recommended every three to seven days and it is not clear why it is required. For the first week of my using CoaguChek in August 1997 I measured my international normalised ratio twice daily at about 8 am and 8 pm. Morning and evening readings ranged from 2.4 to 3.0 from a regular 8 pm dose of 5 mg of warfarin. In addition, on at least 10 occasions since then the ratio has been 3.1 or higher and on at least two occasions 2.0 or lower from the same drug regimen for more than seven days. If I had attended a hospital warfarin clinic on the low days, my dose of warfarin would probably have been increased and not remeasured for at least a week, and with what consequences? I have already had one major epistaxis requiring a 6 unit blood transfusion, urgent ear, nose, and throat surgery, a week in hospital, and a month off work—all secondary to an international normalised ratio of 4.8 created by the warfarin clinic. I wonder what proportion of patients at warfarin clinics have had similar experiences? Had I attended on a high day, my dose of warfarin may well have been reduced. I have not yet had any emboli from my aortic valve replacement, and I do not want any, thank you. In the past three months I have altered my warfarin regimen of 5 mg a day on 11 occasions to keep within the range of 2.5-3.0. In other words, some people taking warfarin, and presumably not just consultant psychiatrists, may have significant individual variation in international normalised ratio. Finally, the current debate on self management of anticoagulation is reminiscent of the dilemmas about insulin dependent diabetes 25 or so years ago, when I was a medical student and finger prick testing for blood glucose estimation became available. Look what has happened there.

US physicians are more pressed than ever to deal with end of life care. Leigh Page looks at the issues Increasingly, US physicians face legal risks for doing too much or too little to help patients with end of life issues. On one hand, doctors are under more pressure to hold discussions with people who are diagnosed with terminal illnesses—exploring whether they would want to stop treatment if it became ineffective. In that case, the patient would shift to palliative care, which involves pain medications and other therapies to enhance quality of life. On the other hand, physicians may have terminally ill patients who are untreatable and want to die, but assisting in their suicide is illegal in most US states. In a few cases, physicians have been criminally convicted and sent to prison for helping a patient die. Even talking about end of life issues can be distressing for physicians, because their overriding concern is to heal patients, said Timothy E Quill, a palliative care specialist in Rochester, New York. “When you’ve been fighting for a patient for a long time, it can be really hard to give up on treatment,” said Quill, who directs the Center for Ethics, Humanities and Palliative Care at the University of Rochester School of Medicine. Quill said there are negative consequences, however, if physicians avoid talking about end of life issues with patients—as is often the case.1 Patients may never have the chance to choose options that could ease their deaths. And if they can’t talk about their desire for suicide, they are cut off from exploring other options, such as taking antidepressants or stronger pain medications. When New York State passed a law in 20102 requiring physicians to discuss end of life options with patients diagnosed with a terminal illness, …

The disease management approach to patient care seeks to coordinate resources across the healthcare delivery system. The growing interest in evidence based medicine and outcomes, and a commitment to integrated care across the primary, secondary, and community care sectors, all contribute to making disease management an attractive idea. A combination of patient education, provider use of practice guidelines, appropriate consultation, and supplies of drugs and ancillary services all come together in the disease management process. But its effectiveness is largely untested, so evaluation is essential.

I was very excited when I read the headline “New approach to surgical care aims to improve recovery.”1 Like many surgeons I have been interested in improving recovery of patients after elective surgery for quite a while. However, the only thing new I was able to find in this “new approach” was a new acronym (enhanced surgical treatment and recovery programme, ESTREP). Surgeons, anaesthetists, and other doctors interested in the topic of enhancing postoperative recovery have known the multimodal approach allegedly developed at University College London Hospitals NHS Foundation Trust for more than a decade under the acronym ERAS (enhanced recovery after surgery) or “fast track.” Except for intraoperative oesophageal Doppler guided fluid management (in some hospitals already a part of fasttrack surgery), the “new approach” does not seem to offer anything new. The BMJ did publish a clinical review on this topic more than five years ago,2 while the first series of fast track rehabilitation for elective colonic resection by Henrik Kehlet and coworkers from Hvidovre-Hospital in Copenhagen, Denmark is as old as 12 years.3 Not only is the “new approach” not really new, but also the potential of fast track or ERAS or ESTREP is underestimated in this article—to reduce the average stay in hospital for patients undergoing complex colorectal surgery from 12 days to eight days. In the Copenhagen group postoperative hospital stay was decreased to two to three days after elective colectomy, postoperative hospital stay was five days in a recent international study,4 and postoperative hospital stay decreased from 12 to five days after introduction of fast track rehabilitation in the Charite Hospital in Berlin.

The author is a medical missionary in southern Africa. He describes the human devastation wrought by HIV/AIDS in the region. The adult wards remain filled with young, wasted males and females with persistent coughs and other manifestations of tuberculosis (TB), generalized lymphadenopathy, Kaposi's sarcoma, pyogenic infection, and neural and ocular manifestations of HIV infection. The main reason for admission to the wards is to exclude or identify treatable infections, especially pulmonary TB. The lack of physical and other resources, however, result in the early discharge of terminal and untreatable cases. Deaths which do occur in the hospital are most commonly caused by untreatable TB or profuse diarrhea combined with chronic wasting and anemia. The children's ward is largely populated by babies and toddlers with a combination of pneumonia and failure to thrive, while outpatient clinics simply providing a preview of future inpatients. The author points out that this heavy toll of AIDS-related morbidity and mortality does not exist in a vacuum, but in the context of many other long-standing diseases. Many AIDS patients die in a state of denial. Finally, there are numerous personal, social, and psychological ramifications associated with each case of AIDS.

Most health carers want to base their practice on evidence and feel that this will improve patient care. 1 2 The original idea that each health professional should himself or herself formulate questions; search, appraise, and summarise the literature; and apply the evidence to patients3 has proved too difficult alongside the competing demands of clinical practice. 1 4 Over 90% of British general practitioners believe that learning evidence handling skills is not a priority,1 and, even when resources are available, doctors rarely search for evidence.5 However, 72% do often use evidence based summaries generated by others,1 which can be accessed by busy clinicians in seconds.6 From this week the NHS will be providing many of its clinicians with one of those sources— Clinical Evidence . Clinical Evidence is a compendium of summaries of the best available evidence about what works and what doesn't work in health care. It is designed to be useful in daily practice by answering common and important clinical questions. It is constructed by transparent methods and updated regularly (so earlier issues should …

Join a global conversation at http://blogs.bmj.com/bmj/2008/12/10/alex-jadad-on-defining-health/ On 7 April 1948, the member states of the United Nations ratified the creation of the World Health Organization. It was set up with the fundamental objective of “the attainment by all peoples of the highest possible level of health.” This lofty goal was coupled with an equally ambitious opening statement that defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1 This definition invited nations to expand the conceptual framework of their health systems beyond the traditional boundaries set by the physical condition of individuals and their diseases, and it forced us to pay attention to what we now call social determinants of health. Consequently, WHO challenged political, academic, community, and professional organisations devoted to …

Case study evaluations, using one or more qualitative methods, have been used to investigate important practical and policy questions in health care. This paper describes the features of a well designed case study and gives examples showing how qualitative methods are used in evaluations of health services and health policy.