810 e-Letters

  • Authors' response to: "UK medical schools are not academically equal"

    We agree that variation exists across UK medical schools as highlighted by the cited paper by McManus et al. (2008). It was partly this that we had in mind when we state, in the limitation section of our discussion:

    “In terms of the outcome measures, the categorisation of undergraduate examinations into skills and knowledge was not operationalised and therefore rely on the participating medical schools to categorise the evaluations. Thus, their definition may vary across medical schools. While some of this variation was handled by the use of multilevel modelling, a more robust definition of undergraduate ‘skills’-based assessments may have been helpful in predicting clinically orientated performance, which may have been a more faithful proxy for later medical practice. In this regard, a methodology has been proposed to achieve this through the ‘nationalisation’ of ‘local’ measures of undergraduate medical school performance for fair comparisons of graduating medical doctors.” [page 10, paragraph 3].

    Indeed, we recognise the use of ‘local educational measures’ as a particular challenge in UK-based Medical Education Research and are shortly to evaluate whether our approach to adjusting for this using ‘Peer Competition Rescaling’ (applied in the report by Tiffin & Paton, 2017) is valid in these circumstances. Thus, it is true to state that at present we cannot rule out the potential selection effect that Dr Banerjee highlights as a possibility. Only emerging...

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  • Increased U.S. primary care consultation duration due to EHR burden?

    We read with great interest the comprehensive review of primary care consultation duration in 67 countries between 1946 and 2016 by Irving et al (1). This review is especially timely given rising physician burnout, as well as dissatisfaction among both doctors and patients in the U.S. As the authors note, many physicians are frustrated by the limited time available to interact with patients.

    The increasing time of U.S. physicians with patients surprised us. Primary care physicians in the U.S. rank fifth out of ten high-income countries on dissatisfaction with time spent per patient (2). What explains this apparent mismatch of quantitative trends and satisfaction?

    One candidate explanation is that much of physician time is spent on activities other than communication with patients. According to an observational study in 2015 of 57 ambulatory care physicians (primary care, cardiology, and orthopedics) in 16 practices in 4 states, of time spent with patients in the exam room, 53% was spent face-to-face, 37% on the electronic health record (EHR) and desk work, and 9% on administrative tasks (3).

    Thus, we wondered if the U.S. trend in primary care consultation duration reported by Irving et al aligned with historical trends in EHR uptake. In the Figure [https://blogs.bmj.com/bmjopen/files/2018/06/Figure-One-2.jpg ] we compare these two temporal patterns. Examination of the Irving da...

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  • Diagnosis of melanoma: clinical rules versus artificial intelligence

    In view of the high mortality and the need for early diagnosis of melanoma, Harrington et al.(1) reviewed the studies on the diagnostic rules to stratify patients with suspected melanoma and concluded that the ABCD rule is more useful than the 7-point checklist. Despite the importance of this result, future evaluations of diagnostic methods should also include among the comparisons the diagnostic tools assisted by artificial intelligence. Computational analysis of dermatological images has shown great potential as a diagnostic tool for melanoma (2,3), and can contribute to reduce costs, increase access and the scope of the examination to regions without specialists, allowing early diagnosis by primary care physicians, mainly in remote areas, lacking specialists.

    1. Harrington, E., Clyne, B., Wesseling, N., Sandhu, H., Armstrong, L., Bennett, H., & Fahey, T. (2017). Diagnosing malignant melanoma in ambulatory care: a systematic review of clinical prediction rules. BMJ Open, 7(3), e014096. http://doi.org/10.1136/bmjopen-2016-014096

    2. Safran T, Viezel-Mathieu A, Corban J, Kanevsky A, Thibaudeau S, Kanevsky J. Machine learning and melanoma: The future of screening. J Am Acad Dermatol. 2018 Mar;78(3):620-621. doi: 10.1016/j.jaad.2017.09.055. Epub 2017 Oct 6. PubMed PMID: 28989109.

