letters to editor hepworth interphone 4-29-06

New UK policy on overseas doctors

What future for international medicalgraduates in the NHS?

Editor—Of 449 applications for six postson our basic surgical training scheme whichstarted in August 2005, 78% graduated fromnon-European Union (EU) countries, 61%coming from India. In all, 276 doctors fromIndia applied for a place on a scheme in adistrict hospital. Anecdotal evidence sug-gests that only a small proportion of themgained positions on official training pro-grammes (one to our rotation). Many of therest will have “settled” for trust grade or staffgrade posts, while many others will havebeen trapped in financially unrewardingclinical assistantships.

Those in trust grade posts make asignificant contribution to the overall medi-cal staffing in the NHS. It remains unclearhow this gap will be filled. There will not besufficient numbers of UK graduates willingand able to fill such service posts. In ourstudy only 6% of applicants came fromnon-UK EU countries.

At this time of crisis1 the GeneralMedical Council continues to hold Profes-sional and Linguistic Assessments Board(PLAB) examinations in India, Africa, andother countries. This practice constitutes anindirect invitation by the GMC to come towork in the UK. Instead, these youngdoctors should be fully appraised of the newregulations and discouraged from coming,

except in extraordinary circumstances ofspecific manpower shortages.Nigel G Richardson consultant [email protected]

Omatseye Edema international medical graduateBroomfield Hospital, Chelmsford, Essex CM1 7ET

Competing interests: OE is an internationalmedical graduate working in the NHS, and NGRis a consultant who regularly works with interna-tional medical graduates.

1 Trewby P, Williams G, Williamson P, Barnes E, Carr P, Cril-ley J, et al. European doctors and change in UK policy. BMJ2006;332:913-4. (15 April.)

International medical graduates invest£7500 in getting first job

Editor—The following is the approximateinvestment each overseas doctor has to putin before applying for jobs in the UnitedKingdom:

IELTS (language exam): £150PLAB1 (medical exam): £145PLAB2 (medical exam): £430Provisional GMC registration: £100GMC limited registration: £290.As each of these doctors has to purchase

a return ticket to their home country (around£500), spends £300 a month on subsistence,spends another £100 a month on jobapplications, takes one year to get the first job,and additionally has to pay a visa fee of about£400, add another £5700. Moreover, visas areonly extended for the period of clinicalattachment (1-3 months) and the candidatehas to apply again. This amounts to a total ofat least £7500 that an international medicalgraduate would have to spend beforesecuring his or her first job in the UnitedKingdom. Multiplying this by the presumed10 000 international graduates that might beaffected by the new rules1 gives £75 000 000that the UK government is willing to takefrom international medical graduates frompoor or developing countries.Sasi Attili senior house officer, dermatologyDepartment of Dermatology and Photobiology,Ninewells University Hospital, Dundee DD1 [email protected]

Competing interests: None declared.


Also affects international medicalgraduates graduating from UK institutions

Editor—The Home Office has stipulatedthat from April 2006, UK medical school

graduates who are foreign nationals willstrictly fall under the work permit system oncompleting foundation training.1 By the endof Foundation Year 2, I will have been in theUK for eight years—long enough to gain thebuilding bricks of medicine, but not longenough to gain residency rights. I readmedicine at Cambridge University with theexpectations that I could continue post-graduate training here. Otherwise, what useis a primary medical degree without special-ist training, unless one is thinking of leavingmedicine, say, to go and work in the city?

