Interpreting the results of an interventional studyConsider three possible outcomes in an interventional study, investigating, say, a novel medicine. The medicine improves the condition, worsens it, or has no effect. How is each of these outcomes to be explained?In all cases the apparent effect could be real. The drug really does what it appears to do. However, leaving aside the possibility that the positive or negative outcome arose merely by chance, or, in the case of the no-effect result, because the study wasn’t adequately powered to detect a difference, there is always the possibility that a bias or biases of some sort played a part. Perhaps bias enhanced or impaired the response, making it appear that a positive or negative effect had occurred, when in fact no such thing had happened. Perhaps there was a combination of biases.Defining biasBiases can affect all types of clinical study, not merely interventional ones....

Doctors are known for our use of jargon, acronyms, and myriad medical phrases that can sometimes feel like a secret code, or even a whole other language, to our patients. Even those who spend the most time with us may hear us using words or expressions that require translation into non-technical language.It has been estimated that medical students learn 9000 new words in their first year,1 and about 55 000 over the course of their medical degree.2 Some have suggested that medical students learn more new words during their time at university than language students.3After commencing our careers, many of us notice how easily medical terms slip into everyday talk (“I’ll vet that idea”). This exchange is not carelessness, but creativity. Language, like medicine, evolves for efficiency and connection. When a borrowed phrase captures intended meaning more precisely, it will make its way into your personal lexicon.This phenomenon is not...

The phenomenon of doctors presenting unfounded statements with unwavering arrogance—colloquially known as “bullshit”—has long been recognised in medical practice.12 In parallel, the tendency of large language models (LLMs) to generate plausible but factually incorrect information, termed “hallucinations,” presents a remarkably similar challenge in healthcare related artificial intelligence applications.3 These parallel behaviours stem from shared underlying mechanisms.In both cases, pressure to produce output regardless of knowledge limitations can lead to a preference for any response over none, driven by a reward seeking intention.45 Misinformation then emerges not as deliberate deception, but as a product of structural demands. As Henry Frankfurt noted in his seminal work on bullshit, the core issue is not lying but rather “a lack of concern with the truth”—a description equally applicable to doctors under social pressure and LLMs under algorithmic constraints.2For doctors who are using LLMs, these parallel pressures create a potentially dangerous feedback loop. By understanding...

As NHS hospitals face huge pressure this winter from one of the worst flu seasons in decades,12 health officials are once again urging people to wear a mask to combat the spread of respiratory illnesses.The UK Health Security Agency last week issued fresh advice for people to wear a mask “when you are unwell and need to go out,” to “protect those at highest risk.”3This was followed by Daniel Elkeles, chief executive of NHS Providers, a body representing NHS trusts, saying that face coverings should be worn on public transport, as they were during the covid pandemic, to tackle the “very nasty strain of flu” circulating in the UK.But some prominent politicians, including the Conservative leader Kemi Badenoch and the Reform UK leader Nigel Farage, have spoken out against the move.Why is there a fresh debate around masks?Mask wearing became highly politicised during the covid pandemic, when it was a...

bmj;391/dec12_1/r2564/FAF1faBob was born in Rugby and went on to study medicine at the University of Birmingham. Shortly after qualifying he commenced a Cancer Research Campaign fellowship overseeing the day-to-day running of the first large UK study of adjuvant chemotherapy in breast cancer. The trial recruited more than 1100 patients from 26 hospitals in the West Midlands and it confirmed treatment benefit and established adjuvant chemotherapy as a component of curative treatment in node positive breast cancer. It also convinced Bob of the benefits of enrolling patients into well run clinical trials and of the necessity of proper staffing and infrastructure.After his research fellowship and completion of specialty training at the Christie Hospital in Manchester, Bob was appointed as the third consultant oncologist (there are now 33) at the Walsgrave Hospital in Coventry with a busy peripheral clinic in his beloved childhood town of Rugby.He began a career long, and highly...

AI chatbot systems, such as ChatGPT, Claude, and Copilot, are used increasingly as confidants of choice.1 On the one hand, this may be seen as a positive democratisation of emotional support and care at the point of need. On the other, there is growing concern surrounding potential psychological and social harms,12 particularly pertaining to social isolation and loneliness.2In 2023, the US Surgeon General declared that the nation was experiencing a loneliness epidemic, constituting a public health concern on par with smoking and obesity.3 The report cited a 26% increase in premature death associated with loneliness,4 with the overall health impact likened to smoking 15 cigarettes a day.56 In the UK, nearly half of adults (25.9 million) report feeling lonely either occasionally, sometimes, always, or often; with almost 1 in 10 experiencing chronic loneliness (defined as feeling lonely “often or always”).7Although many studies focus on loneliness in older adults,5 younger people...

