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Press releases Saturday 01 September 2007

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(1) Concern over recognising serious illness in feverish children
(2) Is Modernising Medical Careers still fit for purpose?
(3) Despite their safety, IUDs are underused in developed countries
(4) Patients with diabetes need better advice about home glucose monitoring
(5) Should medical eponyms be abandoned?

(1) Concern over recognising serious illness in feverish children
(Recognising serious illness in feverish young children in primary care)
http://www.bmj.com/cgi/full/335/7617/409

NHS policy changes may be contributing to problems recognising serious illness in feverish young children, warns a senior doctor in this week's BMJ.

Anthony Harnden, a lecturer in general practice at the University of Oxford, believes we should be offering less telephone advice and more opportunities for prompt assessment by an experienced clinician.

The diagnosis and management of children with fever is an important part of primary care, he writes. Although general practitioners have substantial clinical experience of assessing febrile children, half of children with meningococcal disease are sent home at first consultation.

How can this be and what can we do to improve our assessment of febrile children?

He points to several difficulties, including the increasing rarity of serious bacterial infection and the time point in the illness that the child is seen. Changes in NHS policy have also led to the primary care of febrile children presenting outside office hours being delivered by an increasing number of professional groups with different levels of skill and experience.

This is a major concern, he warns, because the most solid evidence of recognising clinical severity in febrile children in primary care is a full assessment by an experienced clinician. This involves eliciting a clear history and careful observation of signs, including alertness, activity, colour, and respiratory effort.

Such concerns led to the recent publication of guidelines by the National Institute for Health and Clinical Excellence (NICE) for the assessment and initial management of young children with feverish illness.

But Dr Harnden believes that these guidelines, along with the "traffic light" system also proposed by NICE, rely too much on measuring vital signs and may result in the inappropriate referral of large numbers of children, while children who develop a serious illness are sent away.

General practitioners must not be persuaded to disregard their intuition, he says.

"We should recognise that we are seeing only a brief snapshot of a dynamic illness and should always empower and make it easy for parents to consult again – even a few hours later – if symptoms deteriorate. We should trust our clinical intuition and refer and re-refer if concerned," he concludes.

Contacts:
Anthony Harnden, University Lecturer, Department of Primary Care, University of Oxford, UK
Email: anthony.harnden@dphpc.ox.ac.uk 

(2) Is Modernising Medical Careers still fit for purpose?
(Has Modernising Medical Careers lost its way?)
http://www.bmj.com/cgi/full/335/7617/426

In this week's BMJ, father and son, Anthony and George Madden discuss Modernising Medical Careers, the programme of reform of junior doctors' training, and ask is it still fit for purpose?

Modernising Medical Careers (MMC) began as an attempt to address longstanding problems with the senior house officer grade, say Anthony Madden, a consultant anaesthetist at Southmead Hospital in Bristol, and George Madden, a final year medical student at the University of Birmingham (now a Foundation Year 1 doctor in the West Midlands). But it has since expanded in scope to reform all levels of postgraduate medical training and bears little resemblance to the proposals that were approved during consultations.

There is now a real danger, they warn, that it will deliver a generation of highly specialised doctors who lack the breadth of experience and flexibility that will enable them to manage unusual clinical problems or change as medicine advances. This cannot be good for patients, NHS employers or the Government.

So, has MMC lost its way?

The current plans are disappointing for doctors, who need a robust, modern training system which satisfies the 'five principles' for reform, they explain. Specialist training will not be as broadly based as originally envisaged, nor will it be easy to move between programmes. The idea of individually tailored programmes also seems to have been forgotten, career advice is currently lacking, and the provision for flexible training is uncertain.

MMC therefore fails to meet most of the principles on which it was supposed to be based, they write.

For workforce planners, MMC will mean a reduction in the number of Senior House Officers, their most flexible medical staff, and a reduction in their time spent providing a service in favour of training. A workforce made up of doctors forced into specialties they did not really want is not a happy prospect either.

It's better news for the government, which will see its 'increasing need for hospital services to be delivered by fully trained doctors' met by the shorter training, and thus longer time spent as a consultant.

However, the consequences for patients are not good. Consultants produced by MMC will have less experience than those trained in the past, they will have a more limited range of expertise, and be less able to meet the increasingly complex needs of patients, they warn.