If this ruling is not overturned, I suggestthat undergraduate deans immediately stopaccepting foreign students, regardless of thetalent.Jin-Liang James Tee house officerRoyal Cornwall Hospital, Truro TR1 [email protected]



Has far reaching effects

Editor—The new rule has affected not onlytrainee doctors but all the doctors who cameto this country in the early 1960s and 70s tofulfil their dream and ambition of gettingtrained in the United Kingdom.1 They weregiven the option of working as general prac-titioners in underprivileged areas andserved the British public where local gradu-ates dreaded to go. The new rules don’taffect them, but there is a sense of being notwanted in the country as they favourEuropean nationals. Not only doctors butprofessionals from other disciplines arequite seriously thinking about continuing inthe UK for their careers. The UK is losingthousands of skilled staff, and at what cost?Laxmikanth Bangaru senior house officer inpsychiatryHarperbury Hospital, Radlett, HertfordshireWD7 [email protected]


1 Khan MAI. Non-European doctors and change in UKpolicy. BMJ 2006;332:914. (15 April.)

Thank God for the American Dream

Editor—Trewby et al identify the newnationality based employment policy of theNHS as a short term benefit.1 I am gratefulthat the institutionalised bias against foreignphysicians in the United Kingdom wasevident to me seven years ago when Idecided to search for opportunities outside

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We select the letters for these pages from the rapid responses posted on bmj.com favouring thosereceived within five days of publication of the articleto which they refer.

Letters are thus an early selection of rapid responseson a particular topic. Readers should consult the website for the full list of responses and any authors'replies, which usually arrive after our selection.

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India. The US is still a bastion of equalityand democracy, treating foreign medicalgraduates on merit and not being reluctantto hire them. The US shows that hiring peo-ple for talent rather than nationality is goodfor progress as well as ethically sound.Naren Gupta surgery residentDepartment of Surgery, University of VirginiaHealth System, Charlottesville, VA 22908-0300,[email protected]



New ethical framework forpharmaceutical physiciansEditor—Lenzer highlighted the helpinghand that some US news organisations giveto pharmaceutical companies in circum-venting the Food and Drug Administration’srequirements for fair balance in video newsreleases.1 An ethical framework of guidingprinciples for pharmaceutical physicians hasrecently been published.2 Pharmaceuticalphysicians should “ensure that expectationsare not inappropriately raised as a result ofmedia briefings” and “be involved in thedrafting of any briefings about potentialtherapeutic interventions provided to finan-cial analysts or to the media.” Thus thedisproportionate publicity that arose fromstudies such as ASCOT and ASTEROID—targeted directly at the consumer via thenews media—should not occur when othertrials are reported.3 4

The particularly dubious habit of report-ing trials that achieve significance only fortheir secondary end points (ASCOT,PROACTIVE) with the same vigour andpublicity as if the primary end point hadbeen achieved should now also be relegatedto history.3 5 Details of how deviations fromthis guidance will be managed are necessaryif the proposals are to be effective and takenseriously.

Thrown into sharp relief is the paucity ofguidance for and regulation of health servicephysicians whose association and financialdependency on the pharmaceutical industrycan seemingly approach that of pharmaceuti-cal physicians. The General Medical Councilmight be best suited to considering theseissues, but until this need is identifiedpharmaceutical physicians may, ostensibly, beheld more accountable than their non-pharmaceutical colleagues. Perhaps it is nowtime to abandon the artificial dichotomybetween pharmaceutical physicians and non-pharmaceutical physicians and recognise thatsimilar strictures should apply to all.Rubin Minhas general practitionerSunlight Medical Centre, Gillingham, KentME7 [email protected]

Competing interests: Over the past 10 years RMhas attended educational meetings and receivedtravel grants and honorariums for lectures andadvisory boards from a number of pharmaceuti-

cal companies, including AstraZeneca, Bayer,Fournier, GlaxoSmithKline, Pfizer, Merck, MSD,and Sanofi-Aventis.

1 Lenzer J. When drug news is no news. BMJ 2006;332:919.(15 April.)

2 Ethical Issues Committee of the Faculty of PharmaceuticalMedicine of the Royal Colleges of Physicians of the UK.Guiding principles for pharmaceutical physicians. Int JClin Pract 2006;60:238-41.

3 Dahlöf B, Sever PS, Poulter NR, Wedel H, Beevers DG,Caulfield M, et al for the ASCOT Investigators. Preventionof cardiovascular events with an antihypertensive regimenof amlodipine adding perindopril as required versus aten-olol adding bendroflumethiazide as required, in theAnglo-Scandinavian Cardiac Outcomes Trial-Blood Pres-sure Lowering Arm (ASCOT-BPLA): a multicentrerandomised controlled trial. Lancet 2005;366:895-906.

4 Nissen SE, Nicholls SJ, Sipahi I, Libby P, Raichlen JS,Ballantyne CM, et al. Effect of very high-intensity statintherapy on regression of coronary atherosclerosis: theASTEROID trial. JAMA 2006;295:1556-65.

5 Freemantle N. How well does the evidence on pioglitazoneback up researchers’ claims for a reduction in macrovascu-lar events? BMJ 2005;331:836-8.

Role of MRI in diagnosingmultiple sclerosis

Magnetic resonance imaging is valuable

Editor—In investigating the diagnostic util-ity of magnetic resonance imaging (MRI) incases of suspected multiple sclerosis, Whit-ing et al have evaluated imaging findingsreported in many different studies—mainlywhether there are any lesions present in abrain scan.1 This approach does not reflectreal life, where neurologists use a moredetailed interpretation of MRI abnormali-ties in the context of the clinical findings toreach a diagnosis. Clinicians deal with manydifferent clinical settings that make the diag-nosis of multiple sclerosis more or less likelyand also have to consider the differentialdiagnosis. An early and reliable diagnosisfacilitates best management and alleviatesanxiety due to diagnostic uncertainty. Whilethe diagnosis of multiple sclerosis is basedprimarily on clinical manifestations, it isoften helpfully—and sometimes crucially—supported by laboratory investigations.When used appropriately,MRI—and sometimes cerebro-spinal fluid and neurophysi-ological (evoked potentials)examination—improves diag-nostic accuracy and helpsexclude or identify otherimportant conditions.2

Appropriate use of MRI incases of suspected multiplesclerosis involves more thandetermining whether there isa lesion in the brain and if sohow many. White matterlesions have numerous causes,and the correct use of brainimaging to improve specificityin suspected multiple sclerosiswill take into account location (Barkhof-Tintore criteria for dissemination in space3),activity (gadolinium enhancement), and theappearance of new lesions (dissemination intime, a mandatory requirement in diagnos-ing multiple sclerosis3). The currentlyaccepted brain MRI criterion for dissemina-

tion in space has a higher specificity thanthree lesions for multiple sclerosis versusother neurological diseases.3 4 Detection byMRI of the characteristic spinal cord lesionsof multiple sclerosis is of particular diagnos-tic value.5 Because a cord syndrome is thepresenting feature of around a half ofpatients with multiple sclerosis, imaging ofthis region is often needed to exclude analternative treatable disorder such as spinalcord compression.David H Miller professor of clinical neurologyInstitute of Neurology, University College London,London WC1N [email protected]

On behalf of members of the Steering Commit-tee of MAGNIMS, a European network on mag-netic resonance in multiple sclerosis.

The members of the steering committee whoare coauthors of this letter are Frederik Barkhof,Franz Fazekas, Massimo Filippi, Ludwig DKappos, Xavier Montalban, Jacqueline Palace,Chris H Polman, Marco Rovaris, Alex Rovira,Nicola de Stefano, Alan J Thompson, and TarekYousry.Competing interests: None declared.

1 Whiting P, Harbord R, Main C, Deeks JJ, Filippini G, EggerM, et al. Accuracy of magnetic resonance imaging for thediagnosis of multiple sclerosis: systematic review. BMJ2006;332:875-84. (15 April.)

2 Miller DH, McDonald WI, Smith K. The diagnosis of mul-tiple sclerosis. In: Compston A, ed. McAlpine’s multiple scle-rosis. 4th ed. London: Elsevier, 2005:347-88.

3 Polman CH, Reingold SC, Edan G, Filippi M, Hartung HP,Kappos L, et al. Diagnostic criteria for multiple sclerosis:2005 revisions to the “McDonald criteria.” Ann Neurol2005;58:840-6.

4 Nielsen JM, Korteweg T, Barkhof F, Uitdehaag BM, PolmanCH. Overdiagnosis of multiple sclerosis and magneticresonance imaging criteria. Ann Neurol 2005;58:781-3.

5 Bot JC, Barkhof F, Lycklama G, Nijeholt G, van Schaarden-burg D, Voskuyl AE, et al. Differentiation of multiplesclerosis from other inflammatory disorders and cerebro-vascular disease: value of spinal MR imaging. Radiology2002;223:46-56.

Early diagnosis using MRI and earlytreatment delays disease conversion

Editor—Whiting et al ignore data collectedover the past 15 years that show repeatedlythat early diagnosis of multiple sclerosis iscrucial and that early treatment leads to a far

better outcome on numer-ous measures, immunologi-cal and clinical, than latetreatment.1

In patients with oneattack of multiple sclerosisstarting immune therapywith interferon beta-1a candelay the patient meetingdiagnostic criteria for clini-cally definite multiple scle-rosis compared withuntreated patients, and theuntreated patients neverquite catch-up when theyeventually begin immunetherapy.2 At this month’s58th annual meeting of the

American Academy of Neurology SanDiego another study (BENEFIT) usinginterferon beta-1b confirms the same point(M S Fredman; C H Polman, scientificsessions).

The management of multiple sclerosishas slowly been moving towards early

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diagnosis and treatment because it is thebest way yet known to avoid the accumula-tion of significant deficits in the daily life ofpatients and to afford them the best qualityof life and health possible for the longestpossible time. That is why so much effort hasbeen put into magnetic resonance imaging(MRI) studies and early treatment trials.Bharani Padmanabhan directorAngels MS Service, Angels Neurological Centers,536 Washington Street, Abington, MA 02351, [email protected]


1 Whiting P, Harbord R, Main C, Deeks JJ, Filippini G, EggerM, et al. Accuracy of magnetic resonance imaging for thediagnosis of multiple sclerosis: systematic review. BMJ2006;332:875-84. (15 April.)

2 Kinkel RP, CHAMPIONS Study Group. IM interferonbeta-1a delays definite multiple sclerosis 5 years after a firstdemyelinating event. Neurology 2006;66:678-84.

Textbook of PharmaceuticalMedicine warns of trial risksEditor—With reference to the adversereactions with TG1412 being because of thedrug, not the study design,1 I quote fromsection 4.8 on minimising risk in the chapteron exploratory development in the Textbookof Pharmaceutical Medicine on first timedosing in humans2:

“For example, the study design mayrequire administration of intravenous infu-sions to six volunteers. It may be perfectlyfeasible to perform these on a single day butit is inadvisable to start all the infusionssimultaneously. Drug-related adverse reac-tions would be likely to occur at the sametime in all the subjects, which could be verydifficult to manage and put subjects atunnecessary risk. Indeed, it may be wise tostop the study after the first significantadverse reaction has been detected andreconsider the dose, speed of administra-tion or whether to proceed at all.”Chek C Chan former pharmaceutical physicianBracken Ridge Family Practice, 59 Gawain Road,Bracken Ridge, Brisbane, QLD 4017, [email protected]


1 Mayor S. Inquiry into adverse events in trial blames drug,not study design. BMJ 2006;332:870. (15 April.)

2 Posner J. In: Textbook of pharmaceutical medicine. 4th ed.London: BMJ Books, 2002:205-6.

Mobile phone use and risk ofglioma in adults

Results are difficult to interpret becauseof limitations

Editor—The UK part of the Interphonestudy concluded that mobile phone use is notassociated with an increased risk of glioma.1

However, ≥ 10 years ipsilateral use yielded anodds ratio of 1.60 (95% confidence interval0.92 to 2.76) and contralateral use an oddsratio of 0.78 (0.85 to 1.3).

Only 51% of the cases and 45% of thecontrols participated. Controls were more

affluent than non-participating controls andparticipating cases. Mobile phone use isassociated with social class. In our study useof cellular telephones was reported by 48%of the most affluent cases and 36% of theleast affluent.2 3

Use of cordless telephones was notassessed and in the analysis of laterality the“unexposed” group contained subjects withexposure to microwaves on the oppositeside of the head.

