February 13th, 2012
Selections from Richard Lehman’s Weekly Review: Week of February 13th
CardioExchange is pleased to reprint selections from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.
Week of February 13th.
JAMA 8 Feb 2012 Vol 307
Shared Decision Making
565 There are signs that JAMA is gradually improving under its new editor, although moving its perspective pieces to the beginning of the journal doesn’t really count as progress. The BMJ has also tinkered with its order of contents, almost as if to hide the fact that they are improving at the same time. And it will certainly take a lot more than swapping chairs around to improve The Lancet. Anyway, here is a Viewpoint piece that is well worth reading if you are interested in screening and shared decision-making with patients. In a clear and well-structured piece, the authors trace the gradual path of disillusionment from the “spotting cancer early is always good” mindset to “there are harms and costs” attitudes of the present. They point out that dumping these issues on to individual clinicians to share with patients is a dubious strategy (not least in health systems where patients are called for screening independently of their normal health care provision). “Expert groups may dispute the ‘facts’; the science can be difficult for physicians to communicate and for patients to understand; some patients demure [sic] and want the physician to decide; physicians may lack the time, reimbursement, or motivation to engage in long discussions; and social attitudes and medicolegal pressures may influence the decision.” I particularly like their concluding sentences: “However, society’s first concern should be to confirm that screening is a net good for public health. This requires harms to be considered independently of costs. Until the reality of harms becomes more palpable to clinicians and the public, concerns about the safety of screened populations will continue to be mistaken for frugality.”
567 The next Viewpoint piece also raises an important issue in shared decision-making with patients. When we mention the potential harms of the treatment we propose – as we often must – can this interfere with its effectiveness? Again I would recommend everyone to read this article on Nocebo Effects, Patient-Clinician Communication, and Therapeutic Outcomes. This is not as coherent a piece as the previous one, but it’s good to see this discussion coming out into the open. So much simplistic talk about shared decision-making ignores the extraordinary power of clinicians to instill fear and hope in their patients by the words they use and the attitudes they convey. We need to be realistic and indeed scientific about this. We have a duty to be honest, but we also have a professional and ethical duty to understand the effect we have on people in situations where they are vulnerable and we have the power to help them or harm them.
BMJ 11 Sep 2012 Vol 344
In my recent experience of general practice (increasingly geriatric on both sides), about half of gout is brought on by diuretics. So it’s no surprise that this trawl through the UK GP Research Database to find associations between blood pressure lowering drugs and gout points the finger most clearly at thiazides. What is slightly less expected is that beta-blockers increase the risk of gout by around a half and ACE inhibitors blockers and angiotensin II blockers increase it by about a quarter. Except for losartan, which decreases gout risk by about 20%, as do calcium channel blockers.