14 Mar, 16 | by BMJ
Doctors have faced up to the challenge of treating obesity. Is it now time to address that other major weight disorder—malnutrition? Less common in the general population than obesity, malnutrition is an ever-present health risk for older people—with one in ten over 65s either already suffering or at risk of becoming under-nourished, according to a new report by BAPEN (the British Association of Parenteral and Enteral Nutrition).
Malnutrition affects around one million older people in the UK—typically the result of a loss of appetite alongside an increase in mobility problems, mental or physical disability, and isolation. Essentially a process of slow starvation, malnutrition leads to low energy and mood, increased susceptibility to infections, loss of muscle mass increasing the risk of falls, and reduced mobility as well as loss of subcutaneous fat leading to pressure sores and delayed wound healing, thereby significantly extending hospital stays. It’s also linked to mild cognitive impairment. As such malnutrition, “accounts for 30 per cent of hospital admissions, 35 per cent of care home admissions, 15 per cent of outpatient clinic attendances, and 10 per cent of those presenting at their GP”, BAPEN reports. The costs are huge: £19 billion in health and social care every year.
Yet it remains “under-detected and under-treated,” according to the report’s author, Professor Marinos Elia of the Malnutrition Action Group of BAPEN and Professor of Clinical Nutrition & Metabolism at the National Institute for Health Research Southampton Biomedical Research Centre. “We spend extremely large amounts on this problem, which could be readily helped by doing simple things well,” he said at the launch of the report in London in December 2015.
A key step forward is greater awareness and increased diagnosis of the problem--with professionals, and more recently the general public, able to access a screening tool called MUST (Malnutrition Universal Screening Tool). The Malnutrition Task Force’s pilot scheme at Salford Royal NHS Foundation has also developed a Paperweight Armband, claimed to be “a non-intrusive, non-medical intervention solution that health care providers and the voluntary sector would be able to implement quickly and easily into their practice.” But what then? Research by the Malnutrition Task Force in February 2016  showed that only 51 per cent of health professionals thought malnutrition was a priority in their organisations and 47 per cent “felt confident that their knowledge and skills were sufficient to help people most at risk.”
Yet clinicians shouldn’t assume that tackling malnutrition in older people is beyond their scope. For a start, screening for under-nutrition on admission to hospital should be universal, according to Andy Jones, immediate past chair of the Hospital Caterers Association and a co-organiser of Nutrition and Hydration Week. And once identified, the disorder should be documented in discharge summaries and referral letters. It’s not good enough, Elia points out that when spotted in hospital, for instance, ‘patients are not then given a care plan that will carry over from hospital to GP surgery.’
Once identified, “food and drink must become an integral part of the recovery plan,” argues Andy Jones. He says hospitals should have a “mealtimes matters” policy, with no wards rounds to be done when patients are eating—and “doctors encouraged to be on the wards and get involved if they can in assisting people to eat.” This focus on mealtimes is an essential part of the evidence-based “Namaste” programme  for people with dementia, developed by St Christopher’s Hospice and the South London and Maudsley Foundation Hospital and already implemented in care homes in South London.
As to the best source of nutrients for frail older people, prescription fortified shakes and other foods have a part to play particularly in providing protein. But, says Andy Jones, doctors could also encourage consumption of real food. “Currently it’s too easy for a doctor to prescribe a fortified shake when a scone with cream would be eaten and probably better received,” he says. What is also working in a number of trusts, he says, are “24/48 discharge packs” handed to patients who are deemed at risk and “which contain essentials like ½ pt milk, small loaf. Coffee/tea, soup, dinners, cheese, jam all of which gives the person food to eat when they get home and allows social care processes to ‘kick in’ again.” And once GPs are able and willing to identify frail older people at risk of, or already suffering from malnutrition, they can then be helped by voluntary schemes led by dietitians—such as Age UK’s Staffordshire Make Every Mouthful Matter Care Pathway, developed and introduced by the Stoke on Trent and Staffordshire Partnership.
Such schemes don’t rely on doctors feeding malnourished patients. But it makes a huge difference when doctors identify frail older people at risk of malnutrition and make systems work to support those who can help them. “The key for doctors is to recognise that malnutrition co-exists with obesity—and it’s just as important to treat it,” says Dr Simon Gabe, chair of BAPEN. “That will make a huge difference.”
