Transcript: Twitter Journal Club Second Meeting 8pm, Sunday 12th June 2011

Geoffrey Rose (1981) Strategy of prevention: lessons from cardiovascular disease, BMJ - Available at http://t.co/Grhzf6d Hosted by Fi Douglas and Natalie Silvey

twitjournalclub Right, tweeps, welcome to the second Twitter Journal Club, which this week will be discussing Geoffrey Rose's Prevention Paradox. #TwitJC -8:00 PM behrouzn RT @twitjournalclub: Right, tweeps, welcome to the second Twitter Journal Club, which this week will be discussing Geoffrey Rose's Prevention Paradox. #TwitJC -8:01 PM twitjournalclub Please have a look at our blog if you want to familiarise yourself with the paper: http://twitjc.wordpress.com #TwitJC -8:02 PM davecurtis314 First point seems to have four questions? #twitjc -8:03 PM davecurtis314 Sorry, five. #twitjc -8:03 PM petermbenglish Interesting choice for a journal club paper. Usually I've done studies. This paper is more of an editorial, floating an idea #TwitJC -8:04 PM doctorblogs now: @twitjournalclub Week2: points http://wp.me/p1BLwH-1j PDF http://1.usa.gov/iM7Ybh Prevention Paradox BMJ;1981 #twitjc -8:04 PM frolickingfood Joining in by iPhone this evening so bear with me! Dave #TwitJC -8:04 PM petermbenglish This means that the usual criteria for critiquing a [study] paper are not applicable #TwitJC -8:05 PM twitjournalclub If we can start with introductions... Fi will be presenting this paper, tweeting from @fidouglas. #TwitJC -8:05 PM dtwatkin Sorry I'm late. #twitjc -8:05 PM northern_doctor @petermbenglish Agreed - more of a general debate, but some interesting stuff there! #twitjc -8:06 PM amitns GP registrar #twitjc -8:06 PM fidouglas Hi, I'm Fi, medical student at Cambridge going into my 3rd year in October. Currently based in a developmental biology lab. #TwitJC -8:06 PM themattmak #TwitJC agree with @petermbenglish - will be interesting to 'critique' as not a study as such -8:06 PM silv24 Hi, Natalie, F1 in gastroenterology at the moment #twitjc -8:06 PM anaestheticdoc Hia consultant anaesthetist. #twitjc -8:07 PM northern_doctor I'm Mark, ST3 in Geris & stroke, currently working as TRF #twitjc -8:07 PM carlylou I'm Carly I'm a nurse & student health visitor, so v interested in public health & prevention #twitjc -8:07 PM fidouglas See http://t.co/xr8CYfG for why I think this is an important paper to discuss. #TwitJC 8:07 PM

dtwatkin David, paediatrics specialty trainee. #twitjc -8:07 PM medicscott Scott, medical student, just finished 1st Year at Warwick. #TwitJC -8:07 PM themattmak #TwitJC hi all, I'm Matt, a medical SHO based in London, will probably spend the evening lurking and learning from much cleverer people! -8:08 PM DrDLittle Oops my wife was logged in. First iPhone fail of the evening. I'm Dave, soon to be radiology trainee #TwitJC -8:08 PM aj0610 Sorry slightly late! AJ, 4th year medic in Aberdeen #twitjc -8:08 PM davecurtis314 Consultant psychiatrist. Do statistical and psychiatric genetics. #twitjc -8:08 PM NHS_GP Hi Twoctors, I hadn't read this paper before. Really good, and as a GP very applicable. Re all statins we are meant to prescribe #TwitJC -8:08 PM Hamstav Denis, pharmacist in Montral #TwitJC -8:08 PM amitns Agree this is an interesting and important paper to discuss, thoug unconventional #twitjc 8:08 PM davecurtis314 Hardest part so far is spelling #twitjc -8:08 PM DrDLittle @amitns one of the great points of #TwitJC -8:09 PM fidouglas Please remember this paper was chosen back when we thought 5 people were going to show up for #TwitJC, hence it being a bit unconventional! -8:09 PM drpaulmorgan Hi, ICU consultant. May not interact much as dinner nearly ready! #twitjc -8:09 PM amitns RT @DrDLittle: @amitns one of the great points of #TwitJC Couldn't agree more -8:10 PM davecurtis314 Um, so, first point seems to ask five questions? #twitjc -8:10 PM northern_doctor RT @fidouglas: See http://t.co/xr8CYfG for why I think this is an important paper to discuss. <-- Good summary! #twitjc -8:10 PM fidouglas Nonetheless, I still think it is immensely important, especially today when there is so much preventive medicine being prescribed. #TwitJC -8:10 PM davecurtis314 I think the paper misses the point is that the high risk patient has most to gain. #twitjc -8:11 PM fidouglas The first area we're going to discuss, is what this paper tells us, and how that can affect clinical practice. Any thoughts? #TwitJC -8:11 PM Trisha_the_doc Hi, I'm Trisha, a Med of Elderly consultant in Edinburgh. Good paper very relevant. I will still stop statins in 99 yr olds tho! #twitjc -8:11 PM petermbenglish This was a bright shiny new idea when the paper was published. Has it become tarnished in the mean time? #TwitJC -8:11 PM GabrielScally Intros?? Hello, I'm a Regional Director of PH. That means I'm too busy to read new papers but old enough to remember the old ones! #twitjc -8:11 PM themattmak @fidouglas I agree. Especially with all the news about measles at the moment, I feel this will always be an important paper #TwitJC -8:12 PM northern_doctor Population vs patient risk prevention discussion very interesting (& relevant to many areas of clinical practice) #twitjc -8:12 PM

silv24 Most interventions in preventative medicine still seem to conform to this paradox - statins are a perfect example #twitjc -8:13 PM GarethEnticott @fidouglas Rose was v influential for sociology of health and illness too. But also way ahead of Thaler and Sunstein "Nudge" theory #twitjc -8:13 PM fidouglas How do the points outline by Rose affect e.g. the threshold cholesterol concentrations at which doctors prescribe statins? #TwitJC -8:13 PM petermbenglish @themattmak Can you explain what you mean about measles? #TwitJC -8:13 PM davecurtis314 I agree still relevant. Many people still think best to focus on high risk patients. #twitjc -8:13 PM northern_doctor @GabrielScally Great that we've got someone to give us a PH point of view for this paper! #twitjc -8:14 PM laikas Hi, I'm Jacqueline , medical librararian (medical biologist by education) - the Netherlands #twitjc -8:14 PM amcunningham @fidouglas ok- I'll join in. I@m Anne Marie- gp, masters in public health , and interested in great doctors and improving health #twitjc -8:15 PM davecurtis314 This is the argument for a polypill which everybody takes? #twitjc -8:15 PM silv24 Why do you think people still focus so much on high risk patients @davecurtis314 #twitjc 8:15 PM petermbenglish There seem to me to be (at least) two related points .What is the public health benefit; what is the benefit to the indiv #twitjc -8:15 PM NHS_GP acceptability of drug harm in high risk/benefit pt cf med risks /benefit and the acceptability of harms not stressed enough I think #TwitJC -8:15 PM petermbenglish And how do we pitch this to the low risk patient. #twitjc -8:16 PM DrDLittle Problem with this whole idea is than human nature makes it difficult to comprehend longterm benefits when no tangible change #TwitJC -8:16 PM Puffles2010 @silv24: Why do you think people still focus so much on high risk patients @davecurtis314 #twitjc *Puffles asks which people?* -8:16 PM GabrielScally Medical training based on treating the individual. #TwitJC -8:16 PM thilb2 RT @northern_doctor: RT @fidouglas: See http://t.co/xr8CYfG for why I think this is an important paper to discuss. <-- Good summary! #twitjc -8:16 PM aj0610 Felt that the paper overlooked the risk to the individual in favour of benefit to population #twitjc -8:16 PM thilb2 RT @silv24: Most interventions in preventative medicine still seem to conform to this paradox - statins are a perfect example #twitjc -8:16 PM amcunningham @fidouglas for statins to be beneficial and justifiable, we need evidence that risk of events is correlated with cholesterol level #twitjc -8:16 PM fidouglas @davecurtis314 But Rose argues that that carries risk. Low risk people have low chance of benefit, but same chance of side FX. #twitjc -8:16 PM The_Netherlands RT @laikas: Hi, I'm Jacqueline , medical librararian (medical biologist by education) - the Netherlands #twitjc -8:16 PM