    3. Jaworek-Korjakowska J, Kłeczek P. Automatic Classification of Specific Melanocytic Lesions Using Artificial Int...

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  • Comment on: "Long-term incidence trends on HPV-related cancers, and cases preventable by HPV vaccination: a registry-based study in Norway "

    Dear Editor,

    We have with great interest read the article by Hansen et al. (1). We have though two comments for reflection. First, the authors state that the stable incidence of cervical cancer indicates “apparent exhaustion of the cancer-reducing potential of current cervical screening”. Given that the coverage by examination can be increased with e.g. self-sampling (2), that the follow-up of abnormal findings is still suboptimal (3), and that Norway among other countries plans implementation of HPV-based screening (4) which provides better protection than cytology-based screening (5), we find the authors’ statement to be a bit too pessimistic especially for the many birth cohorts of women who still have to rely on screening for their primary protection against cervical cancer.

    Second, the authors divide the HPV-vaccine preventable cancers into cervical squamous cell carcinomas and other cancers, and they argue - based on increasing trends - that the HPV vaccine can prevent a “substantial” number of these other cancers in both women and men. It should, however, be taken into account that the incidence of these cancers is low despite increasing trends. Out of 32,000 new cancer cases in Norway in 2016 (6), 271, 0.8%, fell into the other HPV-vaccine preventable category. The additional potential for prevention of cervical cancer is actually greater. With 3205 treatments per year for cervical intraepithelial neoplasia (3), the HPV-vaccine could prevent an addi...

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  • Follow-up paper to the data sharing initiative, intended as a first step towards a generic but practical framework

    In the original publication a consensus document on providing access to individual participant data (IPD) from clinical trials was developed, using a broad interdisciplinary approach within the H2020 funded project CORBEL. The taskforce reached consensus on 10 principles and 50 recommendations, representing the fundamental requirements of any framework used for the sharing of clinical trials data. What was still missing was a generic framework or architecture for data sharing that could be used for modelling, describing, and designing operations, data requirements, IT-systems and technological solutions. As a first step in developing an inventory of existing tools/services, and examining their quality and applicability for data sharing, a systematic analysis of processes and actors involved in data sharing was performed, based on the consensus document and summarized in a follow-up paper (1). The work done resulted in a systematic and comprehensive list of the processes and subprocesses that need to be supported to make data sharing a reality in the future. It is foundational work against which existing tools/services can be mapped, and gaps, where new tools/services are needed, can be identified. This follow-up work will facilitate the extension of the ideas in the original paper to create a generic but practical framework for the sharing of IPD from clinical trials. That framework is currently under development.


    1. Ohmann C, Canham S, Banzi R e...

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  • Hearing Loss and Healthcare

    Although hearing loss is referred to in this study, it is mostly between-the-lines (as a disability?). Given the statistics, it is probably the condition that affects effective communication for more patients/caregivers than any other. It can have significant impacts on outcomes (like when my uncle heard "colostomy" instead of "colonoscopy", and refused the procedure for two days until someone thought to write it down for him). I have many other examples, and have given presentations to RNs in the clinical phase of their training. If you are interested in pursuing hearing loss in healthcare settings, I'd be happy to participate. One problem is that mis-hearings often go unnoticed, and so might be under-reported in a survey. Thanks for doing this; much-needed.

    Kathi A. Mestayer
    Staff Writer, Hearing Health Magazine
    Advisory Board, Va Department for the Deaf and Hard of Hearing
    Advisory Committee, Hearing Loss Association of America Greater Richmond Chapter
    N-CHATT (Hearing Assistive Technology) Trainer, HLAA/Gallaudet

  • UK medical schools are not academically equal

    Whilst the study addresses an important problem there appears to be no correction for the relative competitiveness within different UK medical schools. Whilst all UK medical schools meet high international standards and meet stringent GMC criteria for approval, there are differences in the academic rigour between medical courses, and also the academic standards achieved, demonstrated by the speed and success rate of acquisition of skills and knowledge based higher qualifications such as MRCP [ McManus et al., 2008]. If the lower performing students at A level gravitate towards the lower academically schools, they may be placed higher in ranking of skills based assessment in those medical schools. Paradoxically the higher performing grade students , by getting places in the most academically rigorous schools ( such as Oxford and Cambridge), might sit lower in the academic rankings of their respective medical school. An alternative hypothesis would be that state school students with weaker A levels are more likely to attend less academically competitive medical schools, where individually they will be higher in the skills ranking. It would be more meaningful if the A level correlations were extended to success rates in a common medical qualifying exam and postgraduate qualifications, prior to changing medical school selection policy.