In table 3, 13 of the 14 odds ratios are< 1.0 and one is > 1.0, indicating non-random variation. Patients with braintumours (cases) may not be best interviewedface to face shortly after their operationbecause of cognitive behavioural defects suchas memory loss and aphasia. The interviewersknew that it was a case under interview.

Our publication on malignant braintumours on this topic is not cited, thoughavailable on 14 July 2005.4 We found anincreased risk for high grade astrocytomawith > 10 years’ latency. The currentpublication does not give results for highand low grade glioma separately.1

The article cites critics of our studiespublished even before our results appearedin the scientific literature. Two of the citedreports have never been published in a peerreviewed journal and are not possible torebut. The third cited report was publishedin 2000, when our first large case-controlstudy was ongoing and no data had beenreported.Lennart Hardell professorDepartment of Oncology, University Hospital,SE-701 85 Örebro, [email protected]

Kjell Hansson Mild professorNational Institute for Working Life, SE-907 13Umeå, Sweden


1 Hepworth SJ, Schoemaker MJ, Muir KR, Swerdlow AJ, vanTongeren MJA, McKinney PA. Mobile phone use and riskof glioma in adults: case-control study. BMJ2006;332:883-7. (15 April.)

2 Hardell L, Carlberg M, Hansson Mild K. Pooled analysis oftwo case-control studies on the use of cellular and cordlesstelephones and the risk of benign brain tumoursdiagnosed during 1997-2003. Int J Oncol 2006;28:509-18.

3 Hardell L, Carlberg M, Hansson Mild K. Pooled analysis oftwo case-control studies on use of cellular and cordlesstelephones and the risk of malignant brain tumours diag-nosed during 1997-2003. Int Arch Env Health. 2006; DOI10.1007/s00420-006-0088-5.

4 Hardell L, Carlberg M, Hansson Mild K. Case-controlstudy on the association between the use of cellular andcordless telephones and malignant brain tumors diag-nosed during 2000-2003. Env Res 2005. doi:10.1016/j.envres.2005.04.006.

Study has many flaws

Editor—In years past Hepworth et al’sstudy would never have been publishedbecause a low participation rate would havebeen cause for rejection.1 With 51% of casesand 45% of the controls participating thereis little reason to believe any of the reportedresults. There are additional flaws:x Controls were more affluent controlsthan casesx Non-participating controls were morelikely than participating controls not to usecellphones2

x The reference group was never/non-regular cellphone users. Because this refer-ence did not exclude the users of cordlessphones, the reference group cannot bedescribed as unexposedx Regular cellphone use is defined ascellphone use for at least once a week for sixmonths or more. Regular cellphone use isset to such a minimal standard that fewcould imagine a finding of risk.

In spite of these flaws, the study reporteda 60% increased risk of glioma for regularcellphone use of ≥ 10 years of ipsilateral use.

Interphone studies receive cellphoneindustry funds isolated from a study. Thissame conflict of interest issue can be seen inthe US government’s Food and DrugAdministration (FDA) where pharmaceuti-cal companies pay fees for drug approvalisolated from specific research projects. It isquite apparent that the FDA has come to seethe pharmaceutical industry as their cus-tomer, not the American public.3–5

If this were a study of the risk of lung can-cer from smoking would there be a likelihoodof finding a risk of lung cancer from smokerswho had smoked at least once a week for sixmonths or more? And, would there be a find-ing of risk if, as is the case in this study forcellphone use, the lifetime years of smokingfor 10 years or more included only 3.9% ofthe smokers in the study?L Lloyd Morgan retired electronic engineer2022 Francisco Street, Berkeley, CA 94709, [email protected]


1 Hepworth SJ, Schoemaker MJ, Muir KR, Swerdlow AJ, vanTongeren MJA, McKinney PA. Mobile phone use and riskof glioma in adults: case-control study. BMJ2006;332:883-7. (15 April.).

2 Lahkola A, Salminen T, Auvinen A. Selection bias due todifferential participation in a case-control study of mobilephone use and brain tumors. Ann Epidemiol2005;15:321-5.

3 Hilts PJ. Protecting America’s health: the FDA, business, and onehundred years of regulation. New York: University of NorthCarolina Press, 2004.

4 Kaufman M. Bill to boost industry fees that fund FDA.Critics fear conflicts. Washington Post 2002 May 23:A01.

5 Public Citizen. Public Citizen decries conflict of interestcreated by new law regulating safety of medical devices.www.citizen.org/pressroom/release.cfm?ID = 1244(accessed 20 Apr 2006).

Conclusions are questionable

Editor—The study by Hepworth et al hassevere shortcomings, including faulty inter-pretation and unfounded conclusions.1 Isthere really any occupational or environ-mental factor capable of inducing glioma ina period of 3 to 4 years (the average durationof use of a mobile phone in this study)? Not

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even after high doses of therapeutic x rayshave such short latencies been observed.2 3

Only 5% of cases had used a mobilephone for 10 or more years. Therefore,induction of glioma cannot be studied. Onlyan effect on tumour development andgrowth can possibly be detected. As pointedout,4 5 the case-control design is inefficient tostudy such effects if the duration of exposureis short.

Furthermore, if an effect on an alreadypremalignant lesion is studied only expo-sures to that region are exposures at all.Therefore the only relevant analysis is thatof laterality. And, surprisingly, this analysisresulted in a significantly increased risk thatincreased further if longer exposure dura-tions were considered. Hence the onlyanalysis compatible with the natural historyof the disease and exposure conditionsshowed a significantly increased risk. But stillthe authors conclude that the study foundno increased risk of developing a gliomaassociated with mobile phone use. Theypoint to the fact that the odds ratio for con-tralateral exposure is below 1 and seem tointerpret this as an indication for recall bias.However, this is simply a consequence oftheir method of analysis and of thesignificant effect on the ipsilateral side.Michael Kundi headInstitute of Environmental Health, Center for PublicHealth, Medical University of Vienna, [email protected]


1 Hepworth SJ, Schoemaker MJ, Muir KR, Swerdlow AJ, vanTongeren MJA, McKinney PA. Mobile phone use and riskof glioma in adults: case-control study. BMJ 2006;332:883-7. (15 April.)

2 Simmons NE, Laws ER Jr. Glioma occurrence after sellarirradiation: case report and review. Neurosurgery1998;42:172-8.

3 Kranzinger M, Jones N, Rittinger O, Pilz P, Piotrowski WP,Manzl M, et al. Malignant glioma as a secondary malignantneoplasm after radiation therapy for cranio-pharyngioma—report of a case and review of reportedcases. Onkologie 2001;24:66-72.

4 Kundi M. Mobile phone use and cancer. Occup Environ Med2004; 61:560-70.

5 Kundi M, Hanson Mild K, Hardell L, Mattsson M-O.Mobile telephones and cancer—a review of epidemiologi-cal evidence. J Toxicol Environ Health B 2004;7:351-84.

Fetuses can feel painEditor—Derbyshire argues against the abil-ity of fetuses to feel pain.1 He states: “Goodevidence exists that the biological systemnecessary for pain is intact and functionalfrom 26 weeks.” He then adopts a definitionof pain from the International Associationfor the Study of Pain as “an unpleasant sen-sory and emotional experience associatedwith actual or potential tissue damage” butconcludes that pain is “a conscious experi-ence” rather than “merely the response tonoxious stimuli,” so a fetus cannot experi-ence pain.

This is a specious argument. There aremany examples of the ability of babies of thisgestation to feel pain. In the first fewmoments after birth, even with extremelypremature neonates (23-26 weeks), a nox-ious stimulus—for example, phlebotomy—can cause bradycardia, desaturation, and

hypertension as a stress response. A neona-tologist would seek to relieve this distresswith analgesia, and a parent would seek tosoothe. Also, as Derbyshire notes, fetalprocedures (such as in utero chest drainplacement) are increasingly being carriedout with analgesia.2

The problem lies with his definition ofpain and the subsequent development of hisargument. If a pregnant woman asks whetherthe fetus feels pain a conscious rationalisationis not necessarily implied. The Oxford EnglishDictionary instead describes pain as “astrongly unpleasant bodily sensation such asis produced by illness, injury or other harmfulphysical contact.”3 There is thus a gapbetween the definition Derbyshire hasadopted and his patients’ understanding ofpain, resulting in ill-informed counselling or,worse (as he encourages in his conclusion),“avoiding a discussion of fetal pain withwomen.” His argument that fetuses cannotfeel pain needs correcting.Mark Tighe paediatric specialist registrarSouthampton General Hospital, SouthamptonSO16 [email protected]


1 Derbyshire SWG. Can fetuses feel pain? BMJ2006;332:909-12. (15 April.)

2 Davis CF, Sabharwal AJ. Management of congenitaldiaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed1998;79:F1-3. (July.)

3 Thompson D, ed. The concise Oxford dictionary of currentEnglish. 9th ed. Oxford: Clarendon Press, 1995:432.

Predictive value of metabolicsyndrome is not clearEditor—Sundstrom et al claim that in theircohort of 50 year old men the identificationof the metabolic syndrome (as defined)added to the prediction of total and cardio-vascular mortality obtained from classic riskfactors.1

However, the electronic version of thearticle clearly shows that this superiorityemerges only after about 15 years of follow-up. As most guidelines for therapeutic inter-vention are predicated on 10 year risk, theobservation does not have pragmatic value.

Furthermore, the comparatively poorperformance of the classic risk factors seemsto be due to the unusually low predictivepower of total cholesterol in this cohort,

which suggests that the result would not begenerally applicable.Richard J Jarrett emeritus professor of clinicalepidemiology, University of LondonLondon SE26 [email protected]


1 Sundström J, Risérus U, Byberg L, Zethelius B, Lithell H,Lind L. Clinical value of the metabolic syndrome for longterm prediction of total and cardiovascular mortality: pro-spective, population based cohort study. BMJ2006;332:878-82. (15 April.)

Clinical research in primarycare needs urgent boostEditor—Let us hope that the cogentarguments advanced by Rothwell in supportof more and better clinical research in theUnited Kingdom begin a serious dialoguethat will correct the asymmetries in researchfunding, kudos, and leadership that havedeveloped over the past 5-10 years.1 Roth-well’s arguments apply with even greaterforce to the need for a clinical research effortin primary care and in health servicesresearch on topics such as the natural historyof common diseases; the value of interven-tions, both therapeutic and preventive; andcritically, as Rothwell points out, the difficul-ties of individualising risk and benefit in asingle patient on the basis of large scale trials.

In addition to the clinical researchnetworks described in the new NHSresearch and development strategy,adequate project and programme fundingmust be made available to support theresearch that Rothwell identifies. Thisincludes follow-up studies of large cohortsof patients after the completion of therapeu-tic trials, health economic evaluations ofinterventions, studies of the success orotherwise of getting newly proved interven-tions into practice, research aimed atimproving understanding of patients’ will-ingness to accept therapeutic and preventiveinterventions, and high quality healthservices research to define the optimumways of providing new services.

There is an urgency about this. Theimpending research assessment exercise hasled to quick-fix institutional solutions, includ-ing playing the research star transfer marketand redistributing clinical academic fundingto support laboratory based research. Non-clinical researchers underestimate the needfor clinical research, partly because they sim-ply can’t see it and partly because it is likely tobe uncomfortable in terms of their ownpriorities. They need to understand thattranslational doesn’t simply mean getting theprotein out of the test tube into the zebra fish,but getting the therapeutic intervention intothe patient and the population.Roger Jones Wolfson professor of general practiceKing’s College London School of Medicine,London SE11 [email protected]


1 Rothwell PM. Medical academia is failing patients andclinicians. BMJ 2006;332:863-4. (15 April.)

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letters to editor hepworth interphone 4-29-06

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