GarethEnticott Rose's book http://t.co/0HcUzFF goes through ideas in more depth #twitjc -8:16 PM DrDLittle @silv24 @davecurtis314 because it is much more satisfying in the short term? #TwitJC 8:16 PM davecurtis314 People focus on high risk patients because they don't understand Rose. But for individual patient this is actually best. #twitjc -8:17 PM adriamarilla #twitjc relevant paper show us the importance of an appropriate and preventive strategy -8:17 PM laikas I wonder... was involved in #meded. On basis of SR it was clear that tert/sec prevention with statines worked, but NOT primary... #twitjc -8:17 PM amcunningham @fidouglas and that reducing cholesterol level with statin- even at TC of 5 say, will also reduce risk of CV event #twitjc -8:17 PM petermbenglish I think the importance of the pyschology has become more obvious. Taking tabs turns you into a patient, for many people. #TwitJC -8:17 PM carotomes #twitjc I'm a public health registrar, so i'm all about population health. Although the Rose paper is dated it couldnt' be more relevant -8:17 PM davecurtis314 High risk patients get more benefit. But population risk reduced by applying intervention to all. #twitjc -8:18 PM NHS_GP Big difference between vaccines where herd immunity vital and statins where individual unlikey to benefit and no protection society #TwitJC -8:18 PM aj0610 @laikas NNT for 2ndry etc was about 20 whereas 1ry more like 200+ #twitjc -8:18 PM MsPhelps Intro: I'm a medical information specialist (academic hospital), also from the Netherlands (hi @laikas!) #twitjc -8:18 PM northern_doctor @amcunningham Not necessarily - research suggests statins may have other benefits not directly related to total chol #twitjc -8:18 PM silv24 Need to examine the risks as well as the benefits when giving preventative treatment, that has to apply to every individual #twitjc -8:18 PM kevfrost @silv24 #twitjc because with shared decision making, health professionals are looking at individual risk benefits not population ones? -8:18 PM Dr_Stuart Sorry I can't make it to @TwitJournalClub this week, feel free to listen to Radio 1 in the background! ;-) #TwitJC -8:18 PM The_Netherlands RT @MsPhelps: Intro: I'm a medical information specialist (academic hospital), also from the Netherlands (hi @laikas!) #twitjc -8:18 PM aj0610 @NHS_GP Absolutely. Plus what is cost to society of SEs from statins? #twitjc -8:18 PM davecurtis314 Often "risks"/"costs" understimated. #twitjc -8:19 PM laikas @davecurtis314 that does depend on the intervention and the target disease doesn't it? #twitjc -8:19 PM amcunningham @northern_doctor well, we are calculating risk reduction based on CV events... #twitjc -8:19 PM Trisha_the_doc @drpaulmorgan I'm cooking ours at the same time! Multitasking during #twitjc 8:19 PM

anaestheticdoc Anyone mentioned cost. What the financial implications of treating everyone. Is it cost effective. #twitjc -8:19 PM northern_doctor @amcunningham Yes, but we know that statins reduce cardiovascular events, so focus should not solely be on chol #twitjc -8:19 PM amitns @kevfrost @silv24 SDM is where I think many guidelines disappoint & confuse #twitjc -8:19 PM fidouglas How can we go about deciding on where to draw the line between benefit to the individual vs benefit to the population as a whole? #twitjc -8:19 PM davecurtis314 If RR constant high risk individuals get most benefit. #twitjc -8:20 PM NHS_GP @silv24 Exactly. Do we yet know the risks of long term statin use in women? Who are unlikely to benefit individually. #TwitJC -8:20 PM alijmbacon Interesting that small individual benefit plays the other way in e.g. Palliative chemo (with greater potential harms) #twitjc -8:20 PM themattmak @amcunningham @fidouglas Exactly! And there's plenty of evidence from secondary prevention trials in cholesterol lowering #TwitJC -8:20 PM amcunningham I read Rose as suggesting that it is better to try and improve health of entire population eg more exercise raher than statins #twitjc -8:20 PM silv24 Primary prevention means treating more people with fairly low benefit to individual, this changes with secondary prevention #twitjc -8:20 PM davecurtis314 Could be read as saying give statins to all. #twitjc -8:20 PM fidouglas @amcunningham Yes, in the last part of the paper he distinguishes been normalisation interventions and medications. #twitjc -8:20 PM Trisha_the_doc RT @davecurtis314: I think the paper misses the point is that the high risk patient has most to gain. #twitjc -8:21 PM petermbenglish @NHS_GP Yes. And vaccination is a one-off (or at least, occasional) event; whereas statins have to be taken daily. #twitjc -8:21 PM GabrielScally The point is that there are times when either or both strategies are appropriate. It needs judgement. #TwitJC -8:21 PM northern_doctor Using statins as an example, NNT is 27, NNH (serious events) is 3400! #twitjc 8:21 PM davecurtis314 Doctors forget that people really _hate_ having injections. #twitjc -8:21 PM laikas @northern_doctor: @amcunningham Focus should NOT at ALL be on cholesterol = surrogate marker #twitjc -8:21 PM fidouglas @davecurtis314 I disagree - he says "consequently we cannot accept long term mass preventive medication" #twitjc -8:21 PM Trisha_the_doc @davecurtis314 But we need to do both to save more lives... #twitjc -8:21 PM laikas RT @GabrielScally: The point is that there are times when either or both strategies are appropriate. It needs judgement. #twitjc -8:21 PM rodedun @anaestheticdoc well said, it's important to remember wilson's screening criteria #twitjc 8:21 PM

danjrharvey Interventions with limited SE for individual (seat belts) will remain ethical & practical where drugs (statins) will not #twitjc -8:22 PM carotomes what are your thoughts on the polypill? A one-for-all drug which effectively would target prevention on a population level #twitjc -8:22 PM davecurtis314 K, point taken. Not what others propose though. #twitjc -8:22 PM aj0610 @GabrielScally Like everything in medicine, it's essential to look at each case individually #twitjc -8:22 PM amcunningham I don't think that Rose would argue for polypill without a great deal more evidence than we have now #twitjc -8:22 PM pawlu Rose has already been implemented time and again to good use: eg: Fluoride in water supplyto improve population dentition. #twitJC -8:22 PM Hamstav If intervention is based on education/peer pressure and benefits are not tangible to the indiv. It can be hacked for other puposes #TwitJC -8:22 PM fidouglas I think Rose is opposed to wide-scale long-term pharmaceutical intervention, but instead emphasises importance of e.g. lifestyle. #twitjc -8:22 PM Trisha_the_doc RT @GabrielScally: The point is that there are times when either or both strategies are appropriate. It needs judgement. #TwitJC -8:23 PM amitns RT @fidouglas: @amcunningham Yes, in the last part of the paper he distinguishes been normalisation interventions and medications. #twitjc -8:23 PM aj0610 @carotomes Healthy diet, exercise, smoking cessation etc would offer same benefits with less risk #twitjc -8:23 PM doctorblogs RT @northern_doctor: Population vs patient risk prevention discussion very interesting (relevant to many areas of clinical practice) #twitjc -8:23 PM robhowardspr #TwitJC need to consider cost effectiveness too. -8:23 PM NHS_GP Seems Rose is suggesting stringent safety data needed before 1 prevention with high NNT. #TwitJC -8:23 PM petermbenglish It's a shame that Nick Wald couldn't join us #twitjc -8:23 PM northern_doctor @laikas Yes it's a surrogate marker, but one that is reliably linked (with others) to CV risk. Therefore it should be a focus. #twitjc -8:23 PM davecurtis314 Sure main point of Rose paper is about aiming at population rather than high risk groups? #twitjc -8:23 PM criticalinsight @carotomes Never heard of this paper, a refreshing read despite age. Have we got more uptight in the literature ? #twitjc -8:23 PM northern_doctor RT @GabrielScally: The point is that there are times when either or both strategies are appropriate. It needs judgement. <-- Yes! #twitjc -8:23 PM DrDLittle @aj0610 @GabrielScally but this paper essentially says the opposite? #TwitJC -8:23 PM silv24 RT @NHS_GP: Seems Rose is suggesting stringent safety data needed before 1 prevention with high NNT. #twitjc -8:23 PM fidouglas Can we simplify things down to "Treat as long as NNT value is smaller than NNH"? #twitjc -8:23 PM