Jane Feinmann is a freelance medical journalist with a particular interest in patient safety based in London. She belongs to Imperial College Health Partners’ Patient Safety Champion Network.
Competing interests: The author has no competing interests to declare.
 Online survey of health and care professionals conducted by Dods Research, sample size 1518, fieldwork conducted between 9th and 18th December 2015
 Stacpoole M, Hockley J, Thompsell A, Simard J, Volicer L. (2014) The Namaste Care programme can reduce behavioural symptoms in care home residents with advanced dementia. Int J Geriatr Psychiatry.
Jane Feinmann first published in HEALTHINSIGHTUK
How much longer can the charity Diabetes UK continue to provide advice on diet to the UK’s 3.9 million people with type 2 diabetes that is based on the discredited Seven Countries Study carried out by Ancel Keys back in the 1950/1960s? The urgency of this question cannot be overstated.
On the one hand, type 2 diabetes is almost certainly the most poorly managed chronic disorder of modern times. Two out of three people with the disorder fail to control their blood glucose despite GPs handing out diabetic medication amounting to 10 per cent of the NHS drugs budget.
The long-term consequences of this failure are staggering and tragic – both financially and at an individual level.
Every year, 80 per cent of the £10bn that the NHS spends on diabetes is used to treat the consequences of poorly controlled blood sugar: kidney and heart failure, increased risk of heart attack and stroke as well as blindness and nerve damage. Each week surgeons carry out more than 100 diabetes-related amputations – with 24,000 deaths every year because people with type 2 diabetes are not able to control their blood glucose.
A policy based on a discredited study
At the same time, there is virtually universal acceptance that type 2 diabetes is the classic life-style disorder where what you eat makes a crucial difference.
So why does Diabetes UK (with the support of both Nice and NHS Choices) persist in sticking to a recommendation that everyone with type 2 diabetes should continue to consume ‘a normal’ healthy diet’ – ie.one that’s low in fat and with plenty of daily starchy carbohydrates including bread, rice and pasta, based on the now discredited 1950/1960s Keys study.
Sure – as Diabetes UK continually points out – not everyone with type 2 diabetes is obese: some indeed are ‘skinny’. But eight out of ten people with the disorder have a BMI above 30 which suggests that a key factor is diet – with new evidence showing why there is no single BMI linked to type 2 diabetes.
‘We now know that individuals have different levels of tolerate to fat within the liver and pancreas,’ explains Professor Roy Taylor of Newcastle University’s Diabetes Research Group. ‘Only when a person has more fat than they can cope with does type 2 diabetes develop. What’s more, we now know that when they successfully lose weight and go below their personal fat threshold, their diabetes will disappear,’ he explains.
Trying to hold back the tide of evidence
The last two or three years has seen a growing pile of highly persuasive evidence showing the benefits of weight loss for people with type 2 diabetes who switch to a low carb diet. Last year, the journal Diabetologia published a study of 19 patients with type 2 diabetes at the Southport surgery of Dr David Unwin, a GP and diabetes specialist.
All the patients lost an average of 8.65kg (19lb) over seven months on a low-carb, high-fat diet, reducing their blood glucose levels by nearly a quarter. Later this year, Dr Unwin is set to publish a further study of 69 patients with non-alcoholic fatty liver disease, a precursor of type 2 diabetes as well as heart disease, showing a 46 per cent improvement in liver blood tests, and therefore a reduced risk of high blood glucose levels after an average of 13 months on a low-carb high-fat diet. .
What’s more common sense supports the low carb protocol, according to diabetes specialist, Dr David Cavan, author of Reverse Your Diabetes. ‘We know that type 2 diabetes develops when blood glucose rises above a certain level – and whether it’s sugar, rice, bread or potatoes, these carbohydrates rapidly turn into glucose in your bloodstream,’ he says.
His patients and many others are able to control blood glucose by becoming more active and switching to a low carb diet. Indeed under his influence, around 280,000 people with diabetes have signed up to the online forum, diabetes.co.uk where they are able to swap tips on low carb meals and provide comradely support to each other as they’re forced to ignore the advice from their GP or diabetes nurse.
Desperate patients forced onto dangerous diet
When I wrote about this dilemma in the Daily Mail recently, the piece triggered over 200 responses from readers caught in this invidious position.
