Herrmann-Werner et al (2019) brought to our attention an increasingly relevant topic. The study proposed that the obesity simulation suit (OSS) could be used to address the issue of stigmatisation of obesity(1). We are medical students at Imperial College London. As part of our course, we have regularly attended clinical communication sessions in the form of simulated role play.
We believe that whilst using a simulated patient in an OSS may be useful, it is a superficial way of addressing the deep-rooted societal problem of how obesity is viewed and may even reinforce the stigma. The use of simulated patients should be adapted to reduce prejudice towards obese patients, especially with reference to their physical and psychological comorbidities.
The study argues that using healthy weight actors in the OSS was of benefit because using obese actors ‘entails the potential danger of issues becoming too personal for the patient’(1). However, we believe that using actors with a healthy BMI may reinforce to students that obese patients are embarrassed or ashamed to have a conversation about their weight. At Imperial College, we simulate consultations with real patients to better understand their conditions. Rees et al also prefer the use of real patients, arguing that it provides medical students with a more realistic experience(2). Therefore, we recommend that students talk to obese patients who are willing to partake and understand the sensitive n...
The study argues that using healthy weight actors in the OSS was of benefit because using obese actors ‘entails the potential danger of issues becoming too personal for the patient’(1). However, we believe that using actors with a healthy BMI may reinforce to students that obese patients are embarrassed or ashamed to have a conversation about their weight. At Imperial College, we simulate consultations with real patients to better understand their conditions. Rees et al also prefer the use of real patients, arguing that it provides medical students with a more realistic experience(2). Therefore, we recommend that students talk to obese patients who are willing to partake and understand the sensitive nature of the session.
Furthermore, actors with a healthy BMI may not have experienced the same physical and psychosocial problems endured by many obese people. This limits the usefulness of the session, especially the ways in which obese people feel stigmatised. Speaking to real patients during our time at Imperial College has furthered our understanding of the physical and psychosocial impact of disease. In addition, teaching sessions exploring how body image is portrayed in social media, the fashion industry and other areas of society may help medical students recognise and understand their own attitudes towards obese patients.
Allowing students to talk to obese patients with related health conditions would be more beneficial than using actors with an OSS. Furthermore, the physical and psychosocial aspects of disease should be explored alongside formal teaching about disease pathology, to help reduce the stigma surrounding obesity.
1 Herrmann-Werner A, Loda T, Wiesner LM, Erschens RS, Junne F, Zipfel S. Is an obesity simulation suit in an undergraduate medical communication class a valuable teaching tool? A cross-sectional proof of concept study. BMJ open. 2019 Jul 1;9(8):e029738.
2 Rees C, Sheard C, McPherson A. Medical students’ views and experiences of methods of teaching and learning communication skills. Patient Education and Counseling. 2004 July;54(1): 119-121
Kapoor et al. highlight one aspect of gender discrimination, gender injustice and gender prejudice in Indian society using data acquired from their hospital information system at AIIMS New Delhi.1 Under a title of introduction the authors write, ”There have been a handful of small sample studies on gender bias in access to healthcare in select patient groups or for specific medical conditions….” Then under a title of Discussion, they cite several studies, some conducted at their Institute in the department of Cardiology, some in Pediatrics and some conducted abroad. Here we want to state that we too conducted a manual small study in Emergency Department of our hospital. We assessed demographic profile of alleged self -harm patients presenting to our referral tertiary care public hospital. In our study -among other variables- when we estimated sex ratio among male and female patients, it was 62:38(2). And that’s eerily close to 63:37 in this study. So there is a difference of just 1 percentage point. When 38 women per hundred patients present in our hospital in Lucknow with a history of alleged self- harm , 37 present to AIIMS New Delhi on an average in OPDs.
Similarly at reference number 8, there is a study to estimate gender- bias in (availing) cardiovascular healthcare at a tertiary care center of north India. In the study Chhabra et al. assess that the ratio of girls to boys to avail cardiac interventions for their congenital and rheumatic heart disease is 38:62...