petermbenglish RT @aj0610: @GabrielScally Like everything in medicine, it's essential to look at each case individually #twitjc <<Really? -8:24 PM GarethEnticott #twitjc Trouble with Rose is people think it is an either/or choice. Rose concludes both strategies have to be used -8:24 PM NHS_GP RT @fidouglas: @davecurtis314 I disagree - he says "consequently we cannot accept long term mass preventive medication" #twitjc -8:24 PM davecurtis314 I argue not just safety: "cost" of taking tablet daily, having injection, etc. #twitjc 8:24 PM carlylou #twitjc yes paper clearly advocates for normalisation interventions - also much easier to convince patients of than taking medication -8:24 PM petermbenglish RT @aj0610: @carotomes Healthy diet, exercise, smoking cessation etc would offer same benefits with less risk #twitjc <<not necessarily -8:24 PM aj0610 @fidouglas I think that's what Rose is trying to say - but also have to consider how "good" benefit is vs how "bad" risk is #twitjc -8:25 PM davecurtis314 Need to consider cost to health service and cost to patient. #twitjc -8:25 PM fidouglas @davecurtis314 Financial or personal cost? How can you measure personal cost? (I vaguely remember a paper on that somewhere). #twitjc -8:25 PM amitns @Trisha_the_doc @GabrielScally Good research to back judgement is what is needed #twitjc -8:25 PM GarethEnticott #twitjc but Rose should have been a sociologist. His basic argument is that intervention success depends on social context/environment -8:25 PM kevfrost @daunorubicin discussing itnow on #twitjc -8:25 PM Hamstav @fidouglas #twitjc but there is a gap in time. We know NNT before we know NNH. -8:25 PM silv24 I agree @davecurtis314 - Rose highlights the benefits of population based interventions including those at low or moderate risk #twitjc -8:25 PM DrDLittle @fidouglas no, depends on what effects are on both sides. #TwitJC -8:25 PM carlylou #twitjc though convincing someone of the benefits and getting them to put it into a practice are two different problems -8:25 PM danjrharvey RT @davecurtis314: People focus on high risk patients because they don't understand Rose. But for individual patient this is actually best. #twitjc -8:25 PM davecurtis314 @fidouglas That might be my paper you're thinking of. #twitjc -8:25 PM northern_doctor Same points about population benefit apply to smoking cessation, weight loss etc - will benefit some, but not all #twitjc -8:26 PM kevfrost @fidouglas the one about weekend in paris?#twitjc -8:26 PM Trisha_the_doc @aj0610 @gabrielscally Agreed. On the ground though I appreciate the likes of SIGN guidelines to help me. #twitjc -8:26 PM fidouglas @davecurtis314 Quite possibly. ;-) You'll have to tell me it later... #twitjc -8:26 PM laikas Was thinking the same #medicalization RT @aj0610: Healthy diet, smoking cessation etc would offer same benefits w/ less risk #twitjc #twitjc -8:26 PM

davecurtis314 @fidouglas It's the one I cheekily posted earlier. #twitjc -8:27 PM doctorblogs MT @amcunningham: @fidouglas 4 statins to be beneficial&justifiable,we need evidence that risk of events is correlated w cholesterol #twitjc -8:27 PM silv24 If we only tackle those at high risk than we miss the majority of cases according to Rose #twitjc -8:27 PM petermbenglish RT @silv24: If we only tackle those at high risk than we miss the majority of cases according to Rose #twitjc Tha't the point I think. -8:27 PM fidouglas Next topic is risk presentation. How does Rose present risk? And how do doctors present risks and risk reductions to patients? #twitjc -8:27 PM northern_doctor ...but wt loss & smoking cessation likely to confer less risk than starting new meds, therefore safer for whole population #twitjc -8:27 PM laikas @northern_doctor but smoking cessation & healthy lifestyle has MORE benefits & doesn't cost much #twitjc -8:27 PM davecurtis314 Quite right! RT @silv24: If we only tackle those at high risk than we miss the majority of cases according to Rose #twitjc -8:27 PM doctorblogs RT @amcunningham for statins to be beneficial&justifiable, we need evidence that risk of events is correlated with cholesterol level #twitjc -8:27 PM NHS_GP I think Rose provides an argument for 1prevention done by public health not GPs. #TwitJC -8:28 PM drgrumble "Healthy diet, smoking cessation etc would offer same benefits w/ less risk" But less easy to implement than pill! #TwitJC -8:28 PM pawlu Surely policies are tailored to public health, and then treatment to the individual? Clinician duty is to tailor protocol to patient #twitjc -8:28 PM amcunningham @silv24 but you need evidence that the intervention will have some benefit in those at low wisk- that is KEY #twitjc -8:28 PM carotomes @GarethEnticott #twitjc public health is both a 'science and art' - social science should be integral to all interventions -8:28 PM silv24 Should we be aiming for improvement in the patient sat in front of us or the population as a whole? #twitjc -8:28 PM themattmak @fidouglas I actually think doctors are quite poor at presenting risk, whether it be for meds or procedures #Twitjc -8:28 PM laikas @doctorblogs @amcunningham @fidouglas I remember the case of fibrines, where statines were lowered but no pos effect on MI #twitjc -8:28 PM amitns RT @pawlu: Surely policies are tailored to public health, and then treatment to the individual? Clinician duty is to tailor protocol to patient #twitjc -8:28 PM silv24 Precisely RT @amcunningham: @silv24 but you need evidence that the intervention will have some benefit in those at low risk-is KEY #twitjc -8:28 PM davecurtis314 Cool, let's do risk presentation. #twitjc -8:29 PM northern_doctor @laikas Agreed. Safer too. Just saying will statistically benefit population, but not every individual. #twitjc -8:29 PM amcunningham @drgrumble pills aren't easy to implement either.... #twitjc -8:29 PM

NHS_GP @fidouglas Badly. #TwitJC Or cynically, whichever way we think will lead them to make the choice we think is best. -8:29 PM dtwatkin Excellent question Dr. Silvey. #twitjc -8:29 PM northern_doctor @drgrumble Cynic ;-) #twitjc -8:29 PM alijmbacon Isn't the public purse a good reason to prevent events? Is this a different discussion in private system? #twitjc (Ali hospice dr) -8:29 PM davecurtis314 Though risk presentation a bit disheartening really. #twitjc -8:29 PM duncautumnstore @GarethEnticott - agree. Plus he hints that we should be aiming at changing some of the social & economic deteringants of health #twitJC -8:29 PM fidouglas Relative risk reductions are very misleading in my opinion. #twitjc -8:29 PM laikas fibrinates I mean #twitjc -8:29 PM davecurtis314 What to tell patient is benefit of taking statin? #twitjc -8:29 PM petermbenglish By making a small difference to the population average systolic, you can prevent a lot of cases. #twitjc -8:29 PM petermbenglish To properly understand the benefits of intervention pts need to understand both AR and RR. #twitjc -8:30 PM petermbenglish These concepts aren't particularly easy to explain. #twitjc -8:30 PM davecurtis314 I agree, should present AR not RR. But a very low number. #twitjc -8:30 PM DrDLittle both? Although easier said than done. @silv24 #TwitJC -8:30 PM dtwatkin RT @fidouglas: Relative risk reductions are very misleading in my opinion. #twitjc -8:30 PM northern_doctor I would always have to rx the patient in front of me - difficulty is knowing whether or not they are the ones who benefit from rx #twitjc -8:30 PM fidouglas @petermbenglish NNT is a much easier to concept to explain to someone with no knowledge of statistics. #twitjc -8:31 PM petermbenglish ARR probably more important, I agree, for individual patient. #TwitJC -8:31 PM drgrumble @davecurtis314 Q: What to tell patient is benefit of taking statin? A: For most very little! #TwitJC -8:31 PM carlylou @petermbenglish yes but how many Drs have time to explain that fully before writing the script? #TwitJC -8:31 PM davecurtis314 E.g. Schizophrenia. Smoke cannabis 2%. Don't 1% probability of avoiding SZ if you stop 1%. #twitjc -8:31 PM amcunningham @themattmak we get very little help with presenting risk ... look at absence of decision aids with new nice guidance on ovarian ca #twitjc -8:31 PM amitns RT @northern_doctor: I would always have to rx the patient in front of me - difficulty is knowing whether or not they are the ones who benefit from rx #twitjc -8:31 PM laikas RT @amcunningham: @silv24 but you need evidence that the intervention will have some benefit in those at low wisk- that is KEY #twitjc -8:31 PM