Mary Megan from London was ‘stunned’ last year when her GP ‘recommended eating carbohydrates as part of a ‘healthy balanced diet’ when I know for a fact from having tested my blood sugar over the years that carbohydrates are the exact cause of my high blood sugar.’
Bob from Sudbury, Suffolk has lost the sight in one eye and suffered kidney failure and nerve damage after being diagnosed with type 2 diabetes 12 years ago but given ‘little to no advice ‘. Sari from Hampshire says her mother ended up with a huge weight problem because her diabetic nurse insisted ‘you are getting it wrong by not eating enough carbs and that is the main cause of your problem.’ Poppy’s daughter in law was told she ‘must eat carbohydrates to use her insulin’.
It’s not just the UK where people with type 2 diabetes are confused.
Earlier this summer, the Academy of Nutrition and Dietetics, representing 90,000 US dietitians, ‘turned its back on decades of dietary dogma’ with a report to ‘de-emphasise saturated fat as a nutrient of concern’ while ‘recognising the strongest evidence that a reduction in intake of carbohydrates and added sugars will improve the health of the American public’.
Nurse told to stop making diabetics well again
Yet at almost exactly the same time, pro-low-carb dietitian Jennifer Elliott was expelled from the Dietitians Association of Australia because of her recommendation to lower carbohydrate diets to people with type 2 diabetes. When she turned up for work at Southern New South Wales health district, she was sacked – and a warning was issued to dietitians that ‘nutritional advice to clients must not include a low carbohydrate diet’. Elliott says she had no choice but to refuse to comply with this advice: ‘Can you imagine having to tell a client with diabetes, who has lowered his blood glucose levels, lost weight and come off all diabetes medications by reducing his carb intake, that he now has to start eating more carbs because SNSW Health says so !? she explains.
‘It’s not easy to be a dietitian in Australia advocating carbohydrate restriction, but even worse to be a person with diabetes in the SNSW Health district where you are denied the choice of a low-carbohydrate diet,’ she says on her website babyboomersandbellies.com.
Here too, it seems as though the health establishment is prepared to prevaricate indefinitely. Last month, Dr Aseem Malhotra, clinical associate to the Academy of Royal Colleges repeated a challenge to the charity Diabetes UK to explain why it continues to recommend ‘carbohydrates known to promote fat storage and hunger’ to a group of people most of whom urgently need to lose weight.
‘Given that type 2 diabetes is a condition related to an intolerance to metabolise carbohydrates, it is puzzling why Diabetes UK recommends as part of a “healthy balanced diet” the consumption of plenty of starchy carbohydrates and modest amounts of sugary food and drinks including cakes and biscuits,’ he said.
An inspirational doctor who is helping diabetics
In a response on its website to the Mail article, Diabetes UK acknowledges that there is indeed ‘evidence that low carbohydrate diets can be effective and control blood glucose’. But the statement by its clinical advisor, Douglas Twenefour, adds the extraordinary assertion that ‘a healthy balanced diet’ (ie with plenty of carbohydrates) ‘is easiest to understand and will benefit the majority of people with diabetes’.
It’s an assertion which assumes there can be no change to the current culture where refined carbohydrates are widely promoted and easily and cheaply available - a bit like a lung cancer charity saying that giving up smoking is a good idea but that it’s too difficult to get message across.
Making lifestyle changes to control blood sugar isn’t easy but it’s possible provided people are given detailed information – as the online community, diabetes.co.uk has shown. Dr Unwin has described how, as a committed, informed GP, he has been able to help patients with type 2 diabetes to lose weight and gain control over the blood sugar with a low carb diet – at the same time saving £20,000 per year in prescription costs – an important factor bearing in mind that Diabetes UK has recently warned that type 2 diabetes will bankrupt the NHS.
As for those who can’t imagine an end to advertising and product placement of refined carbs, they should consider the impact of smoking cessation policies on both health and culture over the past five decades.
For the sake of Mary, Bob and Sari’s mum and the three million other people diagnosed with type 2 diabetes in the UK, we need Diabetes UK to bring about a tipping point on carbs advice.
Jane Feinmann is an award-winning medical journalist with a special interest in investigating safe and effective healthcare. She belongs to Imperial College Health Partners’ Patient Safety Champion Network. Her website is janefeinmann.com.
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23 Sep, 15 | by BMJ
I’m at my GP surgery on the point of becoming a nuisance patient—it seems I have all the qualifications.