Similarly at reference number 8, there is a study to estimate gender- bias in (availing) cardiovascular healthcare at a tertiary care center of north India. In the study Chhabra et al. assess that the ratio of girls to boys to avail cardiac interventions for their congenital and rheumatic heart disease is 38:62 (same as in ours). So findings of the authors reveal an all pervasive ingrained truth of our patriarchal society- marginalising women, uncaring for even when they struggle for their survival while fighting to maintain their bodily integrity, and losing their battle many a times.
Early this year Government of India issued a Report on the Ranks of States and Union Territories, entitled “Healthy States Progressive India”(3). On page number 44 of this report, there is an indicator 1.1.5 - Sex Ratio at Birth (SRB). Y Axis of this diagram measures number of girls born per thousand boys born. On having a glance on this diagram it’s apparent that UP, Bihar and Haryana treat girl children badly (in fact Haryana fairs the worst). Therefore what is “normal’ in this study, including normal baseline ratio; is actually picked up from discriminatory population. What is normalised in our society is injustice meted out,
oppressing the body and minds of potential female workforce.
As in Discussion the authors write, “This discrimination of(against) women is not fully captured in the overall sex ratio or excess mortality of women relative to men, we want to draw attention towards reference number 1 of the Research Article. There Amartya Sen writes ,” But after conception, biology seems on the whole to favour women. Considerable research has shown that if men and women receive similar nutritional and medical attention and general health care, women tend to live noticeably longer than men. Women seem to be, on the whole, more resistant to disease and in general hardier than men, an advantage they enjoy not only after they are forty years old but also at the beginning of life, especially during the months immediately following birth, and even in the womb. When given the same care as males, females tend to have better survival rates than males.” So as women are less likely to fall ill due to their better biological design, our hospital based indicators of disease -monitoring of incoming patient population are likely to have their own limitations.
And in 1992, Prof. Amartya Sen wrote in the same journal, “Considerable direct evidence exists of neglect of female children in terms of health care ,admission to hospitals, and even feeding.” Under a title ,”Missing Women”(4). Therefore both the author and our team demonstrate a very small aspect of gender -discrimination ,and that’s reflected in admission to (and attendance at) hospitals. As usually research questions explore a very limited prespecified objective, other facets of differential treatment should be taken into account, which are likely to have a bearing on women’s health.
18 Years ago Prof. Amartya Sen wrote an essay- The Gendered Body. In the essay he writes in part 3, “Indeed there is some direct information about comparative medical neglect of girls vis -a vis boys in South Asia. When I studied, with Jocelyn Kynch, admissions data from two large public hospitals in Bombay (Mumbai), it was very striking to find clear evidence that the admitted girls were typically more ill than boys, suggesting the inference that a girl has to be more stricken before she is taken to the hospital. Undernourishment may well result from greater morbidity, which can adversely affect both the absorption of nutrients and the performance of bodily functions.”(5) This area needs further exploration in our times.
Moreover while visualising the world, sometimes our lens of scrutiny should move inwards too. While we discuss and debate gender- bias in the population at large, it’s time to have a fair opinion for ourselves too: the academia. While it’s a routine experience that female patients are short -changed, same is also true for healthcare providers. Female workforce in the position of authority makes only a minor proportion in several regions(6-8). Government of India recognises the fact and plans to make suitable amendments in rules(9). In this paper our government states,”Sex ratio is also a major area of concern for our country.” And on course correction ,”India is expected to gain from its ‘demographic dividend’ in the coming years and women are an integral part of this development process if India wants to tap its full potential. It is only through empowering the women in all forms that women will transcend beyond the constraints they presently face. It is essential to focus on these aspects if India wants to achieve its vision of ‘A society in which women attain their full potential and are able to participate as equal partners in all spheres of life and influence the process of social change (Draft National Policy for Women 2016)”.
What is intriguing is that out of 6 authors of this research article, only one is female although it looks specifically into female subjugation and mistreatment to women. We believe that in near future when more women are around, hitherto unexplored areas will be investigated to give us a new vision. With the beginning of harmonious representation of all the sections of our society in our investigative team, new avenues of research will be created and together we will make a world where injustice of any sort will be rapidly identified and timely course correction be made. And to begin with, in that utopian world, women will not die soon!