They end by saying: It is difficult not to conclude that MMC has lost its way and will not fulfil its original aims.

Contact:
Anthony Madden, Consultant Anaesthetist, Department of Anaesthesia, Southmead Hospital, Bristol, UK
Email: anthony.madden@nhs.net 

(3) Despite their safety, IUDs are underused in developed countrie
(Pain and heavy bleeding with intrauterine contraceptive devices)
http://www.bmj.com/cgi/full/335/7617/410

Misconceptions around intrauterine contraceptive devices (IUDs) mean that they are underused in developed countries, despite being a safe and effective form of contraception, says a women's health expert in this week's BMJ.

IUDs are suitable for most women, are cost effective when continued long term, and can have health benefits beyond contraception, writes Sally Rose, Research Fellow at the University of Otago, New Zealand.

Fertility is restored on their removal, and unlike other forms of contraception their efficacy does not depend on the user's behaviour. Consequently, such devices are an excellent alternative to female sterilisation (which women may later regret) and are a long term alternative to other methods of birth control prone to misuse or failure.

Side effects such as pain and heavy bleeding are common reasons for discontinuing use of an IUD within the first year, but can usually be managed with appropriate pain relief.

Despite this, data shows these devices are underused in developed countries, says the author.

Nearly half of all users are in China, while only 6% of women of reproductive age in the United Kingdom, 4.6% in Australia and New Zealand, and fewer than 1% in the United States use this method of contraception.

Reluctance to offer or use intrauterine devices seems to stem largely from the experience with the Dalkon Shield in the 1970s, she says, which caused pelvic infections that had serious health consequences for many thousands of women.

Legal action against manufacturers of that and other devices led to a sharp decline in the use of all intrauterine contraceptive devices and their subsequent withdrawal from the US market in the 1980s.

Since then, misconceptions based on outdated information have persisted, such as the belief that these devices cause pelvic inflammatory disease and infertility.

Evidence from trials suggests there might be a small increased risk in the first 20 days after insertion, but beyond that the risk of upper genital tract infection does not differ from that in non-users, she writes.

Pelvic inflammatory disease is frequently caused by untreated Chlamydia so testing for and treating any infection before inserting a device is recommended clinical practice along with and advice on the use of condoms to protect against sexually transmitted infections.

Contact:
Sally Rose, Research Fellow, Women's Health Research Centre, Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
Email: sally.rose@otago.ac.nz 

(4) Patients with diabetes need better advice about home glucose monitoring
(Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives)
http://www.bmj.com/cgi/content/full/bmj.39302.444572.DEv1

A new study published on bmj.com today calls for better advice about home blood glucose monitoring for patients with non-insulin dependent (type 2) diabetes.

Type 2 diabetes usually develops in people over 40, especially when the person is overweight. In most cases, insulin injections are not needed. Instead, a combination of dietary measures, weight reduction, and oral medication controls the condition.

Some experts believe that daily self monitoring helps to control blood glucose levels and it is often recommended. But others believe that self monitoring is complex and inconvenient and can lead to feelings of frustration and guilt. As such, there is still no firm agreement about the role and value of self monitoring for patients with type 2 diabetes.

So Dr Elizabeth Peel and colleagues interviewed 18 patients with newly diagnosed type 2 diabetes over four years to explore their views about self monitoring over time.

They found that self monitoring decreased over time, and those who did continue monitoring did so less frequently. Some patients expressed uncertainty about the meaning of the test results and how to act on them, while others found self monitoring to be reassuring.

How to act on high readings was a consistent problem.

Most patients also voiced concerns about the value health professionals placed on their readings. Doctors generally appeared to show little interest in patients' test results after the initial phase, leading some patients to see self monitoring as not very important or even pointless.

Interestingly, some patients continued to self monitor despite lack of guidance and the perceived disinterest from health professionals.

Clinical uncertainty about the role of self monitoring in patients with type 2 diabetes is mirrored in patients' own accounts, say the authors. Patients tended not to act on their self monitoring results, in part because of a lack of education and dialogue about the appropriate response to readings.

They urge health professionals to be explicit about whether and when such patients should self monitor and how they should interpret and act upon the results, especially high readings.

Contact:
Elizabeth Peel, Lecturer in Psychology, School of Life and Health Sciences, Aston University, Birmingham, UK
Email: e.a.peel@aston.ac.uk 

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