Five years ago I was discharged from hospital after a medical mishap, serious enough to have my family gather at my bedside. I’ve tried and failed to get a full explanation of what went wrong. Now, with new complications, I have to see a specialist again—and I’m asking my GP to refer me to a consultant other than the one who was responsible for the medical mishap and who has proved to be unwilling to discuss it.
As I start to outline the medical mishap and its consequences, the atmosphere in the consulting room starts to cool. I’ve no plan to make a complaint about what happened to me, but I clearly have a grievance. And as the paper “Taking Complaints Seriously: using the patient safety lens,” published in BMJ Quality & Safety, says, that puts doctors on their guard.
Doctors dismiss dissatisfied patients as troublemakers, because complaints are so rare, according to authors, Thomas Gallagher and Kathleen Major from the University of Washington Medicine Center for Scholarship in Patient Care Quality. “Even for the most complaint prone providers, the number of complaints relative to the total number of patients seen is extremely small,” they write. These small numbers can easily be interpreted to mean “that the perceptions [of those who make complaints] are wrong and the complaints are attributable to the patient’s personality.”
Even health professionals who recognise that a small number of complaints signal a genuine problem can find it “difficult to identify underlying problems with confidence” as most patients on the receiving end of this problem appear to be managing perfectly well.
This response is dangerous, they say, contributing to unsafe care. “In complex medicine today, patients and family members are often the first to detect lapses in safety or quality, to identify worsening outcomes, or to point out breakdowns, in communication that providers have missed.”
But patients have to accept equal responsibility in failing to raise concerns about possible unsafe care. Someone like myself, happy and able to stand up for my rights in most areas of life, gets anxious at the prospect of their doctor seeing them as a nuisance. Hyper-aware of a doctor’s body language: a slightly raised eyebrow, a small shift of body weight that says loud and clear: “Here we go, another difficult patient,” the instinct is to zip it and re-join the throng of grateful patients, the ones that doctors like and look after. Yet my experience of persisting with my request has to be typical: my doctor may not have wanted to listen, but having heard the situation, he acted entirely appropriately, and I will get the care I need.
Currently, Health Education England’s Commission on Education and Training for Patient Safety, chaired by Professor Sir Norman Williams, is taking evidence on how to ensure that “patient safety is embedded in the heart of our staff and workforce culture“—and is due to report in November.
A priority must be to clarify this doctor/patient interaction identified by Gallagher and Mazor and state explicitly that good doctors don’t make judgments about people who make complaints. It’s equally important, however, to encourage patients to have the confidence to speak up in a consultation and seek their doctor’s help in managing examples of unsafe care.
Jane Feinmann is a freelance medical journalist with a particular interest in patient safety based in London. She belongs to Imperial College Health Partners’ Patient Safety Champion Network.
Competing interests: The author has no competing interests to declare.
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It’s a problem that wastes hundreds of millions of pounds every year while causing untold damage to the health of frail older people admitted to hospital for treatment for an infection or a fall - and then trapped there because they are unable to be discharged. Ending this appalling failure of care will be complex and require innovation - as I found, when I investigated the issue for an article that appeared in the Daily Mail this week, http://dailym.ai/1FqTjyP.
1. Therapists need to work 7/7
Hospitals pay medical and nursing staff over the weekend - but they can choose whether to fund occupational therapists and physiotherapist seven days a week. That’s not because therapists themselves are unwilling to work weekends. ‘We’re happy to help + fully support well managed 7 day working’, tweeted Lorraine Bridges of the College of OTs in response to my piece. Let negotiations begin.
2. Keep the old and frail out of hospital
Several readers described how their relatives had been trapped in hospital after being admitted for relatively minor conditions - especially out of hours when, as Prof David Oliver, President of the British Geriatric Society point out: ‘A&E is the only place where the lights are on’. Once pulled out of their routine, it’s more difficult for frail older people to maintain their health and independence. What’s more, as well as being trapped in hospital, they’re also more at risk of being sent home too early (http://dailym.ai/13Cw17u). Keeping the lights on in general practice has to be normal.
3. Focus on discharge from the moment patients are admitted
Personalised care is the future of compassionate, effective medicine. For frail older people, that means ‘only keeping them in for as long as hospital is the best place for their needs to be met’, says Prof Oliver. The whole team, perhaps led by occupational therapists, should prioritise planning for care and support after patients are discharged from hospital.