Medical science has been remarkably successful over the past two centuries at preventing and curing what were once common infectious diseases in children and young adults in the UK. Vaccination has prevented diseases such as polio, smallpox, tetanus, and diphtheria. Better sewage treatment and clean water have removed cholera and typhoid. Antibiotics have substantially reduced the risks posed by bacterial diseases, and antivirals have reduced the burden of HIV and hepatitis C.In the UK neonatal infections remain a considerable risk, and children and younger adults can still become severely unwell, but the overwhelming majority of deaths from infections and much of the preventable morbidity is in older adults, as laid out in the chief medical officer’s latest annual report.1 In 2023 around 4000 deaths were attributed to infectious diseases in people aged under 65 in England, which compares with around 47 000 deaths in people aged 65 and over.1 Yet...

A drug rollout that officials hailed as a demonstration that the UK was still a “science superpower,” has reached only a fraction of eligible patients.NHS England announced in 2021 that 300 000 people would get the “revolutionary new” anti-cholesterol drug inclisiran (Leqvio) by autumn 2024 and that that figure could rise to “nearly half a million people beyond the initial period.”But The BMJ has found that just 30 000 patients have been prescribed the drug in primary care since 2021, meaning that just one in 10 of the patients that officials aimed to reach by 2024 have actually received it.Inclisiran is a twice yearly injection that can be used in patients who have a history of cardiovascular events and persistently high levels of low density lipoproteins despite taking the maximum tolerated lipid lowering therapies such as statins.1The rollout of the drug 2021 was hailed as a “world leading deal” between...

Deep seated problems facing Scotland’s NHS make the service unsustainable in its present form, a critical report from Audit Scotland has warned.1Since 2019 extra funding of £3bn has been provided and more than 20 000 additional staff have been hired, but performance has not improved in line with commitments made by the Scottish government, said Audit Scotland’s latest annual report.It added that although hospital based activity had increased in the past year—helping to cut waiting lists and waiting times—performance remained below pre-pandemic levels.The report also repeated warnings from previous years that the service would need reform to meet demand.2 It said, “Improvements in productivity and reform of the health and care system are essential if health outcomes are to get better, health inequalities are to be reduced and service delivery to improve.”Despite funding being 25% higher than a decade ago—at £20bn a year—the report warned that the NHS in Scotland...

Two cases of Middle East respiratory syndrome related coronavirus (MERS-CoV) have been identified in France, the first for 12 years, the nation’s health ministry has confirmed.The two patients are men in their 70s who are being treated in hospitals in Lyons and southwest France. “The patients are being monitored [in hospital] as a precautionary measure and their conditions are stable,” Stéphanie Rist, minister for health, families, autonomy, and people with disabilities, said in a statement.Measures have been implemented to limit the risk of onward transmission to contacts of the patients including healthcare workers, she added. These include contact tracing, barrier measures, testing, isolation, and instructions on what to do if symptoms appear, even if they are mild.Antonin Bal, the virologist who has been coordinating tests for the patients and their contacts, told The BMJ that both had mild cold-like symptoms.“The symptoms of the first patient to be diagnosed worsened briefly,...

England is facing an “unprecedented flu wave,” with the NHS warning that up to 8000 hospital beds could be occupied by patients with flu by the end of next week.An average of 1717 patients were in hospital with flu in the last week of November, NHS England data show,1 a record high for this time of year.With 2% of hospital beds in England now occupied by flu patients, NHS England is warning that bed occupancy for flu is already more than 50% higher than the same time last year and 10 times higher than in 2023.“Today’s numbers confirm our deepest concerns: the health service is bracing for an unprecedented flu wave this year,” Julian Redhead, the national medical director for urgent and emergency care, warned on 4 December.“Cases are incredibly high for this time of year and there is no peak in sight.”On the same day, NHS chief executive Jim...

Developed by RAND in the mid-20th century, the Delphi method is a structured, group based communication process and elicitation technique for obtaining reliable consensus opinions of a group of experts.1 Experts (also known as Delphi panelists) anonymously respond to an iterative series of questionnaires that are interspersed with controlled feedback about panelist responses from previous questionnaires. Panelists use their expertise and personal experience to respond to the initial questionnaire. The research team (also known as Delphi conveners) may also provide panelists with summaries of existing research evidence on the topic under consideration before or in conjunction with completion of the first Delphi questionnaire. Panelists respond to subsequent questionnaires after reviewing previous responses of other panelists. This process continues until the responses are stable, a consensus is reached, or a certain number of rounds is completed.2 The conveners then summarize the final panel results, often generating a set of consensus statements....

New rules that force general practices in England to accept online queries from patients during core working hours are already risking harm to patients and increasing GPs’ workload and stress, a survey indicates.More than half (55%) of general practices polled in a BMA survey said online consultations were having a negative effect on patient care.Some 1341 practices responded to the survey, around 22% of England’s total number. Together, those practices represent almost 14 million registered patients.The Department of Health and Social Care dismissed the data, saying the survey involved a “small minority of GP practices” and did not reflect the national picture.Since 1 October practices in England have been required to accept online consultations or queries from patients between 8 am and 6.30 pm, Monday to Friday. The rules were designed to avert the so called “8 am scramble” by patients to reach practices by telephone.However, concerns over patient safety...

Patients over 16 years with suspected sepsis should get smaller amounts of intravenous fluid initially and then have regular reassessments to tailor treatment, updated guidelines recommend.1At least 245 000 sepsis cases are diagnosed in the UK every year, the National Institute for Health and Care Excellence (NICE) has said. Its new guidelines recommend that a patient with suspected sepsis be given an intravenous fluid bolus within one hour of identifying that they are at high risk. An initial bolus of 250ml should ideally be given over 10 to 15 minutes. Further 250 ml boluses should then be given if needed up to 1000 ml in total. The patient should be reassessed after each fluid bolus and if they have not improved enough—with increased blood pressure or improved consciousness level, for example—after 1000 ml has been given, then senior clinical advice should be sought, NICE recommends.Giving smaller amounts of fluid initially...

More strikes by resident doctors could take place, with the BMA already considering further industrial action next month.The union, which called a five day strike between 14 and 19 November,1 said it was determined to continue its efforts to improve pay and working conditions for resident doctors.However, the government is also not backing down on its position, meaning more strikes are likely.In a letter to the health and social care secretary, Wes Streeting, on 19 November the BMA called on him to re-enter discussions and agree a deal to “avert further strikes.”2The BMA is seeking measures that would show progress towards restoring pay levels for resident doctors, such as an inflation linked multiyear pay deal over the next few years, and to tackle the problem of a lack of specialty training places.Recent official data showed that 91 999 applications were made in England for just 12 833 specialty training posts...

A major UK study to track the long term health of young people attending the NHS’s gender incongruence service has started recruiting participants.The Puberty Suppression and Transitional Healthcare with Adaptive Youth Services (Pathways) Horizon study, led by King’s College London and co-sponsored by the South London and Maudsley NHS Foundation Trust, was quietly approved in July and has now begun. It aims to recruit 3000 participants, making it the largest global study of its kind.This comes as New Zealand moved to align with UK policy by announcing a ban on prescribing of puberty blocking drugs for young transgender people, citing the absence of “high quality evidence that demonstrates the benefits or risks.”1In the UK, the Pathways Horizon study seeks to establish how the NHS can best support young people with gender incongruence and to help patients, parents, and health professionals make informed choices about the treatment and support options available.Emily...

Jess Brady died at the age of 27 in December 2020 after 20 appointments with her general practice to evaluate her symptoms. She eventually had adenocarcinoma diagnosed after seeking help from private healthcare1 and died three weeks later. In September 2025, NHS England launched Jess’s rule, describing it as a “life-saving patient safety initiative”1 to encourage practitioners to “reflect, review, rethink”2 if a patient presents three times with the same or escalating symptoms. Although the rule seems simple, as with many ideas for change, its implementation in an overloaded general practice is likely to be complicated. Many questions remain, including how practices should show compliance with a rule that encourages reflection.Diagnosis is a complex, sociotechnical process that involves uncertainty and relies on information that is gathered and integrated over time and across multiple clinical settings.3 Diagnostic errors, considered as failures to establish an accurate and timely explanation of a patient’s...

The NHS sits seventh on the list of the world’s largest employers, rubbing shoulders with the armies of China, India, and the US, as well as mega-corporations.1 It’s also part of the “gig economy.” This is what an investigation into the data, testimonies, and analysis of the fate of locally employed doctors (LEDs) reveals in this week’s BMJ (doi:10.1136/bmj.r2383)2—although it may sound like a fantastical claim.The number of LEDs—UK doctors contracted to an NHS trust rather than nationally—is approaching 40 000. This group is the fastest growing in the NHS, and probably the fastest growing in discontent, over the past decade. The ambitions of a productive health service, optimally staffed and delivering the best patient care, can’t possibly be advanced by a group of doctors working in such dysfunctional circumstances, despite the best efforts of individual doctors. Many LEDs are overseas graduates or from ethnic minorities, although not exclusively. They...

F. Gordo Vidal
Med Intensiva. 2023;47:191-2

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Francisco Álvarez-Lerma, Mercedes Catalán-González, Joaquín Álvarez, Miguel Sánchez-García, Mercedes Palomar-Martínez, Inmaculada Fernández-Moreno, José Garnacho-Montero, Fernando Barcenilla-Gaite, Rosa García, Jesús Aranaz-Andrés, Francisco J. Lozano-García, Paula Ramírez-Galleymore, Montserrat Martínez-Alonso
Med Intensiva. 2023;47:193-202

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