GabrielScally "No mass disorder afflicting mankind has ever been brought under control or eliminated by attempts at treating the individual" #twitjc -8:31 PM silv24 We do present risk really badly in my opinion, both for the benefits of treatment and for the harms of treatment #twitjc -8:31 PM petermbenglish Agreed, NNT also good. #TwitJC -8:31 PM pawlu @petermbenglish And also, is that within the scope of the 10-minute GP consultation session? #twitjc -8:31 PM northern_doctor RRR is only useful in context of ARR - both are needed! #twitjc -8:32 PM petermbenglish RT @carlylou: @petermbenglish yes but how many Drs have time to explain that fully before writing the script? #TwitJC Good point, but... -8:32 PM themattmak @laikas @doctorblogs @amcunningham @fidouglas We have to remember some risks are discovered post-hoc e.g rosiglitazone #TwitJC -8:32 PM fidouglas But this Sheridan paper argues that discussing NNT alone is not good. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494938/ #twitjc -8:32 PM amcunningham RT @GabrielScally: "No mass disorder afflicting mankind has ever been brought under control or eliminated by attempts at treating the individual" #twitjc -8:32 PM davecurtis314 Problem is that effect on individual tiny, effect on population/NHS huge. #twitjc 8:32 PM criticalinsight Another interesting point is that Doctors would often choose a different route than that they "recommend" see http://bit.ly/ivd0PU #twitjc -8:32 PM silv24 NNT seems a good way of explaining it to patients but it isnt perfect as @fidouglas has highlighted #twitjc -8:32 PM davecurtis314 Argh! Another paper? #twitjc -8:32 PM silv24 RT @davecurtis314: Problem is that effect on individual tiny, effect on population/NHS huge. #twitjc -8:32 PM alijmbacon But patients often don't understand simple risk-benefit situations, never mind ones like this #twitjc -8:32 PM aj0610 OCP and DVT risk illustrates AR vs RR well, like Fi said re: bisphosphonates and gastric ca, double a v small no is still v small #twitjc -8:33 PM davecurtis314 Most primary interventions NNT is in order of 1000. #twitjc -8:33 PM drgrumble NNTT might be high for some immunisations but the Rx is still obviously necessary. #TwitJC -8:33 PM carotomes @criticalinsight Not always referenced, but yes. Study on metformin v placebo v lifestyle showed lifestyle = most effective #twitjc -8:33 PM DrDLittle If some doctors don't understand these concepts? How can the patients ever be expected to? #TwitJC -8:33 PM Trisha_the_doc @GarethEnticott Agreed #twitjc -8:33 PM fidouglas @davecurtis314 But for many patients, taking a tablet a day is an inconvenience and adherence can be rubbish. #twitjc -8:33 PM petermbenglish ... perhaps part of the point is that we need better methods to describe NNT, ARR to pts outside the consulting room #TwitJC -8:33 PM

doctorblogs agree... RT @NHS_GP Seems Rose is suggesting stringent safety data needed before 1 prevention with high NNT #TwitJC -8:34 PM davecurtis314 Who here would take a pill every day if chances of benefit to them were 1/1000? #twitjc -8:34 PM northern_doctor The only way around this dilemma is to genetically profile every patient and individualise rx - we're not there yet #twitjc -8:34 PM laikas @fidouglas NNT alone not sufficient: depends on the risk of getting the disease (yeah still) and the kind of risk #twitjc -8:34 PM fidouglas @petermbenglish I think communication in this respect is very important. #twitjc -8:34 PM silv24 We explain risks and benefits really badly, sometimes to our shame not at all. How is that informed consent? #twitjc -8:34 PM Hamstav RT @davecurtis314: Who here would take a pill every day if chances of benefit to them were 1/1000? #twitjc -8:34 PM danjrharvey @davecurtis314 sorry, probably right ought not to start other refs....but maybe people will look back afterwards for more! #twitjc -8:34 PM Trisha_the_doc Has the whole situation become more complicated than in Rose's day because cost benefit analysis ends up coming in as well? #twitjc -8:35 PM dtwatkin @DrDLittle I think that in the context of premature babies; if I have doubts myself, how can parental consent ever be informed? #twitjc -8:35 PM carotomes @DrDLittle this is my concern with the move towards GP commissioning... do they have the population-health knowledge? #twitjc -8:35 PM davecurtis314 We just say "It will reduce risk" and we recommend it and that's that. #twitjc -8:35 PM fidouglas @davecurtis314 Quite a few patients I've interviewed have told me they "just take what the doctor tells them to take". #twitjc -8:35 PM GabrielScally If it's a 'mass disorder' prevent it, and also treat. Don't be fooled by medico-industrial complex only to do the latter. #twitjc -8:35 PM duncautumnstore @GabrielScally where is that quote from, it's fantastic #twitJC -8:35 PM northern_doctor Recent cochrane review discusses how to communicate these stats to patients natural frequencies preferred (http://bit.ly/l3WeDi) #twitjc -8:35 PM danjrharvey Whoops, keep tweeting from both accounts - these 2 both me @criticalinsight @danjrharvey #twitjc -8:35 PM criticalinsight Whoops, keep tweeting from both accounts - these 2 both me @criticalinsight @danjrharvey #twitjc -8:35 PM carlylou @petermbenglish definitely. Statistical literacy is a big issue in society generally #TwitJC 8:35 PM fidouglas @silv24 did you read my blog post? http://occamstypewriter.org/irregulars/2011/01/05/informed-consent/ #twitjc -8:35 PM kevfrost @petermbenglish is this included in the english pharmacy new medicines service? #twitjc 8:36 PM

doctorblogs No! Depends what the harm is RT @fidouglas Can we simplify things down to "Treat as long as NNT value is smaller than NNH"? #twitjc -8:36 PM amcunningham #twitjc RT @medskep: Fig 1 in Rose is vry interesting as it shows CHD in US & Aust declining sharply before the widespread use of statins. -8:36 PM silv24 Are doctors trained well enough to explain risk and benefits to patients? I only vaguely remember lectures on it #twitjc -8:36 PM petermbenglish RT @kevfrost: @petermbenglish is this included in the english pharmacy new medicines service? #twitjc No idea! I'm a CCDC -8:36 PM fidouglas Next point for discussion: Has the separation between preventive and therapeutic medicine changed since this paper was published? #twitjc -8:36 PM DrDLittle not sure I remember having ANY lectures on it?! @silv24 #TwitJC -8:37 PM doctorblogs RT @themattmak: we have to remember some risks are discovered post-hoc e.g rosiglitazone #TwitJC -8:37 PM petermbenglish QoF is largely based on Rose ideas #TwitJC -8:37 PM davecurtis314 I think preventive and therapeutic have come closer together? #twitjc -8:37 PM amcunningham @fidouglas no- it's got even more blurred! many think that when they are preventing illness they are treating #twitjc -8:37 PM Trisha_the_doc @Hamstav @davecurtis314 Bizarrely though many do the lottery with odds of 14million to 1.... #twitjc -8:37 PM danjrharvey @northern_doctor yes, I saw that, I thought it was interesting, although limited underlying evidence base., no need for RCT for this #twitjc -8:37 PM DrDLittle @dtwatkin precisely, makes the argument somewhat redundant. #twitJC -8:38 PM silv24 RT @davecurtis314: I think preventive and therapeutic have come closer together? #twitjc 8:38 PM pawlu @silv24 Explaining risk to patients is not taught in lectures - role for apprenticeship method here. #twitjc -8:38 PM fidouglas @Trisha_the_doc @Hamstav @davecurtis314 Exactly. People don't make rational choices when it comes to risks. #twitjc -8:38 PM petermbenglish I think there's a lot more understanding of the psychological issues of becoming a patient #TwitJC -8:38 PM amitns RT @silv24: Are doctors trained well enough to explain risk and benefits to patients? I only vaguely remember lectures on it #twitjc -8:38 PM davecurtis314 GPs getting paid for loads of preventative stuff? #twitjc -8:38 PM dean_jenkins @amcunningham @medskep before a lot of things so why choose 'statins' #twitjc 8:38 PM petermbenglish RT @pawlu: @silv24 Explaining risk to patients is not taught in lectures - role for apprenticeship method here. #twitjc <<Perhaps not ideal -8:39 PM themattmak @davecurtis314 I agree - they are pretty much venn diagram like now. #TwitJC -8:39 PM northern_doctor I'm not in best position to comment on primary prevention. Most of my patients have already had events - different population #twitjc -8:39 PM