(1) Kapoor M, Agrawal D, Ravi S, et al. Missing female patients: an observational analysis of sex ratio among outpatients in a referral tertiary care public hospital in India. BMJ Open 2019;9:e026850. doi: 10.1136/bmjopen-2018-026850
(2) Agrawal M, Tiwary NK, Nigam N, et al. Assessment of demographic profile of patients admitted with a diagnosis of alleged self-harm at a teaching hospital in Hindi heartland. J. Evid. Based Med. Healthc. 2019; 6 (17), 1288-1291. DOI: 10.18410/jebmh/2019/267 ,available at https://jebmh.com/latest_articles/98391
(3) Healthy States Progressive India , by NITI Aayog , available at https://www.niti.gov.in/writereaddata/files/document_publication/NITI-WB...(Web%20Ver)_11-06-19.pdf
(4) Sen A. Missing Women. BMJ 1992;304:587 ,available at https://doi.org/10.1136/bmj.304.6827.587
(5) Sen A. Many faces of gender inequality. Frontline 2001 Nov 9; 18(22) ,available at https://frontline.thehindu.com/static/html/fl1822/18220040.htm
(6) The Editors of the Lancet group. The Lancet group’s commitments to gender equity and diversity. Lancet 2019 Aug 10; 394: 452-453 ,doi https://doi.org/10.1016/S0140-6736(19)31797-0
(7) Rexrode KM. The gender gap in first authorship of research papers. BMJ 2016;352:i1130 https://doi.org/10.1136/bmj.i1130
(8) Chaudhary K, Dhanda SK. India’s top science awards heavily gender skewed. Nature India 2019 Feb 11 doi:10.1038/nindia.2019.14 ,available at https://www.natureasia.com/en/nindia/article/10.1038/nindia.2019.14
(9) National consultation on SDG 5 - Gender Equality , by NITI Aayog , available at https://www.niti.gov.in/writereaddata/files/National%20Consultation%20on...
We accessed all the webpages at the time of submission of this letter.
We read with interest the paper by Van de Velde et al delineating the concept of self-management in chronic conditions.1 We agree that there is a lack of consensus on the meaning of self-management, ambiguity regarding the concept, and an urgent need for uniformity with regard to terminology. One major area of ambiguity is the relationship between self-management and self-care. These terms are often thought of as synonyms, used interchangeably, or considered as integrated concepts (e.g. self-care as an overarching or umbrella term, with self-management as onecomponent of self-care).2 This is why, until 2018, major search engines combined the terms. When one searched for “self-management”, literature on “self-care” was provided as well. Since Van de Velde and co-workers aimed to delineate the concept of self-management and develop a definition for its use in healthcare, we expected a more thorough review of related concepts in their concept analysis. Thus, we were surprised to find that several important publications on self-care were excluded.
We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managi...
We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managing illnesses” (p. 195),3 a definition quite similar to the definition provided for self-management. Since publication, investigators around the globe have used our theory to study how individuals maintain their health, monitor and manage their illnesses. But even before the official publication of the Middle-Range Theory of Self-Care of Chronic Illness, there was a wealth of publications studying self-care that might have been included in the present concept analysis.
We agree with the authors that self-management, or self-care, is important for the sustainability of our healthcare systems into the future. Discussions aimed at reaching consensus on shared terminology can only benefit society and the development of the science. So, we thank you for your efforts to examine “self-management” and hope that you will do the same for “self-care”. Such an effort to compare and contrast the two common terms would be a major contribution to our shared goal of consensus.
1. Van de Velde D, De Zutter F, Satink T, et al. Delineating the concept of self-management in chronic conditions: a concept analysis. BMJ Open. 2019;9(7):e027775.
2. Godfrey CM, Harrison MB, Lysaght R, Lamb M, Graham ID, Oakley P. Care of self - care by other - care of other: the meaning of self-care from research, practice, policy and industry perspectives. Int J Evid Based Healthc. 2011;9(1):3-24.
3. Riegel B, Jaarsma T, Stromberg A. A middle-range theory of self-care of chronic illness. ANS Adv Nurs Sci. 2012;35(3):194-204.