4. Coordinate with practitioners in the community
‘What’s the point of having OTs available at weekends to discharge patients when their opposite numbers in the community aren’t available,’ ask OT readers of the Mail. True - but by prioritising the patient’s journey from essential admission to hospital and back to their place of residence, it has to be possible to get the right people at the end of the right phone at the right time. Decide who should take responsibility for making this happen.
5. Convalescence matters
Convalescent homes may be part of history but people still need to take it easy for days or weeks following surgery or acute illness - and for those living alone or with multiple chronic problems, that’s not straightforward. Care homes that offer convalescent beds could be one answer; another could be ‘Home from Hospital’ programmes involving ‘collaborative relationship’s between hospitals and community care services that provide daily support for people in their own homes. That means hospital discharge managers taking a pro-active role in setting up these relationships instead of ignoring invitations to get involved - as so often happens, according to Angela Gifford, director of Able Community Care.
6. Home helps - a case for renationalisation?
The Home Help service was privatised in 1990 with hundreds of profit-based organisations set up over the last 25 years, many, sadly, providing inadequate care. In its first ever guidance on social care issued this week (September 23 2015), Nice has criticised five-minute visits that are the norm. And not a moment too soon: this is a social issue with a direct impact on cost-effective and efficient health care. With the question of renationalisation of services back on the political agenda and the need for home care greater than ever, is it time to consider the renationalisation of this crucial and previously well-run local authority service.
7. Use words carefully
If you want to stop ‘bed-blocking’, stop using the term, says Prof Oliver - and he may be right. It’s a phrase that appears to express a big problem in a couple of words and therefore widely used in the press as well as by charities and even the NHS. But the College of Occupational Therapists ‘firmly rejects the term’ - something the rest of us should be aware of. Also avoid talking about: ‘the elderly’ for the same reason you wouldn't use a single word for people with epilepsy or diabetes.
I’m at my GP surgery on the point of becoming a ‘nuisance’ patient. It’s been five years since I was discharged from hospital following a medical mishap - serious enough to have my family gather at my bedside. In that time, I’ve tried and failed to get a full explanation of what went wrong. Now with new complications, I have to see a specialist again - and I’m about to ask my GP to refer me to a consultant other than the one that was responsible for the medical mishap and who refuses to discuss it. And it’s tough going.
‘Oh really why is that?’ asks the GP when I ask to be referred to a different specialist - giving me what feels like a hard stare. |As I explain the details of the medical mishap and its consequences, the atmosphere starts to cool. I've no plan to make a complaint, I'm simply putting my request in its clinical context. But it's clear I have a grievance - and suddenly I feel judged.
It’s a common experience for patients - and one that’s actually dangerous, according to a paper in the BMJ Quality & Safety (April 2015), Taking Complaints Seriously: using the patient safety lens, http://bit.ly/1XBight. According to the authors, Dr Thomas Gallagher and Dr Kathleen Mazor, it’s normal practice for health practitioners to dismiss patients who complain as troublemakers. 'It's easy,’ they say, ‘to dismiss complaints as attributable to the patient’s personality; the fact that complaints are relatively rare contributes to this tendency to undervalue them’.
After all, even for ‘the most complaint-prone providers’… the number of complaints relative to the total number of patients seen is extremely small. ‘These small numbers can be interpreted to mean that the complainers are unusual and that their perceptions are wrong,’ say the researchers. Further, those health professionals who recognise that a small number of complaints signal a genuine problem can find it ‘difficult to identify underlying problems with confidence’ when most patients on the receiving end of this problem appear to be managing perfectly well.
Patients understand all this at some level. We’re hyper-aware of a doctor's body language: a slightly raised eyebrow, a small shift of body weight that says loud and clear: ‘Here we go. Another difficult patient!’ The self-monitoring risk-averse-scanner hard-wired into the brain goes into overdrive: the instinct is to zip it and re-join the throng of grateful patients, the ones that doctors like and look after. Unfortunately, this common interaction between doctor and patient is a major contributor to unsafe care, explain Gallagher and Mazor. ‘In complex medicine today, patients and family members are often the first to detect lapses in safety or quality, identify worsening outcomes or point out breakdowns in communication that providers have missed’.