danjrharvey @silv24 Do patients (or drs) actually make rationale decisions though? I think we ignore the emotional aspects & fear #twitjc -8:39 PM fidouglas @pawlu @silv24 We had a lecture series (and exam) on medical stats. Lots of stuff on different ways of presenting risk. #twitjc -8:39 PM silv24 In hospital most is about secondary prevention - applies more to an individual & their risk rather than a population based approach #twitjc -8:39 PM Trisha_the_doc @silv24 And that's before you add in the fact that in the future many of the people we are making decisions with have dementia! #twitjc -8:39 PM northern_doctor @danjrharvey Yes, and no evidence that it alters behaviour or decision-making! #twitjc -8:39 PM GabrielScally The quote, from John Gorden, continues (bad reading for doctors!) "... nor by training large numbers of therapists." #twitjc -8:39 PM amcunningham @pawlu to explain the risk you have to have access to the stats... should be part of all guidelines and research papers but aren't #twitjc -8:39 PM JoBrodie RT @criticalinsight: @carotomes Never heard of this paper, a refreshing read despite age. Have we got more uptight in the literature ? #twitjc -8:39 PM danjrharvey An example would be food scares, risk tiny but behaviour changed massively (cf diet in general) #twitjc -8:39 PM davecurtis314 In psychiatry we certainly have emphasis on preventing relapse. Maybe not quite the same. #twitjc -8:39 PM DrDLittle @danjrharvey @silv24 not to Mention misunderstanding #TwitJC -8:40 PM amcunningham @dean_jenkins I'm guessing @medskep mentioned statins cause that's what we were discussing in #twitjc -8:40 PM Andrew_Mott @carotomes ...perhaps we (GP commissioners) don't, but we will clearly be needing close links to public health colleagues. #twitjc -8:40 PM petermbenglish RT @danjrharvey: An example would be food scares, risk tiny but behaviour changed massively (cf diet in general) #twitjc <<Or pill scares... -8:40 PM fidouglas @davecurtis314 Are many of the drugs used for treatment also used to prevent future episodes? #twitjc -8:40 PM Trisha_the_doc @DrDLittle @silv24 me neither! #twitjc -8:40 PM amcunningham @davecurtis314 psychiatry .... and the NNT to treat with an SSRI is? #twitjc -8:40 PM dtwatkin More (?) importantly, the #bbcf1 starts again in 10 mins... #twitjc -8:40 PM davecurtis314 @fidouglas Yes, make sure people have enough Rx so they don't relapse. And catch them early. #twitjc -8:41 PM themattmak @petermbenglish @danjrharvey or vaccine scares? #TwitJC -8:41 PM northern_doctor Aspirin is another good example - reduces CV events, but increases bleeds #twitjc -8:41 PM davecurtis314 @amcunningham 3. #twitjc -8:41 PM fidouglas @davecurtis314 I remember reading that NNT for lithium is about 8. Which really is rather good. Can you verify that? #twitjc -8:41 PM

pawlu @amcunningham Agreed thoroughly - was commenting about method, not content. #twitjc 8:41 PM silv24 Are some specialities better with preventative medicine than others? Thoughts? #twitjc -8:41 PM Trisha_the_doc @pawlu @silv24 Not sure it's well done out in the real world either! #twitjc -8:41 PM petermbenglish RT @davecurtis314: In psychiatry -emphasis on preventing relapse. - #twitjc Not same - Rose is about how small popn diff -> big popn diff -8:42 PM northern_doctor CV events reduction outweighs bleeds if you look at population data, but difficult to predict outcome in individual #twitjc -8:42 PM davecurtis314 @fidouglas Not right now. Struggling to keep head above water. But sounds about right. #twitjc -8:42 PM dean_jenkins @fidouglas metformin for diabetes prevention #twitjc (not as good as exercise or the 'out-of-favour' glitizones) -8:42 PM laikas just thinking. Prev. medicine often based on observ research 1st, but RCT's often don't confirm efficacy: PC, MC screening; vitamins #twitjc -8:42 PM dtwatkin @silv24 Paediatrics and vaccination? #twitjc -8:42 PM fidouglas I think psychiatry is perhaps an area where treatment and prevention do have massive overlap. #twitjc -8:42 PM NHS_GP It not just NNH conventionally, or cost. What about medicalisarion, doctor dependence and invoked anxiety? For 1 prevention... #TwitJC -8:42 PM danjrharvey @fidouglas @davecurtis314 could consider anti virals during H1N1 in this regard, aim as much to damp transmission as treat / prevent #twitjc -8:42 PM northern_doctor We use population data to make informed decisions about individual patient treatment #twitjc -8:42 PM amcunningham @silv24 real prevention happens outside of medicine- it's about reducing the causes of inequalitites #twitjc -8:42 PM CiaranWasson RT @amcunningham: #twitjc RT @medskep: Fig 1 in Rose is vry interesting as it shows CHD in US & Aust declining sharply before the widespread use of statins. -8:42 PM GabrielScally Read the Gordon quote in this paper: http://t.co/JQhWvSu I have it on mugs at work to remind us all! #twitjc -8:43 PM themattmak @silv24 Public Health, Paediatrics and maybe sometimes GP? #TwitJC -8:43 PM davecurtis314 TBH, I think other specialties could learn a thing or two from psychiatry. #twitjc 8:43 PM northern_doctor Very few medical treatments lead to 100% certain outcomes - it's a case of playing the odds #twitjc -8:43 PM alijmbacon Sometimes sold too well - I often have to persuade terminally ill to stop statins, antihypertensives etc! #twitjc -8:43 PM petermbenglish I mean, small diff to e.g. mean cholesterol or BP -> big diff in popn mortality/morbidity #TwitJC -8:43 PM fidouglas Lots of screening in women's health. Also increasingly in sexual health. I'd argue this counts as prevention (catch illness early). #twitjc -8:43 PM

silv24 Rose highlights obstetrics & antenatal care as being largely preventative medicine, done well at population level & individual one #twitjc -8:43 PM laikas @northern_doctor yes but these are stratified according to risk (or ought to be) #twitjc -8:43 PM aj0610 @silv24 Interesting q - depends as in some specialties lifestyle or screening more important/available than meds eg oncology #twitjc -8:43 PM carlylou RT@amcunningham @silv24 real prevention happens outside of medicine- it's about reducing the causes of inequalitites #twitjc<totally agree -8:44 PM davecurtis314 Should have cardiologists following people up to prevent second infarct. Holistic, multidisciplinary reviews. #twitjc -8:44 PM doctorblogs & individual patients make rational decisions RT @davecurtis314 Problem is that effect on indiv tiny, effect on population/NHS huge #twitjc -8:44 PM drgrumble @CiaranWasson @amcunningham @medskep That was and I think still is a great puzzle. #TwitJC -8:44 PM dean_jenkins I think we've moved a long way in the debate from labelling preventive treatment as 'unnatural factors'. #twitjc -8:44 PM laikas @kevfrost oh damn, *English*, did I use the wrong word #twitjc -8:44 PM Trisha_the_doc @northern_doctor Mine have usually survived several! (med of elderly = evidence free zone!) #twitjc -8:44 PM fidouglas @carlylou @amcunningham @silv24 I think Rose would agree with that too. #twitjc -8:44 PM adriamarilla #twitjc in cuba doctors are training with a population preventive approach but in my country we were more focus on treatments -8:44 PM petermbenglish This is an area where old fashioned public health is important. Health promotion in all its aspects. #TwitJC -8:45 PM NHS_GP @danjrharvey @fidouglas @davecurtis314 I felt political "something must be done" lots of s/e esp in kids and psych with tamiflu #TwitJC -8:45 PM laikas @themattmak: @doctorblogs @amcunningham @fidouglas We have to remember some risks are discovered post-hoc e.g rosiglitazone #TwitJC TRUE -8:45 PM amcunningham RT @adriamarilla: #twitjc in cuba doctors are training with a population preventive approach but in my country we were more focus on treatments -8:45 PM DrDLittle @davecurtis314 but that would cost too much? #TwitJC -8:45 PM davecurtis314 I'm a psychiatrist - medical student asked me: "Why do you keep telling patients to stop smoking?" #twitjc -8:45 PM doctorblogs for life, r til what age???RT @davecurtis314 Who'd take a pill every day if chances of benefit to them were1/1000? #twitjc -8:45 PM danjrharvey @adriamarilla Yes, my experience working in Cuba would back this up, and they get great results on min. resource! #twitjc -8:45 PM GabrielScally To discuss one needs to understand primary, secondary and tertiary prevention. Otherwise confusion reigns. #twitjc -8:45 PM northern_doctor @laikas To an extent yes, but as the paper points out if you only treat high risk patients you miss treating others! #twitjc -8:45 PM