4. Riegel B, Jaarsma T, Lee CS, Stromberg A. Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness. ANS Adv Nurs Sci. 2019;42(3):206-215.
Thank you for your recent BMJ Open article,1 which has correctly noted that it is critical for journal editors’ potential conflicts of interest to be publicly disclosed. A limitation of the study is that only the digital version of the journals were considered. Obstetrics & Gynecology has included a conflict of interest statement for the Editor-in-Chief and Deputy or Associate Editors on the masthead of the print journal since the July 2008 issue. The article by Dal-Ré has prompted us to review our digital presence, and the website has since been updated to reflect our long-standing presentation of the editors’ potential conflicts of interest. I thank the authors for highlighting the importance of disclosing potential conflicts of interest but express concern that their work is biased toward the digital presence only.
1. Dal-Ré R, Caplan AL, Marusic A. Editors’ and authors’ individual conflicts of interest disclosure and journal transparency. A cross-sectional study of high-impact medical specialty journals. BMJ Open 2019;9:e029796. doi: 10.1136/bmjopen-2019-029796.
While it is important for medical students, along with those that teach them, to know how to communicate appropriately with their clients of all sizes, a simulation such as a fat suit is NEVER an accurate substitute for speaking with a client that lives every day with a fat body. Unless the person wearing a fat suit has lived with the stigma, discrimination and overt hatred of their body by a medical professional, their is no way the communication/conversation about their bodies will be the same. If you want to learn how to treat a fat client, please read the brochure NAAFA Guidelines for healthcare providers with fat clients available at https://www.naafaonline.com/dev2/about/Brochures/2017_Guidelines_for_Hea....
We recently reported no increase in any brain tumour histological type or glioma location between 1982 and 2013 in Australia that can be attributed to the use of mobile phones1. Our analysis included brain tumour incidence in adults aged 20–59 years but Phillips2 criticised this age-range mentioning that it was inappropriate not to include the 60+ age group which has the highest incidence of brain tumours. In a response to Phillips3, we reiterated that the age-range in our study was chosen in order to compare our results with the Interphone study4. We further mentioned that including cases older than 60 would be more affected by improvements in diagnosis and their inclusion would reduce the chance of assessing mobile phone related changes to tumour incidence.
As a follow up to our original analysis, we investigated the incidence trends of brain tumour histological types and anatomical location in Australians aged 60+ diagnosed between 1982 and 2013. The methods of our follow up analysis were the same as our original study1 and the observed incidence trends, given as annual percentage change (APC) and 95% confidence limits, were examined over the time periods 1982–1992, 1993–2002 and 2003–2013 (representing increased CT and MRI use, advances in MRI and substantial and increasing mobile phone use, respectively).
There was a total of 20300 eligible brain cancer cases aged 60+ that were diagnosed between 1982 and 2013. The observed incidence trends for glioma we...
There was a total of 20300 eligible brain cancer cases aged 60+ that were diagnosed between 1982 and 2013. The observed incidence trends for glioma were: 3.62 (2.60 – 4.65) during 1982–1992; 0.96 (0.03 – 1.91) during 1993–2002; and 0.30 (-0.41 – 1.02) during 2003–2013. Specifically for glioblastoma the incidence trends were 5.18 (3.75 - 6.63), 2.57 (1.43 - 3.72) and 1.28 (0.47 - 2.10) for the three time periods, respectively. Thus there were substantial and significant increases in the first two periods, concordant with diagnostic improvements, and much smaller or no trend in the third period.
There were decreasing trends in the 60+ age group for brain tumours with unspecified histology during the periods of increased and more precise diagnosis i.e. during 1982–1992 and 1993-2002. With the redistribution of unspecified tumours as was performed in our original study, there were no significant changes to the histological trends.
It has been previously reported that the temporal and parietal lobes are more highly exposed to radiofrequency radiation than other brain sites when using a mobile phone5. In the analysis of glioma location of the 60+ age group the incidence trends for the temporal lobe were 10.07 (6.95 - 13.28), 3.93 (1.77 - 6.15) and 3.25 (1.76 - 4.77) for the three time periods, respectively. Specifically in the last period there were 1912 cases of temporal lobe glioma. With the redistribution of a high number of gliomas with unspecified and overlapping location there was a much lower trend for gliomas on the temporal lobe during the period of substantial mobile phone use i.e. 1.69 (0.16 – 3.23) during 2003–2013. Therefore, no significant increased incidence was observed for gliomas of the temporal lobe after accounting for the unspecified tumour locations. For the parietal lobe the incidence trends were 10.07 (7.49 - 12.72), -3.26 (-5.30 – (-1.17)), and -1.28 (-3.07 - 0.55) for the three time periods, respectively. With the redistribution of gliomas with unspecified and overlapping location the trend for parietal lobe tumours decreased further during the period of substantial mobile phone use i.e. -2.58 (-4.16 – (-0.98)).
We also compared the observed incidence of the 60+ age group during the period of substantial mobile phone use (2003–2013) with predicted (modelled) incidence for the same period by assuming a causal association between mobile phone use and glioma (with varying relative risks ranging from 1.5 – 3). Similar to our original results for the 20-59 age group, the predicted incidence rates for the 60+ age group were higher than the observed rates for latency periods up to 15 years.
The pattern of these results is consistent with increased and more precise diagnosis, especially during 1982-1992 and also during 1993-2002. In the last period (2003-2013) there were very small increases in glioblastoma and gliomas of the temporal lobe in the 60+ age group which were most likely due continuing improvements in diagnosis and classification. We maintain that the age range used in our original study was the most appropriate for investigating mobile phone related changes to tumour incidence.
1. Karipidis K, Elwood M, Benke G, et al. Mobile phone use and incidence of brain tumour histological types, grading or anatomical location: a population-based ecological study. BMJ Open 2018;8:e024489.
2. Philips A. Significant flaws and unjustifiable conclusions. Letter to the Editor, BMJ Open, 2019.
3. Karipidis K, Elwood M, Benke G, et al. Response to letter from Alasdair Philips. Letter to the Editor, BMJ Open, 2019.
4. INTERPHONE Study Group. Brain tumour risk in relation to mobile telephone use: results of the INTERPHONE international case-control study. Int J Epidemiol, 2010(39):675–94.
5. Cardis E, Deltour I, Mann S, et al. Distribution of RF energy emitted by mobile phones in anatomical structures of the brain. Phys Med Biol 2008;53:2771–83.
This paper is interesting and a welcome addition to the literature. The authors discuss the potential issues related to the use patient post codes. The case of the New Forest, considered a hot spot, is interesting in this regard. The number of residents currently is 38,000 and the annual number of visitors is 13.5 million according to the New Forest District Council.
In their recent paper, exploring prognostic signs and symptoms in relation to survival of 72 hours, White N, Reid F, Harries P, et al. (BMJ Open 2019), mention that a ‘large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient.’ This comment highlights, in my experience, the absence of documented information about a patient’s psychological and spiritual well-being prior to the final days of life. For some patients, an important aspect of spiritual well-being is religious faith, including the support of a faith community and the opportunity to receive end-of-life religious rites.
When patients are admitted for end-of-life care, there can be occasions when there is little or no time for an in-patient team to learn about a person’s spiritual or religious needs. This may be due to the fact that a patient is unconscious on admission and there are no accompanying relatives or friends. In such situations, the referral form is crucial. Yet, the pan-London Specialist Palliative Care (SPC) Community and SPC Inpatient Unit Referral Form does not provide a specific ‘religion’ box.
This form does have a section for ‘any other comments/information (including preferences expressed about care, other psychosocial or spiritual issues or DOLS)’, but almost invariably the referrer fails to mention spiritual or religious needs. Clearly, it is important to know i...
This form does have a section for ‘any other comments/information (including preferences expressed about care, other psychosocial or spiritual issues or DOLS)’, but almost invariably the referrer fails to mention spiritual or religious needs. Clearly, it is important to know if the patient has a religious faith as, for example, a Catholic patient may need to be anointed with some urgency, and a Muslim or Jewish patient may need to be buried within strict timelines. Acknowledging and ensuring that a patient’s religious needs are met, as part of end-of-life care, may contribute to the spiritual well-being not only of the patient but also of the immediate family.
