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Press releases Saturday 9 September 2006

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(1) AGEISM ENDEMIC IN HEALTH SERVICES

(2) CLAIMING DIAGNOSTIC TESTS FOR DIABETES GENES IS MISLEADING, SAY EXPERTS

(3) FRONTLINE NHS STAFF SHOULD BE TRAINED TO TACKLE ALCOHOL MISUSE

(4) MEDICAL EDUCATION MUST ADAPT TO SOCIETY’S CHANGING ATTITUDES

(1) AGEISM ENDEMIC IN HEALTH SERVICES

(Underinvestigation and undertreatment of carotid disease in elderly patients with transient ischaemic attack and stroke: comparative population based study)
http://bmj.com/cgi/content/full/333/7567/525

(Editorial: Ageism in services for transient ischaemic attack and stroke)
http://bmj.com/cgi/content/full/333/7567/508

Ageism is endemic in health services, argues a senior doctor in this week’s BMJ.

His warning follows a study published online last month, and appearing in this week’s print journal, that found substantial undertreatment of stroke and mini-stroke (transient ischaemic attack) in patients over the age of 80, despite good evidence that older patients benefit from treatment. The authors concluded that the older patients were discriminated against.

In England, decades of health service underfunding have provided an environment in which ageism has flourished, writes Professor John Young in an editorial.

Whenever a clinical stone is turned over, ageism is revealed, he says. For example, in cancer services, coronary care units, prevention of vascular disease, and in mental health services. To this list, we must now add the management of transient ischaemic attacks and minor strokes.

He believes that education is key and suggests redesigning stroke services and integrating specialist and primary care responses to the management of transient ischaemic attacks in a similar way to the approaches developed for coronary heart disease, which have led to a welcome reduction in the degree of related ageism.

Ageism will always prosper when resources are inadequate for the target population, and governments have a responsibility here, he adds. Tackling institutionalised age discrimination more broadly in health services will require national leadership, with governments and health services openly acknowledging the presence of ageism.

In England some early progress has been made through the National Service Framework for Older People since 2001. Deaths from coronary heart disease and cancer declined between 1993 and 2003, and access to elective surgery increased between 2000 and 2003.

Some will argue, however, that ageism is so deeply embedded in our health service that policy initiatives will never represent more than a tinkering round the edges, says the author.

Don’t be surprised if older people lose trust in their health service and lobby for protection through anti-discrimination legislation. The result would indeed be a patient led health service, he concludes.

Contacts:

Study: Peter Rothwell, Professor of Neurology, Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK
Email: peter.rothwell@clneuro.ox.ac.uk

Editorial: Professor John Young, Academic Unit of Elderly Care and Rehabilitation, St Luke’s Hospital, Bradford, UK
Email: john.young@bradfordhospitals.nhs.uk

(2) CLAIMING DIAGNOSTIC TESTS FOR DIABETES GENES IS MISLEADING, SAY EXPERTS

(Editorial: Predictive genetic testing for type 2 diabetes)
http://bmj.com/cgi/content/full/333/7567/509

Claims that the discovery of a gene could help prevent diabetes may raise unrealistic expectations, warn doctors in this week’s BMJ.

Earlier this year, scientists discovered that a variant of the TCF7L2 gene was associated with type 2 diabetes. In subsequent media coverage, they claimed this could lead to a diagnostic test to identify people who carry the variant gene and that people who knew of their extra risk would then be motivated to avoid the lifestyle habits that lead to diabetes.

Undeniably this discovery is noteworthy, write Cecile Janssens and colleagues. Type 2 diabetes is a leading cause of illness and death in the developed world and is increasing in prevalence worldwide. The association is robust - the investigators replicated their finding in three large, independent study populations - and it offers potential new insight into the pathobiology of diabetes.

Yet the claim that this knowledge will lead to a diagnostic test and hence to disease prevention – now routine for such genetic discoveries – may not be true and, above all, misleads the public.

Even if this discovery led to a 100% effective intervention that specifically targeted the effects of the genetic variant, 45% of the general population would need to receive this intervention to prevent 21% of diabetes cases, they explain. An intervention that specifically targets the effects of TCF7L2 variants would therefore need to be cheap, harmless, and burdenless to warrant such substantial overtreatment.

Alternatively, the genetic test could identify people at high risk who would benefit from appropriate advice on diet and physical activity. But many carriers would find their risk increased from 33% to only 38%. Would these figures provide enough incentive for them to change their lifestyles, they ask?

Ultimately, genetic discoveries may lead to better understanding of the disease process and to better therapeutic and preventive interventions, say the authors. In the meantime, scientists and the media are responsible for accurately and carefully interpreting the implications of studies of genetic associations for the benefit of the general public.

“Raising unrealistic expectations – even inadvertently – could distract attention from what can be done by applying what we already know to prevent diabetes and its complications, they conclude.

Contact:

Cecile Janssens, Epidemiologist, Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, Netherlands
Email: a.janssens@erasmusmc.nl

(3) FRONTLINE NHS STAFF SHOULD BE TRAINED TO TACKLE ALCOHOL MISUSE

(Editorial: Tackling alcohol misuse at the front line)
http://bmj.com/cgi/content/full/333/7567/510

Large amounts of money and resources would be saved if all frontline NHS staff had basic knowledge about the social and physical ill effects of alcohol misuse, say doctors in this week’s BMJ.

In 2004 in England 38% of men and 16% of women aged 16-64 had an alcohol use disorder (26% overall), equivalent to around 8.2 million people.

About £217m is currently spent on specialist alcohol treatment, compared with the £20bn estimated cost of alcohol misuse. The government recently announced that £3.2m was to be made available for new initiatives for people who may be damaging themselves with alcohol. But will this new money be used wisely, ask Robin Touquet and Alex Paton?

Most conurbations in England have one or more specialist alcohol units, which are usually run by psychiatrists and largely deal with complex problems. These are controlled by mental health trusts, which are separated administratively from acute hospital trusts, so services tend to be fragmented.

In many areas voluntary agencies also provide a local service for people with alcohol problems, funded from various sources such as the local authority, primary care trusts, and charitable foundations. NHS services now rely solely on funds from primary care trusts.

Funding by primary care trusts for alcohol services could be well used in hospital emergency departments, where nearly a third of overall attendances are alcohol related, and more than two thirds may be so after midnight.

Research carried out by the emergency department team at St Mary’s Hospital London has shown that routine clinical staff can be trained to detect potential alcohol problems and to offer brief advice, with support from an alcohol health worker in the hospital. This approach is cost effective.

Studies have also shown that alcohol problems are underdetected in general practice, and the authors suggest closer liaison between general practitioners and local voluntary alcohol agencies, wider availability of alcohol workers, and alcohol clinics in general practices.

They also suggest that all general hospitals should have a senior consultant with an interest in alcohol misuse. Yet a recent review found that only 21 acute hospital trusts in England had an alcohol health worker.

If all frontline staff had basic knowledge about the social and physical ill effects of and the detection of alcohol misuse, and the benefits of brief advice and liaison with alcohol health workers, problems would be tackled far earlier – often preventing the development of dependence – and large amounts of money would be saved, they write. The new two year foundation training for junior doctors offers an important opportunity to develop such knowledge.

Contacts:

Robin Touquet, Emergency Medicine Consultant, St Mary’s Hospital and Imperial College, London, UK
Email: r.touquet@imperial.ac.uk

Alex Paton, Retired Consultant Physician, Oxfordshire, UK
Email: alexpaton@doctors.org.uk

(4) MEDICAL EDUCATION MUST ADAPT TO SOCIETY’S CHANGING ATTITUDES

(Analysis and comment: Challenges for educationalists)
http://bmj.com/cgi/content/full/333/7567/544

What are the challenges facing medical education? This question is discussed in this week’s BMJ, ahead of the annual meeting of the Association for Medical Education in Europe.

Medical education needs to adapt to society’s changing attitudes, write experts from the University of Maastricht, and they outline four major challenges that need to be tackled if the specialty wants to be taken seriously.

Firstly, practical training must be made more effective to counter reduced working hours, they say. Research has shown that deliberate practice is a far better method to acquire expertise than simple unstructured practice. This involves supervision and detailed feedback, and ample opportunity to improve performance gradually by performing tasks repeatedly. Top athletes and musicians apply a similar approach.

The second challenge is to develop new methods of assessment to reflect the focus on competencies (tasks that a qualified medical professional should be able to handle successfully).

Improving research standards in medical education is another challenge, and the authors suggest that high quality, relevant research requires more interdisciplinary collaboration.

The final major challenge is overcoming negative attitudes to assessment, say the authors. This will involve changing the culture of assessment into one where assessment is informative, helps people to improve their work, and where the goal is not to be better than the others but to be better today than you were yesterday.

One conclusion from all of these challenges is that a close collaboration between doctors and educationalists is indispensable for good medical education and development of better education, they write.

Contact:

Lambert Schuwirth, Assistant Professor of Medical Education, University of Maastricht, Netherlands
Email: l.schuwirth@educ.unimaas.nl

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