    McManus IC, Elder AT, Champlain A, Dacre JE, Mollon J , Chis L
    Graduates of different UK medical schools sh...

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  • Interventricular vessel of the heart and sudden infant death syndrome

    I read with interest the article of Levieux K et al concerning French prospective multisite registry on sudden unexpected infant death (OMIN): rationale and study protocol (1). In the formation of the fetal muscular part of the interventricular septum (IVS), the expanding ventricles grow and their medial walls approach and fuse, forming the septum. The inside corner between the septum and the right anterior ventricular wall exhibits the deep pits being called interventricular sinuses (ISs). The IS passes through the right IVS formed from the medial wall of the expanding fetal right ventricle (RV). The opening of the interventricular vessel (IV) (kuuselian vessel) is located in the IS between the medial walls of the expanding fetal RV and fetal left ventricle (LV). The IV is not a canal or channel or blood vessel, but a slit between the fibres of the muscle to the outer layer of the left central muscular part of the IVS and runs at an angle of about 90 degrees through the sphincter and the left IVS into the LV. The IV exhibits 2 to 3 oval 2x5 mm openings in the left central muscular part of the IVS surrounded by the interventricular sphincter (ISP). Hypoxia may be the physiological factor to recruit IV of the fetal heart and augment the flow of the oxygenated blood from right to left. The ISP and the IV are feasible to be patent by relaxing and widening of the helical heart at the right atrial filling phase at the end of the fetal diastole. The sinoatrial node initially ac...

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  • Tool now includes 2017 data (update from the author)

    In this paper we described how we created an open-data exploration tool at OpenPrescribing.net by compiling and normalising England’s national prescribing data for 1998–2016 [1], with the aim of facilitating the exploration of long-term prescribing trends. We have now updated this tool to include the data for 2017, which was released in March. Anyone can access our data tool at OpenPrescribing.net/long-term-trends.

    The Office for National Statistics does not release official mid-year population estimates for the previous year until June. Until then, for 2017 we have used their projected England population figure [2] and will update the tool again with the final figure when available.

    Our tool shows that the total number of items prescribed in 2017 increased marginally on the previous year, with a slight reduction in overall cost, across the core chapters (1-15) of the British National Formulary (BNF). The sections with the greatest increase in cost were Drugs used in Diabetes (+£7.8k inflation-corrected cost per 1,000 population) and Anticoagulants and Protamine (+£6.5k), whereas Lipid-Regulating Drugs decreased by £5.2k. Antidepressant Drugs have seen the largest increase in prescribing (+464 items per 1,000 population). Users can use the tool to explore the data down to the level of individual brands for each chemical substance.

    A further improvement to the tool was also carried out recently, to smooth out sudden increases and decreases in prescribi...

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  • COMMENT: Are efforts to attract graduate applicants to UK medical schools effective in increasing the participation of under-represented socioeconomic groups? A national cohort study.

    Dear Editor,

    I have read the article entitled “Are efforts to attract graduate applicants to UK medical schools effective in increasing the participation of under-represented socioeconomic groups? A national cohort study” by B Kumwenda et al, published in BMJ Open 2018 Vol 8(2): e018946 and would like to make some contributions.

    The article was pertinent in considering the socioeconomic backgrounds of graduate applicants to medical schools in the UK: as referenced by the article, it is widely recognised that there is a lack of diversity in terms of socioeconomic background of medical students1.

    As a graduate-entry medical student myself, I was interested to note that the study only considered ‘a subset of graduate applicants’ who had sat the UK Clinical Aptitude Test (UKCAT). The study briefly mentioned the Graduate Australian Medical School Admissions Test (GAMSAT), but I believe a key limitation in this study’s usefulness is in terms of only considering applicants who have taken the UKCAT. This could be particularly relevant when considering graduate applicants and their socioeconomic backgrounds: the GAMSAT is a considerable barrier to applying for GEM. It currently costs £262-£312 (including both early and late registrations) for UK applicants to register for the GAMSAT2, compared to £65-£87 to sit the UKCAT3. It is interesting to note that the UKCAT Consortium currently offer a bursary scheme, offering bursaries to cover the full test fee, for ca...

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