Dear Brandon Togioka,
Thanks for the interest in the article.
We actually had similar question ourselves as the numbers were small. The following are the individual trainee failure rates in percentage.
Trainee number Failure Rate (percentage) Group 1= group S, 2= Group P
1. 20 1
2. 10 1
3. 0 1
4. 30 1
5. 10 1
6. 30 1
7. 40 1
8. 30 1
9. 10 2
10. 0 2
11. 0 2...
1. 20 1
2. 10 1
3. 0 1
4. 30 1
5. 10 1
6. 30 1
7. 40 1
8. 30 1
9. 10 2
10. 0 2
11. 0 2
12. 0 2
13. 0 2
14. 30 2
In contrast with prior literature - which only focused on a limited number of specialties - HJ Vaidya et al (1) demonstrated that medical students who have a longer placement period in a particular speciality are no more likely to pursue a career in that speciality. The study has important implications, and the authors should be commended, as it suggests that increasing exposure to clinical specialties during medical school will not solve current recruitment pressures.
Interestingly, the authors chose to incorporate specialties such as clinical radiology and public health within the statistical analysis. However we question the reliability of the subsequent results, given the small number of medical schools that offered placements in those specialities.
By using the number of weeks allocated to a particular speciality by each medical school, the authors created a useful, objective metric that could be used for statistical analysis. However, upon reading, we noted that it may not wholly reflect a student’s exposure to that speciality during their placement. In our experience as medical students, we feel that due consideration must be given to the quality of a clinical placement as well as it’s duration. The hospital in which a student is based, the medical team that they shadow, and the student’s experience are but some of the factors that may influence the degree of a student’s involvement on a particular firm, thereby influencing their e...
By using the number of weeks allocated to a particular speciality by each medical school, the authors created a useful, objective metric that could be used for statistical analysis. However, upon reading, we noted that it may not wholly reflect a student’s exposure to that speciality during their placement. In our experience as medical students, we feel that due consideration must be given to the quality of a clinical placement as well as it’s duration. The hospital in which a student is based, the medical team that they shadow, and the student’s experience are but some of the factors that may influence the degree of a student’s involvement on a particular firm, thereby influencing their exposure to the speciality. It also allows positive relationships to develop between the trainee and mentor – a feature that should be further exploited in undergraduate education (2).
It is likely that exposure to a speciality is an important, but not the deciding factor, in determining career choice. Take for example students looking to enter a career in surgery. There is an increased cost for surgical training through regular attendance of surgical training courses and conferences, and undertaking higher degrees to increase the likelihood of obtaining competitive posts. Additionally, membership and medical defence fees often leads to surgical trainees having to spend over £130,000 in total (3). Many would also perceive surgery as being a more stressful specialty and this can deter students who are looking for a better work-life balance (4).
Based on this study and prior literature, it may be beneficial for future studies to combine the use of subjective measures and objective metrics to define the quality and quantity of exposure to a particular speciality, as well as surveys to understand the ultimate reasons for final career choices. Additionally, it would be interesting to see the effects of foundation year placements on future career choices.
Conflicts of interest- none declared
1. Vaidya HJ, Emery AW, Alexander EC, McDonnell AJ, Burford C, Bulsara MK. Clinical specialty training in UK undergraduate medical schools: a retrospective observational study. BMJ Open. 2019;9(7):e025403.
2. Hagopian TM, Vitiello GA, Hart AM, Perez SD, Pettitt BJ, Sweeney JF. Do medical students in the operating room affect patient care? An analysis of one institution's experience over the past five years. J Surg Educ. 2014;71(6):817-24.
3. Pereira EA, Dean BJ. British surgeons' experiences of mandatory online workplace-based assessment. J R Soc Med. 2009;102(7):287-93.
4. Rich A, Viney R, Needleman S, Griffin A, Woolf K. ‘You can't be a person and a doctor’: the work–life balance of doctors in training—a qualitative study. BMJ Open. 2016;6(12).