- Email: [email protected]
The teaching of appropriate use of antimicrobials
CORRESPONDENCE
Decision analysis in patients’ care Sir—We strongly believe that behaviour described by Glyn Elwyn and colleagues (Aug 18, p 571)1 about decision analysis in patients’ care is also important for children affected with severe diseases. Our suggestion is that the process of obtaining informed consent should always be managed as negotiated shared consent. The evolutive characteristics of cognitive processes in children and adolescents, the ego defence mechanisms, the coping behaviour activated in the relation among the child patient, his or her family, and the physicians must all be taken into account. Many parents have told us that the informed consent procedure was useful, although commonly confusing. They found that discussions were more helpful than the information they read in the consent forms. Satisfaction was not related to ethnic origin or level of education. We believe that paediatricians must be trained in this topic in addition to their technical studies. They need to acquire an adequate knowledge on communication, relational features, and ethics. Our goal is for paediatricians to become competent even in the family system health model,2 theory of social representation,3 problem-based learning,4 and in communication skills.5 *Ezio F Casari, Luisa M E Massimo Clinical Psychology Unit, University of Genova, “G Gaslini” Research Children’s Hospital, 16147 Genova, Italy 1
2
3
4 5
Elwyn G, Edwards A, Eccles M, Rovner D. Decision analysis in patient care. Lancet 2001; 358: 571–74. Rolland J. Toward a psychosocial typology of chronic and life-threatening illness. Family Sys Med 1984, 2: 245–62. Moscovici S, Duveen G. Social representations: studies in social psychology. Oxford: Blackwell Publishers, 2000. Guilbert JJ. Educational handbook for health personel, 6th edn. Geneva: WHO; 1987. Curry RH, Makoul G. An active learning approach to basic clinical skills. Acad Med 1996; 71: 41–44.
From a moral point of view, this is a consequentialist model.2 The shape of decision analysis, looking mainly towards the outcomes explicitly exhibit this end-oriented (teleological) thought. However, competitive models do exist. With a deontological (rule-based) frame, a good decision is a decision applying a principle, irrespective of the consequences, but different principles may lead to different best decisions. For example, a decision is the right one if the person who takes it is entitled to do it. In our western society, under the paradigm of autonomy, a patient’s decision is, merely by itself, the right decision subject to, among other criteria,3 the prerequisite of information. With another pattern, a decision may be known to be right because it comes from a formal consensus statement. The decision is the right one because the right process had been followed, the right people involved, the right timing provided. When facing a situation with few or inconclusive data on the probability of outcome (clinical research) or outcome with a wide range of value (eg, prophylactic mastectomy) or with merely the kind of outcome unknown (preliminary research), consequentialism is even weaker and the alternative decision patterns rather favoured. Currently we are living under three models related to three key questions: an end-oriented model that answers the question “why this decision”; a model based on autonomy that answers the question “who takes it”; and one centered on the process that answers the question “how was it done”. Complex interactions,4 combinations, result from that or conflicts5 coexistence, without dominance, of these models. François Eisinger Institut Paoli-Calmettes INSERM U379-E9939, 13009 Marseille, France (e-mail: [email protected]) 1
2
Sir—How could we decide whether a decision is right or not? How could we pass a judgment on a judgment? Are the rules or criteria used at level 1 (the decision) still relevant at level 2 (the decision on the decision, or metadecision)? Since ethics may be defined, as the way decisions (behaviours) should be taken, moral theories could help to answer these questions. According to Glyn Elwyn and colleagues’ decision analysis,1 a decision is the right one if its expected consequences are the most desirable.
THE LANCET • Vol 358 • December 22/29, 2001
3
4
5
Elwyn G, Edwards A, Eccles M, Rovner D. Decision analysis in patient care. Lancet 2001; 358: 571–74. Brody BA. Moral theory and moral judgments in biomedical ethics. In: Brody BA, ed. Moral theory and moral judgments in biomedical ethics. Dordrecht: Kluwer Academic Publishers, 1988: 1–12. Muramoto O. Bioethics of the refusal of blood by Jehovah’s Witnesses, part 3: a proposal for a don’t-ask-don’t-tell policy. J Med Ethics 1999; 25: 463–68. Eisinger F, Geller G, Burke W, Holtzman N. Cultural basis for differences between US and French clinical recommendations for women at increased risk of breast and ovarian cancer. Lancet 1999; 353: 919–20. Glick SM. Unlimited human autonomy: a cultural bias? N Engl J Med 1997; 336: 954–56.
The teaching of appropriate use of antimicrobials Sir—The reports of the House of Lords Select Committee on Science and Technology, Resistance to Antibiotics and other Antimicrobial Agents,1 and the UK Standing Medical Advisory Committee, The Path of Least Resistance,2 emphasise the importance of teaching concerned with the appropriate use of antimicrobials at undergraduate level. We did a postal survey of UK medical schools and the University of St Andrews, which offers a 3-year preclinical course, on teaching and learning on this topic. We received replies from 17 (71%) of 24 institutions. The contact times allocated to teaching about the rational use of antimicrobials (as opposed to pharmacology, mode of action, &c) varied greatly (range 0·5–22·0 h). Although many respondents commented that students might receive information on the use and misuse of antimicrobials during teaching time devoted to other topics and while undertaking clinical placements, none was able to quantify this time. All institutions that responded, except one, reported that lectures, generally in years 2 and 3 were the main method of teaching, but in some cases, lectures were supplemented with tutorials or problem-based learning exercises (individually or in groups). One medical school stated that students learned the principles and practice of antimicrobial use through a selfdirected learning module throughout the undergraduate course. In hospitals, antimicrobials are frequently prescribed by inexperienced junior medical staff with insufficient guidance from more senior colleagues.3 This situation underscores the importance of teaching medical undergraduates about good antimicrobial prescribing. However, our results suggest that teaching methods and time devoted to this topic vary widely across medical schools. The threat to public health posed by antimicrobial resistance is such that national guidelines to help dental and medical schools establish core curricula for teaching the appropriate use of antimicrobials, and the potential consequences of misuse, at undergraduate level should be developed. However, chronic under-resourcing of academic units should be addressed if this teaching is to be delivered effectively. One report concludes that UK “[academic] medical microbiology
2173
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
departments, with a few exceptions, are in a state of torpor and are not able to meet the challenges and excitement of the discipline”.4 This difficulty, coupled with the continued reduction in the numbers of chairs of academic microbiology in the UK does not bode well for the future of learning and teaching in such a key component of the undergraduate curriculum. *Kevin G Kerr, Claire Ottery, Peter M Hawkey, Trudie E Roberts *Division of Microbiology, University of Leeds, Leeds LS2 9JT, UK; Division of Immunity and Infection, Medical School, Birmingham; and Medical Education Unit, Leeds University School of Medicine, Leeds 1
2
3
4
House of Lords Committee on Science and Technology. Session 1997–8, 7th report: resistance to antibiotics and other antimicrobial agents. London: Stationery Office, 1998. Standing Medical Advisory Committee, Sub-Group on Antimicrobial Resistance. The path of least resistance. London: Department of Health, 1998. Seaton RA, Nathwani D. Rationale for sepsis management in immunocompetent adults. J R Coll Phys Edin 2000; 30: 224–29. Working Group on Academic Bacteriology. Academic bacteriology in the 21st century. London: Academy of Medical Sciences, 2001.
Usefulness of foreign aid for health care in lessdeveloped countries Sir—Nathan Ford and Ellen ‘t Hoen (Aug 18, p 578)1 criticise the G8 governments for committing a paltry US$1·3 billion to the proposed Global Health Fund for HIV/AIDS, when UN Director General Kofi Annan calls for $10 billion. No relation has been shown between the amount of foreign aid and the lowering of HIV/AIDS infection and mortality rates, despite billions of dollars spent on HIV/AIDS programmes by international development agencies, similar to general poverty reduction.2 Countries implement reforms when they choose to, not because of aid funds offered or withheld.3 Thus, although foreign assistance has an important role, it can be absorbed only when the governments of poor countries effectively invest in economic and social development. WHO Director General Gro Harlem Brundtland has underscored that, for health, “. . . ultimate responsibility for the performance of a country’s health care system lies with government.” She notes that many countries are falling short of their performance potential, and that they must avoid turning a blind eye to a system’s failings.4
2174
Less-developed countries must, therefore, spend more on health care and create the conditions for a healthy private sector. The poorest countries in Africa, especially, must enlarge their health-care budgets—the funds are there. Most African countries devote a higher proportion of their gross national product to military rather than public expenditures on health.5 As a second issue, Ford and ‘t Hoen are concerned that if brand-name drugs are used, lives will not be saved and taxpayers’ money will go to company shareholders of non-generic pharmaceutical companies. Their solution is to buy drugs from generic companies. To rely exclusively on the cheapest medicines is not good practice. High resistance can develop to older lower-priced antimalaria drugs and antibiotics, and use of first-line more-expensive drugs might be better. The purchase of cheaper generic drugs will probably attract more manufacturers from less-developed countries. Safety and quality standards are less developed in many such countries, and counterfeit drugs more prevalent. About half of sampled drugs in Nigeria are substandard, as are just more than a third of sampled tablets from shops in various parts of southeast Asia, sometimes with no drug at all. The Global Health Fund will have to cover the expenses of testing for bioequivalency and good manufacturing practices for drugs purchased in countries with underdeveloped regulatory environments. In addition to drug safety and quality convenience, timeliness, and reduced side-effects are critical to patients’ adherence and health outcomes. Use of more expensive drugs with fewer sideeffects and fewer pills to take frequently leads to better adherence and earlier cure at a lower total cost. To keep prices low, Ford and ‘t Hoen promote various regulatory and trade mechanisms, including compulsory licensing, parallel imports, and technology transfer. However, the focus on low-cost drugs does not seem to be about providing the best supply of medicines for treating sick people in the most cost-effective way. Brazil, for example, did not issue a compulsory licence because they believed it was not in the best medical interest of their patients. *Carol C Adelman, Jeremiah Norris Hudson Institute, Washington, DC 20036, USA (e-mail: [email protected])
1
Ford N, ‘t Hoen E. The Global Health Fund: moral imperative or industry subsidy? Lancet 2001; 358: 578.
2
3
4 5
Hay R. International aid: economics and charity, no. 1. Oxford: Oxford Policy Institute, 2000. International Financial Institution Advisory Commission. Report to US Congress on reform of the development banks and the international finance regime. Washington: IFIAC, 2000. Message from the Director General: World Health Report 2000. Geneva: WHO, 2000. World Bank. World Development Report 1999/2000. New York: Oxford University Press, 2000.
More life for Lifeline Sir—One of your columns seems to be losing its bite—Lifeline—although you express the intention to educate or entertain your readers. Initially, Lifeline certainly was on the entertaining and sometimes the educative side. I vividly remember ascerbic questions such as “Whom, apart from Margaret Thatcher, do you despise most?”, and finely tuned answers (on being asked “how do you relax?”) such as “A holiday once a year and, more frequently, sex”, or such thoughtful comments as “Forget the scientific approach to clinical decisionmaking, and you are a menace to your patients; forget the human approach, and you ignore the aim of medicine”. What do we have now? Many responses reflecting experiences and thoughts in a readable way continue to appear. Increasingly, however, I note a tedious melange of political correctness and irrelevant answers, which in the consulting business, are aptly named non-brainers. I have noticed amazing insights such as “the best public health is based on sound science, not moral beliefs”, or, “in selecting your area of research, go only for the important problems”, “Don’t try to be God, just work hard to be human”. These are answers to which I am inclined to comment “hear, hear”. Are readers really interested to read about the number of citations the interviewee has had? There has been a decline in good laughs, new insights or stimulating thoughts, and there is little to be remembered. It might be helpful to ask more controversial questions and leave less space than at present to introduce the respondent—do we really need a picture and the title of the latest published book? This move would allow the respondent to explain why they have recommended a certain book or film. Perhaps the editors could gently push for more sharp or witty comments. More life for Lifeline please. Konrad Obermann Galvanistr 15, 10587 Berlin, Germany
THE LANCET • Vol 358 • December 22/29, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Decision analysis in patients’ care Sir—We strongly believe that behaviour described by Glyn Elwyn and colleagues (Aug 18, p 571)1 about decision analysis in patients’ care is also important for children affected with severe diseases. Our suggestion is that the process of obtaining informed consent should always be managed as negotiated shared consent. The evolutive characteristics of cognitive processes in children and adolescents, the ego defence mechanisms, the coping behaviour activated in the relation among the child patient, his or her family, and the physicians must all be taken into account. Many parents have told us that the informed consent procedure was useful, although commonly confusing. They found that discussions were more helpful than the information they read in the consent forms. Satisfaction was not related to ethnic origin or level of education. We believe that paediatricians must be trained in this topic in addition to their technical studies. They need to acquire an adequate knowledge on communication, relational features, and ethics. Our goal is for paediatricians to become competent even in the family system health model,2 theory of social representation,3 problem-based learning,4 and in communication skills.5 *Ezio F Casari, Luisa M E Massimo Clinical Psychology Unit, University of Genova, “G Gaslini” Research Children’s Hospital, 16147 Genova, Italy 1
2
3
4 5
Elwyn G, Edwards A, Eccles M, Rovner D. Decision analysis in patient care. Lancet 2001; 358: 571–74. Rolland J. Toward a psychosocial typology of chronic and life-threatening illness. Family Sys Med 1984, 2: 245–62. Moscovici S, Duveen G. Social representations: studies in social psychology. Oxford: Blackwell Publishers, 2000. Guilbert JJ. Educational handbook for health personel, 6th edn. Geneva: WHO; 1987. Curry RH, Makoul G. An active learning approach to basic clinical skills. Acad Med 1996; 71: 41–44.
From a moral point of view, this is a consequentialist model.2 The shape of decision analysis, looking mainly towards the outcomes explicitly exhibit this end-oriented (teleological) thought. However, competitive models do exist. With a deontological (rule-based) frame, a good decision is a decision applying a principle, irrespective of the consequences, but different principles may lead to different best decisions. For example, a decision is the right one if the person who takes it is entitled to do it. In our western society, under the paradigm of autonomy, a patient’s decision is, merely by itself, the right decision subject to, among other criteria,3 the prerequisite of information. With another pattern, a decision may be known to be right because it comes from a formal consensus statement. The decision is the right one because the right process had been followed, the right people involved, the right timing provided. When facing a situation with few or inconclusive data on the probability of outcome (clinical research) or outcome with a wide range of value (eg, prophylactic mastectomy) or with merely the kind of outcome unknown (preliminary research), consequentialism is even weaker and the alternative decision patterns rather favoured. Currently we are living under three models related to three key questions: an end-oriented model that answers the question “why this decision”; a model based on autonomy that answers the question “who takes it”; and one centered on the process that answers the question “how was it done”. Complex interactions,4 combinations, result from that or conflicts5 coexistence, without dominance, of these models. François Eisinger Institut Paoli-Calmettes INSERM U379-E9939, 13009 Marseille, France (e-mail: [email protected]) 1
2
Sir—How could we decide whether a decision is right or not? How could we pass a judgment on a judgment? Are the rules or criteria used at level 1 (the decision) still relevant at level 2 (the decision on the decision, or metadecision)? Since ethics may be defined, as the way decisions (behaviours) should be taken, moral theories could help to answer these questions. According to Glyn Elwyn and colleagues’ decision analysis,1 a decision is the right one if its expected consequences are the most desirable.
THE LANCET • Vol 358 • December 22/29, 2001
3
4
5
Elwyn G, Edwards A, Eccles M, Rovner D. Decision analysis in patient care. Lancet 2001; 358: 571–74. Brody BA. Moral theory and moral judgments in biomedical ethics. In: Brody BA, ed. Moral theory and moral judgments in biomedical ethics. Dordrecht: Kluwer Academic Publishers, 1988: 1–12. Muramoto O. Bioethics of the refusal of blood by Jehovah’s Witnesses, part 3: a proposal for a don’t-ask-don’t-tell policy. J Med Ethics 1999; 25: 463–68. Eisinger F, Geller G, Burke W, Holtzman N. Cultural basis for differences between US and French clinical recommendations for women at increased risk of breast and ovarian cancer. Lancet 1999; 353: 919–20. Glick SM. Unlimited human autonomy: a cultural bias? N Engl J Med 1997; 336: 954–56.
The teaching of appropriate use of antimicrobials Sir—The reports of the House of Lords Select Committee on Science and Technology, Resistance to Antibiotics and other Antimicrobial Agents,1 and the UK Standing Medical Advisory Committee, The Path of Least Resistance,2 emphasise the importance of teaching concerned with the appropriate use of antimicrobials at undergraduate level. We did a postal survey of UK medical schools and the University of St Andrews, which offers a 3-year preclinical course, on teaching and learning on this topic. We received replies from 17 (71%) of 24 institutions. The contact times allocated to teaching about the rational use of antimicrobials (as opposed to pharmacology, mode of action, &c) varied greatly (range 0·5–22·0 h). Although many respondents commented that students might receive information on the use and misuse of antimicrobials during teaching time devoted to other topics and while undertaking clinical placements, none was able to quantify this time. All institutions that responded, except one, reported that lectures, generally in years 2 and 3 were the main method of teaching, but in some cases, lectures were supplemented with tutorials or problem-based learning exercises (individually or in groups). One medical school stated that students learned the principles and practice of antimicrobial use through a selfdirected learning module throughout the undergraduate course. In hospitals, antimicrobials are frequently prescribed by inexperienced junior medical staff with insufficient guidance from more senior colleagues.3 This situation underscores the importance of teaching medical undergraduates about good antimicrobial prescribing. However, our results suggest that teaching methods and time devoted to this topic vary widely across medical schools. The threat to public health posed by antimicrobial resistance is such that national guidelines to help dental and medical schools establish core curricula for teaching the appropriate use of antimicrobials, and the potential consequences of misuse, at undergraduate level should be developed. However, chronic under-resourcing of academic units should be addressed if this teaching is to be delivered effectively. One report concludes that UK “[academic] medical microbiology
2173
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
departments, with a few exceptions, are in a state of torpor and are not able to meet the challenges and excitement of the discipline”.4 This difficulty, coupled with the continued reduction in the numbers of chairs of academic microbiology in the UK does not bode well for the future of learning and teaching in such a key component of the undergraduate curriculum. *Kevin G Kerr, Claire Ottery, Peter M Hawkey, Trudie E Roberts *Division of Microbiology, University of Leeds, Leeds LS2 9JT, UK; Division of Immunity and Infection, Medical School, Birmingham; and Medical Education Unit, Leeds University School of Medicine, Leeds 1
2
3
4
House of Lords Committee on Science and Technology. Session 1997–8, 7th report: resistance to antibiotics and other antimicrobial agents. London: Stationery Office, 1998. Standing Medical Advisory Committee, Sub-Group on Antimicrobial Resistance. The path of least resistance. London: Department of Health, 1998. Seaton RA, Nathwani D. Rationale for sepsis management in immunocompetent adults. J R Coll Phys Edin 2000; 30: 224–29. Working Group on Academic Bacteriology. Academic bacteriology in the 21st century. London: Academy of Medical Sciences, 2001.
Usefulness of foreign aid for health care in lessdeveloped countries Sir—Nathan Ford and Ellen ‘t Hoen (Aug 18, p 578)1 criticise the G8 governments for committing a paltry US$1·3 billion to the proposed Global Health Fund for HIV/AIDS, when UN Director General Kofi Annan calls for $10 billion. No relation has been shown between the amount of foreign aid and the lowering of HIV/AIDS infection and mortality rates, despite billions of dollars spent on HIV/AIDS programmes by international development agencies, similar to general poverty reduction.2 Countries implement reforms when they choose to, not because of aid funds offered or withheld.3 Thus, although foreign assistance has an important role, it can be absorbed only when the governments of poor countries effectively invest in economic and social development. WHO Director General Gro Harlem Brundtland has underscored that, for health, “. . . ultimate responsibility for the performance of a country’s health care system lies with government.” She notes that many countries are falling short of their performance potential, and that they must avoid turning a blind eye to a system’s failings.4
2174
Less-developed countries must, therefore, spend more on health care and create the conditions for a healthy private sector. The poorest countries in Africa, especially, must enlarge their health-care budgets—the funds are there. Most African countries devote a higher proportion of their gross national product to military rather than public expenditures on health.5 As a second issue, Ford and ‘t Hoen are concerned that if brand-name drugs are used, lives will not be saved and taxpayers’ money will go to company shareholders of non-generic pharmaceutical companies. Their solution is to buy drugs from generic companies. To rely exclusively on the cheapest medicines is not good practice. High resistance can develop to older lower-priced antimalaria drugs and antibiotics, and use of first-line more-expensive drugs might be better. The purchase of cheaper generic drugs will probably attract more manufacturers from less-developed countries. Safety and quality standards are less developed in many such countries, and counterfeit drugs more prevalent. About half of sampled drugs in Nigeria are substandard, as are just more than a third of sampled tablets from shops in various parts of southeast Asia, sometimes with no drug at all. The Global Health Fund will have to cover the expenses of testing for bioequivalency and good manufacturing practices for drugs purchased in countries with underdeveloped regulatory environments. In addition to drug safety and quality convenience, timeliness, and reduced side-effects are critical to patients’ adherence and health outcomes. Use of more expensive drugs with fewer sideeffects and fewer pills to take frequently leads to better adherence and earlier cure at a lower total cost. To keep prices low, Ford and ‘t Hoen promote various regulatory and trade mechanisms, including compulsory licensing, parallel imports, and technology transfer. However, the focus on low-cost drugs does not seem to be about providing the best supply of medicines for treating sick people in the most cost-effective way. Brazil, for example, did not issue a compulsory licence because they believed it was not in the best medical interest of their patients. *Carol C Adelman, Jeremiah Norris Hudson Institute, Washington, DC 20036, USA (e-mail: [email protected])
1
Ford N, ‘t Hoen E. The Global Health Fund: moral imperative or industry subsidy? Lancet 2001; 358: 578.
2
3
4 5
Hay R. International aid: economics and charity, no. 1. Oxford: Oxford Policy Institute, 2000. International Financial Institution Advisory Commission. Report to US Congress on reform of the development banks and the international finance regime. Washington: IFIAC, 2000. Message from the Director General: World Health Report 2000. Geneva: WHO, 2000. World Bank. World Development Report 1999/2000. New York: Oxford University Press, 2000.
More life for Lifeline Sir—One of your columns seems to be losing its bite—Lifeline—although you express the intention to educate or entertain your readers. Initially, Lifeline certainly was on the entertaining and sometimes the educative side. I vividly remember ascerbic questions such as “Whom, apart from Margaret Thatcher, do you despise most?”, and finely tuned answers (on being asked “how do you relax?”) such as “A holiday once a year and, more frequently, sex”, or such thoughtful comments as “Forget the scientific approach to clinical decisionmaking, and you are a menace to your patients; forget the human approach, and you ignore the aim of medicine”. What do we have now? Many responses reflecting experiences and thoughts in a readable way continue to appear. Increasingly, however, I note a tedious melange of political correctness and irrelevant answers, which in the consulting business, are aptly named non-brainers. I have noticed amazing insights such as “the best public health is based on sound science, not moral beliefs”, or, “in selecting your area of research, go only for the important problems”, “Don’t try to be God, just work hard to be human”. These are answers to which I am inclined to comment “hear, hear”. Are readers really interested to read about the number of citations the interviewee has had? There has been a decline in good laughs, new insights or stimulating thoughts, and there is little to be remembered. It might be helpful to ask more controversial questions and leave less space than at present to introduce the respondent—do we really need a picture and the title of the latest published book? This move would allow the respondent to explain why they have recommended a certain book or film. Perhaps the editors could gently push for more sharp or witty comments. More life for Lifeline please. Konrad Obermann Galvanistr 15, 10587 Berlin, Germany
THE LANCET • Vol 358 • December 22/29, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.