Currently, Health Education England’s Commission on Education and Training for Patient Safety, chaired by Professor Sir Norman Williams, is taking evidence on how to ensure that ‘patient safety is embedded in the heart of our staff and workforce culture’: http://bit.ly/1JP3zgV - and is due to report in November. Perhaps a key step is to adjust this balance: find a way to give patients the confidence to speak out - and support doctors in becoming less prone to judging patients with a grievance.
Hospitals don't bother to inform patients' relatives when they are about to be discharged, according to Healthwatch England reporting a year long survey in July 21 2015 (http://www.healthwatch.co.uk/safely-home). It's a major factor, the charity says, in the one million readmissions to hospital within 30 days of discharge in 2014 - causing avoidable significant harm and suffering to thousands of people every day.
It's a point I was able to make in an article in the Daily Mail in March 2015: The patients whose lives are put at risk by hospitals sending them home too soon. And it's just one of several examples of shockingly poor routine care in the NHS today - which lays this excellent institution open to accusations of zombie-like lack of compassion as well making a myth out of claims that healthcare today is evidence-based. What does it matter if the drug the patient is taking has been tested when patients are neglected so flagrantly?
Here's just a few examples of substandard care that I have written about recently:
Sepsis is easy to treat so: Why aren’t ALL doctors trained to spot sepsis, the killer which claims 37,000 lives a year
Why are so many broken bones being missed in A&E and thousands of patients being sent home in agony with just a paracetamol?
How thousands are sent home with aspirin for a faulty heartbeat - and risk a crippling stroke
My story in the Daily Mail today, http://dailym.ai/1JfVhTB should be seen as a tribute to two outstanding individuals who have fought unsafe medical practice that has been ruthlessly supported by the authorities - on behalf of all of us.
John Clarke discovered that his mother Marlene's consent form appeared to have been changed post-surgery to accommodate mistakes made during the op. His extraordinary persistence - as first told in HSJ (http://bit.ly/1BIXPHm) - in holding to account those responsible led to a CQC visit to a ward in the hospital where she was treated - with the CQC recording its finding that 85 per cent of consent forms had been retained by the hospital.
Nadine Montgomery and her family spent 16 years fighting in the courts to challenge the view that Nadine’s consultant obstetrician was right to make a decision on her patient’s behalf - that resulted in avoidable brain damage to her son, Sam, now 16. Her doctor’s view was upheld by the British courts until three months ago. Now the Supreme Court has judged in favour of Nadine Mongtomery, 'ending paternalism in healthcare'.
If these two individuals had not devoted years of their lives to heart-breaking & exhausting effort in holding to account the doctors who they believed had acted without consent, we would know nothing about either of these terrible injustices. Which suggests that this is happening more often than is good for us.
Shared decision-making isn't a simple issue. Doctors have to find extra time to discuss complex choices. And patients may be unaware of the importance of informed consent, uninterested in participating - and, as lawyers point out, may well know next to nothing about how to weigh up competing risks. But it’s health policy and there’s evidence that it’s good medicine. As such doctors can’t carry on ignoring it - as they clearly are doing.
For doctors who can’t or don’t want to spend the time discussing decisions, there are shared decision aids (sdm.rightcare.nhs.uk) - a little known but cutting edge and potentially powerful new source of support for people facing difficult health choices - developed by people like risk genius Prof David Spiegelhalter. Yet doctors whose patients could benefit ignore them, says Angela Coulter of the Informed Medical Decisions Foundation. Who in the Department of Health take a lead to bring shared decision-making in healthcare into the 21st century?
My view on what counts in healthcare
Health risks of MedApps – How I helped MHRA to do its Job
How I helped to MHRA to police Health Apps If you Googled ‘skin cancer’ two weeks ago, you may have found a health app, Mole Detective, on Google Play that Read more…
Do we really need a reporters’ guide to rheumatoid arthritis?
As far as I know, RA is a disease with well-established therapy that is becoming increasingly uncommon – and am curious to know the rationale for paid-for publication in a Read more…
A way forward for quality peer review
July 31, 2014, BMJ
Blind faith that the publication of medical research in peer reviewed journals elevates a study to the status of “the evidence,” and therefore “the truth,” may be on the wane among those in the know. But for the public, and a vast number of doctors, this “naïve and misplaced” credulousness persists.
To read more: