Medicine and Science from The BMJ

Don Berwick - you can break the rules to help patients

Don Berwick, president emeritus of the Institute of Healthcare Improvement, and former Administrator of the Centers for Medicare and Medicaid Services.
In this conversation he discusses how he went from being a paediatrician to running Medicare for Obama, how we can create headroom in stressed systems, and breaking the rules to make things better for patients and staff.
Quality improvement series:

Darknet Opioids

When tackling societal problems - like the opioid epidemic in the US - there are two ways of approaching it. One is to reduce demand - by organising treatment programmes, or reducing the underlying reasons why people may become addicted in the first place - but that’s hard. So governments often turn to the other route - reducing supply - and that’s what the US government did in 2014 when it rescheduled oxycodone combination products from schedule 3 to schedual 2 - essentially making it harder for people to obtain a prescription.
Now reducing that legal supply, without in hand reducing the demand, led to fears that those people with an opioid addiction would just turn to illicit routes to obtain their drugs - and new research published on bmj.com has attempted to find out if that happened.
We're joined by 3 of the authors, James Martin, associate professor of criminology at Swinburne University; Judith Aldridge, professor of criminology at the University of Manchester; and Jack Cunliffe, lecturer in quantitative methods and criminology at the University of Kent.
Read the full research:
https://www.bmj.com/content/361/bmj.k2480

09 John Ioannidis

Series two of The Recommended Dose kicks off with polymath and poet, Dr John Ioannidis. Recognised by The Atlantic as one the most influential scientists alive today, he’s a global authority on genetics, medical research and the nature of scientific inquiry itself – among many other things.
A professor at Stanford University, John has authored close to 1,000 academic papers and served on the editorial boards of 30 of the world's top journals. He is best known for seriously challenging the status quo. His trailblazing 2005 paper 'Why Most Published Research Findings Are False' has been viewed over 2.5 million times and is the most cited article in the history of PLoS Medicine. In it, he argues that most medical research is biased, overblown or simply wrong. Here, he talks to Ray about the far-reaching implications of these findings for people both inside and outside the world of health.
While most closely associated with exploring cutting-edge conundrums across science, genomics and even economics, John is also something of a humanist. He’d be right at home with the philosophers of ancient Greece, seeking as he does to find answers to the big questions of the day in science and medicine, as well as in nature and narratives.
A voracious reader himself, John has a lifelong love of ‘swimming in books’ and has penned seven literary works of his own in Greek – two of which have been nominated for prestigious literary prizes. And fittingly, he finds inspiration for his myriad of multi-disciplinary pursuits on Antipaxi, one of Greece’s most beautiful and secluded islands.
He shares some of his distinctive logic, reason - and even a little of his poetry - on this very special episode of The Recommended Dose, produced by Cochrane Australia and co-published with the BMJ.
You'll find our show notes and a full transcript of the show at http://australia.cochrane.org/trd

Ashish Jha tries to see the world as it is.

There’s a lot going on in the world at the moment - Ebola’s back, Puerto Rico is without power and the official estimations of death following the hurricane are being challenged. The WHO’s just met to decide what to do about it all, as well as sorting out universal healthcare, access to medicines, eradicating polio, etc etc.
To make sense of that a little, we grabbed Ashish Jha - Director of the Harvard Global Health Institute to shed some light into how decisions about global health are made, and why he tries to see the world as it actually is - not how he wishes it would be.
Reading list:
Mortality in Puerto Rico after Hurricane Maria
https://www.nejm.org/doi/full/10.1056/NEJMsa1803972
https://www.bmj.com/universal-health-coverage

Nutritional science - why studying what we eat is so difficult.

We at The BMJ care about food, and if our listener stats are to be believed, so do you.
In this podcast we talk to a few of the authors of a new series, published next week on bmj.com, which tries to provide some insight into the current state of nutritional science - where the controversies lie, where there’s broad agreement, and the journey of our understanding of nutrition.
The open access fees for those articles has been paid for by Swiss Re - a wholesale provider of reinsurance, insurance and other insurance-based forms of risk transfer - they have not had any input into the editorial process, which has gone through the same peer review as any of our other analysis articles. Swiss Re are also co-hosting a conference where we’ll be bringing together a lot of these researchers - and which will be live streamed next week - you’ll be able to access that for free on bmj.com
For more on the conference:
http://institute.swissre.com/events/food_for_thought_bmj.html

The misunderstanding of overdiagnosis

In December 2017, the NEJM’s national corespondent, Lisa Rosenbaum, published an article “The Less-Is-More Crusade — Are We Overmedicalizing or Oversimplifying?”
The article aimed a broadside against those who are campaigning against the overuse of medicine, and the over diagnosis of treatment.
This week in the BMJ we’ve published a rebuttal to that article, and in this podcast we talk to Steve Woloshin and Lisa Schwartz - both professors at the Dartmouth Institute for Health Policy and Clinical Practice.
Steve and Lisa’s article carefully deconstructs some of the ideas advanced by Rosenbaum, but in this podcast we discuss how much separate camps are forming in this debate - and how to have a constructive dialogue across that divide.
Read Steve and Lisa's essay
https://www.bmj.com/content/361/bmj.k2035
Iona Heath's essay - The role of fear in overdiagnosis
https://www.bmj.com/content/349/bmj.g6123
Stacy Carter's interview about moral shocks
https://soundcloud.com/bmjpodcasts/preventing-overdiagnosis-2017-stacy-carter-on-the-culture-of-overmedicalisation

Biochem for kids

Each time you order a test for a child, do you think the population that makes up the baseline against which the results are measured? It turns out that that historically those reference intervals have been based on adults - but children, especially neonates and adolescents, are undergoing physiological changes that mean those reference intervals may not be appropriate.
To get around this Khosrow Adeli, head and professor of clinical biochemistry at the Hospital for Sick Children, and the University of Toronto, and colleagues have undertaken a mission to recruit children and young people into a study of their test results.
Read the full practice article:
https://www.bmj.com/content/361/bmj.k1950

Antidepressants and weight gain

Patients who are depressed and prescribed antidepressants may report weight gain, but there has been limited research into the association between the two. However new observational research published on bmj.com aims to identify that association.
Rafael Gafoor, a psychiatrist and researcher at Kings College London, and one of the authors of that research joins us to talk about the potential mechanism of action - is it a physiological response to the drug, is it to do with the underlying reason for the prescription; how they studied the association; and what this might mean for individual prescriptions.
You can read the full research on bmj.com;
https://www.bmj.com/content/361/bmj.k1951

Think of healthcare is an ecosystem, not a machine

Complexity science offers ways to change our collective mindset about healthcare systems, enabling us to improve performance that is otherwise stagnant, argues Jeffrey Braithwaite, professor of health systems research and president elect of the International Society for Quality in Health Care.
Read the full analysis:
https://www.bmj.com/content/361/bmj.k2014
Quality improvement series:
https://www.bmj.com/quality-improvement
The BMJ in partnership with and funded by The Health Foundation are launching a joint series of papers exploring how to improve the quality of healthcare delivery. The series aims to discuss the evidence for systematic quality improvement, provide knowledge and support to clinicians and ultimately to help improve care for patients.

New antivirals for Hepatitis C - what does the evidence prove?

There’s been a lot of attention given to the new antirviral drugs which target Hepatitis C - partly because of the burden of infection of the disease, and the lack of a treatment that can be made easily accessible to around the world, and partly because of the incredible cost of a course of treatment.
But a new article on BMJ talks about the uncertainly of that treatment - do we know that the drugs actually clear a HepC infection, and that this will lead to a corresponding decrease in mortality and morbidity?
Janus Jakobsen from the Copenhagen Clinical Trial Unit joins us to discuss what the literature proves.
Read the full article:
https://www.bmj.com/content/361/bmj.k1382