dean_jenkins @davecurtis314 refer them to the MRFIT trial. #twitjc -8:45 PM davecurtis314 @davecurtis314 Might be well worth while. #twitjc -8:46 PM Trisha_the_doc A lot of my elderly have very firm opinions. Want everything or want nothing! Not usually swayed if fixed view! #twitjc -8:46 PM amitns @fidouglas my understanding is that in psychiatry evidence can be v. v. difficult to inertret #TwitJC -8:46 PM davecurtis314 @doctorblogs Per year. #twitjc -8:46 PM danjrharvey @GabrielScally OK you got me now. What's tertiary prevention? #twitjc -8:46 PM pawlu By increasing monitoring in labour, we increased (potentially lifethreatening) surgical intervention, but decreased stillbirths. #twitjc -8:46 PM aj0610 @davecurtis314 Surely holistic health important?!!! #twitjc -8:46 PM petermbenglish Tamiflu different altogether #TwitJC -8:46 PM dean_jenkins @Trisha_the_doc what age cut-off should you use for statins in the elderly? Makes for interesting debate with trainees. #twitjc -8:46 PM fidouglas What are key points for improving preventive medicine at the present time? New medications? Focus on social/lifestyle factors? #twitjc -8:46 PM petermbenglish Primary prevention is abt reducing risk by eg reducing sodium intake. Effect on indivs small, but effect on overall morbidity large. #TwitJC -8:47 PM pawlu So introducing something to improve public health AND individual health has its pros and cons. We are still debating that line. #twitjc -8:47 PM northern_doctor @Trisha_the_doc There are times when I like the pragmatic approach that the lack of evidence affords us! #twitjc -8:47 PM davecurtis314 Completely ! RT @aj0610: @davecurtis314 Surely holistic health important?!!! #twitjc -8:47 PM danjrharvey @fidouglas I'd vote for economics as the most powerful mechanism for changing the behavior of a population #twitjc -8:47 PM amcunningham @dean_jenkins really? this MRFIT trial? http://is.gd/uJzCKB #twitjc -8:47 PM duncautumnstore RT @GabrielScally: "No mass disorder afflicting mankind has ever been brought under control or eliminated by attempts at treating the individual" #twitjc -8:48 PM kevfrost @laikas #twitjc sorry tosound pedantic over jargon. Efficacy=does it work in this controlled scenario (eg RCT) (cont) http://tl.gd/b2o4iv -8:48 PM silv24 Concerns about medicalisation of the public are high, with new medications & lower limits for treatment we risk increasing that #twitjc -8:48 PM ian_wac @doctorblogs @davecurtis314 I wear a bike helmet on probably similar benefit #twitjc 8:48 PM GabrielScally About half of the cigarettes smoked are smoked by people with mental illness. Which do you 'treat'? #twitjc -8:48 PM DrDLittle social and lifestyle factors in my opinion! Very few side effects of stopping smoking @fidouglas #TwitJC -8:48 PM

Assidens RT @fidouglas: How can we go about deciding on where to draw the line between benefit to the individual vs benefit to the population as a whole? #twitjc -8:48 PM davecurtis314 @danjrharvey I agree, increase cost of alcohol, tobacco and calories! #twitjc -8:48 PM petermbenglish primary secondary tertriary prevntn described at http://bit.ly/kIyfCW #TwitJC 8:48 PM fidouglas @danjrharvey Agreed, socioeconomic status is *still* one of (if not the) most important determinants of heath. #twitjc -8:48 PM GarethEnticott #twitjc BMJ revisited Rose 5 years ago: http://t.co/UKkJHht -8:48 PM danjrharvey @ian_wac @doctorblogs @davecurtis314 I wear a helmet despite no conclusive proof it helps adult cyclists (only kids). seems sensible #twitjc -8:48 PM northern_doctor @dean_jenkins @Trisha_the_doc I think life expectancy needs to be 10 yrs before statins are of significant benefit...? #twitjc -8:49 PM NHS_GP Big issue seems to be finding balance between beneficence (NNT) and non malefalence (NNH) Not always clear, and not prioritised #TwitJC -8:49 PM aj0610 RT @fidouglas: @danjrharvey Agreed, socioeconomic status is *still* one of (if not the) most important determinants of heath. < YES! #twitjc -8:49 PM petermbenglish RT @ian_wac: @doctorblogs @davecurtis314 I wear a bike helmet on probably similar benefit #twitjc Why do you wear it? Social pressure? -8:49 PM amcunningham @GabrielScally hmm depends how you define mental illness ..... #twitjc -8:49 PM davecurtis314 But cycle helmets discourage people from cycling. Very interesting debate. #twitjc 8:49 PM carotomes 1) evaluation evaluation evaluation. This tends to be neglected, and would help guide best practice and cost effectiveness #twitjc -8:49 PM danjrharvey @petermbenglish @ian_wac @doctorblogs @davecurtis314 I wear mine 'cos I work in a neuro ICU! #twitjc -8:50 PM criticalinsight @petermbenglish @ian_wac @doctorblogs @davecurtis314 I wear mine 'cos I work in a neuro ICU! #twitjc -8:50 PM themattmak RT @danjrharvey: I'd vote for economics as the most powerful mechanism for changing the behavior of a population #twitjc << vote seconded -8:50 PM davecurtis314 @danjrharvey Um yes but most stuff unknown and hard to quantify. #twitjc -8:50 PM fidouglas @GarethEnticott Thanks-I think Natalie blogged that this afternoon http://twitjc.wordpress.com/2011/06/12/reflections-on-last-week/ #twitjc -8:50 PM danjrharvey RT @petermbenglish: primary secondary tertriary prevntn described at http://bit.ly/kIyfCW #TwitJC -8:50 PM petermbenglish RT @danjrharvey: I wear mine 'cos I work in a neuro ICU! #twitjc <<So se very unrepresentative patients! -8:50 PM doctorblogs proof re more effective? MT @drkerrynphelps statins NNT...but weigh the risks.Intensive lifestyle change safer&more effective #twitjc -8:50 PM Trisha_the_doc @fidouglas @pawlu @silv24 Sometimes people are turned off by too much stats though. Students and patients. #twitjc -8:51 PM

fidouglas @NHS_GP But asking if NNT<NNH is far too simplistic. #twitjc -8:51 PM EverythingVHost @amitns @fidouglas *Buts in* wouldn't that just be the qualiative side of research? There's still a whole load of quantative psych #TwitJC -8:51 PM carotomes 2) lifestyle changes are cost-effective and sustainable eg: health co-benefits of getting people to walk to work instead of driving #twitjc -8:51 PM davecurtis314 Sorry, that last one went to the wrong tweeter. #twitjc -8:51 PM silv24 RT @danjrharvey: RT @petermbenglish: primary secondary tertriary prevntn described at http://bit.ly/kIyfCW #twitjc -8:51 PM northern_doctor Not sure I agree with Rose's statement that docs should "create social pressure" to effect behaviour change! Thoughts...? #twitjc -8:51 PM carlylou @davecurtis314 @danjrharvey but those who (ab)use these the most often on low incomes social at least as important as economics #TwitJC -8:52 PM Hamstav RT @carotomes: 1) evaluation evaluation evaluation. Agry, but the gap between evaluation and knowledge leads to abuse by many #twitjc -8:52 PM davecurtis314 I'm all for creating social pressure, me. #twitjc -8:52 PM harryrutter traffic danger is an eg of prev paradox - policy targets high speeds, but more total harm by 'normal' drivers at average speeds #twitjc -8:52 PM petermbenglish RT @petermbenglish: primary secondary tertriary prevntn described at http://bit.ly/kIyfCW #twitjc <<New editors (must be medics) welcome -8:52 PM danjrharvey @NHS_GP Exactly, not helped when the trials are not really designed to answer this, rather prove equivalence #TwitJC -8:52 PM laikas @northern_doctor social pressure doesn't work (my guess) #twitjc -8:52 PM medskep Patients can be rational but when they are told that rxs and trtment is very effective why make signif. lifestyle changes #twitjc -8:52 PM davecurtis314 Where I live there are no normal drivers. They're all at high speeds :) #twitjc -8:52 PM silv24 Do doctors manage to create a social pressure? Take alcohol, obesity and smoking - do we manage to have an impact? #twitjc -8:53 PM fidouglas @northern_doctor I think society creates social pressure. Smoking is nearly nonexistent in white NZers, because it is so stigmatised #twitjc -8:53 PM petermbenglish @northern_doctor I think social pressure is the only way it can be done #TwitJC 8:53 PM Trisha_the_doc @themattmak @danjrharvey Yup, agreed. The money gets attention of politicians and senior managers! #twitjc -8:53 PM NHS_GP @silv24 @davecurtis314 That would be a good starting point, but clearly much more to it. Difficulty of measuring harm in all forms #TwitJC -8:53 PM danjrharvey @petermbenglish yep, I agree, which is why I think we (and patients) don't always make rational decisions, often based on fear #twitjc -8:53 PM petermbenglish AFter all, why do people wear bike helmets? Social pressure #TwitJC -8:53 PM siobhanfarmer Can't believe I ended up missing #TwitJC Looks like it is nearly over now :-( I look forward to the summary! -8:53 PM

SarahBoydH RT @GabrielScally: To discuss one needs to understand primary, secondary and tertiary prevention. Otherwise confusion reigns. #twitjc -8:53 PM SarahBoydH RT @GabrielScally: About half of the cigarettes smoked are smoked by people with mental illness. Which do you 'treat'? #twitjc -8:53 PM DrDLittle RT @petermbenglish: @northern_doctor I think social pressure is the only way it can be done #TwitJC -8:53 PM davecurtis314 There is good evidence for doctors creating "social pressure" in individual consultations. Should do more. #twitjc -8:53 PM GabrielScally Doctors did very well on smoking, seatbelts, motorbike helmets etc. The problem is the tradition has been largely lost. #twitjc -8:54 PM MsPhelps Re @silv42 obstetrics/antenatal care: maybe easier b/c defined short timespan (42 weeks max), highly motivated subjects? #twitjc -8:54 PM carotomes @Hamstav knowledge transition is problematic. eg we know what is good, but how can we turn into action #twitjc -8:54 PM hanswest #TwitJC Statins and primary prevention? I don't get it. The evidence is very poor -8:54 PM northern_doctor Social pressures probably are effective motivators, but should addressing them be (part of) the role of a doctor? #twitjc -8:54 PM Trisha_the_doc @carotomes Hard to change that kind of behaviour! #twitjc -8:54 PM fidouglas Do we think more funding needs to go towards research into preventative interventions? (be that pharmaceutical, public health etc). #twitjc -8:54 PM danjrharvey @carlylou we can be smarter with the economics, needn't be negative (eg payments) or discriminatory (proportionality) #TwitJC -8:54 PM petermbenglish Doctors are probably an important part of creating the social pressure; but we need to engage the mainstream media #TwitJC -8:55 PM silv24 I work in gastro - we counsel all our alcoholics to stop drinking etc but know that it doesn't make a blind bit of difference #twitjc -8:55 PM amcunningham social pressure is not about putting pressure on individuals to change behaviourit's about changing society #twitjc -8:55 PM laikas RT @hanswest: #TwitJC Statins and primary prevention? I dont get it. The evidence is very poor thought the same! #twitjc -8:55 PM GabrielScally Gosh!!!! It was doctors that created ASH for example!!! #twitjc -8:55 PM EverythingVHost @northern_doctor If not doctors, then who? #twitjc -8:55 PM carlylou #twitjc social pressure needs to be reinforced by society at large though. Else just a lone voice -8:55 PM aj0610 @MsPhelps @silv42 Also responsible for "other person" ie baby, so less likely to say "so what, it was fun at the time"? #twitjc -8:55 PM NHS_GP @danjrharvey: yep, I agree, which is why I think we don't always make rational decisions, often based on fear" And QoF points #TwitJC -8:55 PM adriamarilla RT @petermbenglish: Doctors are probably an important part of creating the social pressure; but we need to engage the mainstream media #TwitJC -8:55 PM

northern_doctor RT @petermbenglish: Doctors an important part of creating the social pressure; but we need to engage the mainstream media #twitjc -8:55 PM DrDLittle @silv24 why do it then? #TwitJC -8:55 PM Trisha_the_doc @northern_doctor Mind you the Drs might at least be doing it with the right knowledge base? #twitjc -8:55 PM laikas well said @amcunningham: social pressure is not about putting pressure on individuals to change behaviour- its abt changing society #twitjc -8:55 PM danjrharvey @medskep Good point! (I'm still skiing and banking on new knees before I need one for instance) #twitjc -8:56 PM petermbenglish There's a prob in that media often emphasise things that aren't very valuable or which are wrong (like MMR is dangerous fallacy). #TwitJC -8:56 PM fidouglas @laikas @hanswest Think this is the report that shows they're effective. Decent RRR, but tiny ARR = problem. http://bit.ly/iuiBfG #twitjc -8:56 PM petermbenglish @keirshiels Why aren't you on #TwitJC -8:56 PM aj0610 @petermbenglish Media aim to sell stories - sensationalism gets published over sensibility! #twitjc -8:56 PM carlylou @amcunningham yes! #TwitJC -8:57 PM pawlu @MsPhelps Not necessarily highly motivated - a lot of smoking/drinking going on, and difficult to change habits. Pressure needed! #twitjc -8:57 PM carotomes @Trisha_the_doc #twitjc agreed - but does that mean drugs should be default? Difficult but not impossible with the right support -8:57 PM harryrutter @GabrielScally challenges now more complex - morally, politically, practically - eg drugs, food, energy. Need different skills #twitjc -8:57 PM themattmak @silv24 I read a paper once about brief interventions for smoking cessation having effect on COPD. Am sure there is same for ETOH #twitjc -8:57 PM davecurtis314 How do I get this signed off for my CPD? I am wrecked, #twitjc -8:57 PM silv24 @DrDLittle in the hope that we will get through to someone, its tragic to see young patients die from alcohol abuse #twitjc -8:57 PM Trisha_the_doc @harryrutter Good point re traffic #twitjc -8:57 PM carlylou @amcunningham but big Q is how do we do that? #TwitJC -8:57 PM Hamstav RT @petermbenglish: There's a prob in that media often emphasise things that aren't very valuable or which are wrong (like MMR is dangerous fallacy). #TwitJC -8:57 PM DrDLittle @petermbenglish media can't be trusted to do anything useful #TwitJC -8:57 PM northern_doctor @EverythingVHost Good point - maybe docs (esp in public health) are the best placed ones to do it. #twitjc -8:57 PM dickstar Great #behaviourchange debate going on at #twitjc hashtag right now -8:57 PM Trisha_the_doc @davecurtis314: I'm all for creating social pressure, me. #twitjc yup, me too! 8:57 PM alijmbacon Media publish what people want to read - don't jab babies better than give up fags and booze #twitjc -8:58 PM

aj0610 RT @DrDLittle: @petermbenglish media cant be trusted to do anything useful < sadly true! #twitjc -8:58 PM northern_doctor RT @Trisha_the_doc: Mind you the Drs might at least be doing it with the right knowledge base? <-- Hopefully! #twitjc -8:58 PM petermbenglish RT @aj0610: RT @DrDLittle: @petermbenglish media cant be trusted to do anything useful < sadly true! #twitjc <<Not in short term. -8:58 PM fidouglas Do we think we need to allocate more funding for medical research to developing better preventive interventions? #twitjc -8:58 PM danjrharvey @alijmbacon would it be too cynical t point out what the adverts in the media are for ? (hint its not vaccines, might be booze!) #twitjc -8:58 PM silv24 @themattmak probably, but our hardcore group of patients with frequent admissions don't tend to respond well #twitjc -8:58 PM carotomes #twitjc funding needs to go specifically to evaluation AND knowledge transition... turning theory into action -8:58 PM themattmak @DrDLittle @petermbenglish The media have caused a lot of unwanted hassle in recent years i.e. Cervarix, MMR #twitjc -8:59 PM amcunningham @carlylou we have to start by understanding the social causes for illness and health (but some consider that 'knit your own yogurt') #twitjc -8:59 PM amitns @davecurtis314 All for social pressure by doctors as long as they are wise enough themselves. Who judges that? #TwitJC -8:59 PM northern_doctor RT @DrDLittle: Media cant be trusted to do anything useful <-- Sadly true! #twitjc -8:59 PM petermbenglish #TwitJC we need to educate and work with media. It takes time. -8:59 PM GabrielScally Best bit of the paper is p1848, Bottom 3rd para. ' by uncritical propagandists, by, cranks, and by battling commercial interests.' #twitjc -8:59 PM DrDLittle @silv24 @DrDLittle absolutely! Wonder what the NNT is for that as an intervention? #TwitJC -8:59 PM danjrharvey Of course Darzi did highlight the need for more prevention, and it is in the QOF points, and the CQUIN system....#twitjc -8:59 PM silv24 Is it cheaper to prevent a case of a disease rather than treating it once it has occured? #twitjc 9:00 PM fidouglas Preventive treatments provide much better value for money in terms of QALYs (which I know aren't the perfect measure themselves). #twitjc -9:00 PM anaestheticdoc this is presuming that society wants to change. Does everybody want good health, and go with out some unhealthy life style choices. #twitjc -9:00 PM dtwatkin RT @anaestheticdoc: this is presuming that society wants to change. Does everybody want good health, and go with out some unhealthy life style choices. #twitjc -9:00 PM amcunningham #twitjc RT @medskep: People would act more rationally abt prevention if they understood the true degree of efficacy in current trtments -9:00 PM davecurtis314 Prevention is cheaper for society. How to do it though? #twitjc -9:00 PM danjrharvey @silv24 no - but there are fewer votes in it, as the "saves" don't realise and aportion credt, unlike patients and families #twitjc -9:00 PM

Trisha_the_doc @fidouglas @northern_doctor And in middle class Edinburgh...But there lies a tale..the poorer continue to smoke! Despite knowledge. #twitjc -9:00 PM northern_doctor The people best positioned to inform strategies for behaviour change on a population basis should be PH docs! #twitjc -9:01 PM carotomes @silv24 is it absolutely cheaper to prevent rather than cure #WanlessReport #twitjc 9:01 PM silv24 Have to recognise the commercial interest in treating more of the population with medication to reduce cases of a disease #twitjc -9:01 PM fidouglas But value-for-money QALY analyses fail to take into account so many important factors. #twitjc -9:01 PM KP_LD @silv24 in mental health prevention is always cheaper than treatment #twitjc -9:01 PM doctorblogs MT @NHS_GP: Big issue seems to be finding balance btwn beneficence (NNT) & non maleficence (NNH). Not always clear & not prioritised #TwitJC -9:01 PM dean_jenkins @amcunningham Sorry for the delay MRFIT http://t.co/wk8v9UB #twitjc "Smoking cessation ... substantial effect on subsequent mortality" -9:01 PM DrDLittle @anaestheticdoc no they don't, most people have no concept of long term benefits or just don't care #TwitJC -9:01 PM kevfrost @silv24: Is it cheaper to prevent a case of a disease rather than treating it once it has occured? #twitjc <<< depends on the disease. -9:01 PM fidouglas @Trisha_the_doc In NZ, it's very cultural - smoking rates are unbelievably different between Pakeha and Maori/Pacific Islanders. #twitjc -9:01 PM davecurtis314 Government should be desperate to prevent instead of treat. V. short-sighted not to. #twitjc -9:01 PM amitns RT @aj0610: @petermbenglish Media aim to sell stories - sensationalism gets published over sensibility! #twitjc <ditto! -9:01 PM laikas RT @silv24: Have 2 recognise the commercial interest in treating more of the population with medication to reduce cases of a disease #twitjc -9:01 PM tdahlborg RT @doctorblogs: RT @amcunningham for statins to be beneficial&justifiable, we need evidence that risk of events is correlated with cholesterol level #twitjc -9:02 PM harryrutter @silv24 depends on the disease! common cold v type 2 diabetes #twitjc -9:02 PM silv24 Also as definitions of those at risk reduce, i.e. lowering hypertension guidelines, we treat more and medicalise more people #twitjc -9:02 PM KP_LD @northern_doctor and psychologists! You know, experts in behavioural change ;) #twitjc 9:02 PM themattmak RT @carotomes: @silv24 is it absolutely cheaper to prevent rather than cure #WanlessReport #twitjc -9:02 PM anaestheticdoc god forgive me for saying it. But private health care and cost to the individual might make people take healthy life style. #twitjc -9:02 PM Trisha_the_doc @anaestheticdoc #twitjc it's still to do with understanding. Most don't mind idea of sudden death but actually smoking usually long n slow! -9:02 PM carlylou RT @GabrielScally: Best bit of the paper is p1848, Bottom 3rd para. ' by uncritical propagandists, by, cranks, and by battling commercial interests.' #twitjc -9:02 PM

carotomes @fidouglas QALY not perfect but useful hypothetical construct to guide decision making. What factors concern you? #twitjc -9:02 PM medicscott @anaestheticdoc There are many with the "Got to die of something" view, where lifestyle advice will forever fall on deaf ears #TwitJC -9:02 PM petermbenglish Like Hope-Simpson, http://1.usa.gov/l1RLlj , Rose was ahead of his time. #TwitJC -9:02 PM endless_psych @northern_doctor Should be? Perhaps. I suspect psychologists are massively better on this though #twitjc -9:02 PM northern_doctor @GabrielScally My impression is that development & investment in PH posts is being neglected - is that accurate? #twitjc -9:03 PM fidouglas @KP_LD @northern_doctor Agreed - health psychology is a very important field when we consider public health. #twitjc -9:03 PM davecurtis314 Anybody know cost to prevent a case of cervical cancer using vaccination? If no answer in a minute I'll tell you. #twitjc -9:03 PM leighblue RT @themattmak: RT @danjrharvey: I'd vote for economics as the most powerful mechanism for changing the behavior of a population #twitjc << vote seconded -9:03 PM silv24 Ray Moynihan has written extensively about definitions of disease in the BMJ recently - and about the conflicts of interest involved #twitjc -9:03 PM anaestheticdoc @medicscott @anaestheticdoc and why should we presume that we are right? #twitjc -9:03 PM endless_psych @fidouglas QALYs are highly normative in their approach to measuring quality of life #twitjc -9:03 PM danjrharvey @silv24 would be one way of moblising media support - allow direct-to-patient advertising, then pharma will off set the booze advert #twitjc -9:03 PM Trisha_the_doc @danjrharvey @silv24 Yup, and there being votes in it is important if it's going to happen! #twitjc -9:03 PM Andrew_Mott @doctorblogs @nhs_gp NN etc also depend on quality of research and it's provenance, not to mention negative unpublished studies... #twitjc -9:03 PM tdahlborg RT @doctorblogs: proof re more effective? MT @drkerrynphelps statins NNT...but weigh the risks.Intensive lifestyle change safer&more effective #twitjc -9:04 PM fidouglas @carotomes Main issue for me is deciding the quality adjustment - it's very subjective. #twitjc -9:04 PM northern_doctor @KP_LD Yes, obviously a MDT approach would be ideal! Didn't meant to offend - was thinking about role of medics! #twitjc -9:04 PM KP_LD @anaestheticdoc it would for those educated/middle classes. Doubt it would for ppl from lower economic status groups tho #twitjc -9:04 PM Hamstav @davecurtis314: Gvnmnt should be desperate to prevent instead of treat. #twitjc Yes but we know prevention dont always work ;) -9:04 PM DrDLittle Right, goodnight all. Interesting topic but have to go. Well done on another successful #TwitJC -9:04 PM danjrharvey @danjrharvey @silv24 of course I don't actually agree with direct to patient adverts for other reasons #twitjc -9:04 PM

GabrielScally Cancer's very cultural in Bristol too! Difference between West Bristol and South for example. Courtesy of Imperial Tobacco. #twitjc -9:04 PM davecurtis314 Introduce a calory tax, that's what I say! #twitjc -9:05 PM Trisha_the_doc @northern_doctor Need to raise profile of public health I think. At all levels. They can save more lives than best intensifiers #twitjc -9:05 PM petermbenglish RT @northern_doctor: @GabrielScally PH neglected #twitjc <<Probably. Govt doesn't like to hear about inequalities and its role -9:05 PM fidouglas @davecurtis314 Course of Gardasil ~= 350. So about 15000? #twitjc -9:05 PM carotomes @Trisha_the_doc @anaestheticdoc also problem of prevention = treating a non-event. Hard to bestow motivation #twitjc -9:05 PM KP_LD @davecurtis314: Introduce a calory tax, that's what I say! #twitjc <-- I'd be bankrupt in a week! -9:05 PM northern_doctor RT @Trisha_the_doc: Need to raise profile of public health at all levels. They can save more lives than best intensifiers <-- Agreed #twitjc -9:05 PM GabrielScally @northern_doctor One of the major problems is every time the NHS reorganises we loose up to one third of the senior PH people. #twitjc -9:06 PM danjrharvey Will have to sign off shortly, thanks for highlighting a paper I'd never read. Interesting & thought provoking. #twitjc -9:06 PM criticalinsight Will have to sign off shortly, thanks for highlighting a paper I'd never read. Interesting & thought provoking. #twitjc -9:06 PM fidouglas One issue with preventive treatment is is makes asymptomatic individual assume a patient role. #twitjc -9:06 PM davecurtis314 More like 200K. Money well spent. RT @fidouglas: @davecurtis314 Course of Gardasil ~= 350. So about 15000? #twitjc -9:06 PM fidouglas Should individuals receiving preventive treatment be considered patients? #twitjc -9:06 PM petermbenglish Big PH necessary - "make the healthy choices the easy [and cheaper] choices" #TwitJC -9:06 PM northern_doctor @GabrielScally Imagine that makes it very difficult to follow through on longterm plans! #twitjc -9:06 PM silv24 With the risk to public health from the #NHSreforms there is the huge risk that preventative medicine is also under threat #twitjc -9:07 PM laikas I think I lost track. Which question are we? #twitjc -9:07 PM amcunningham @anaestheticdoc have you studied health inequalities much? #twitjc -9:07 PM anaestheticdoc could argue about cooking in schools al la jamie oliver. Maybe doctors arent the best for preventative medicine #twitjc -9:07 PM KP_LD @northern_doctor haha, you didnt offend! MDT all the way :) #twitjc -9:07 PM danjrharvey #twitjc an excellent idea, hope it continues to grow. Can recommend Tweetdeck as good way of keeping up! -9:07 PM criticalinsight #twitjc an excellent idea, hope it continues to grow. Can recommend Tweetdeck as good way of keeping up! -9:07 PM

Trisha_the_doc @DrDLittle @anaestheticdoc Life is so busy most don't think further than next days and also don't believe stuff'll happen to them. #twitjc -9:07 PM endless_psych @fidouglas Should patients be considered patients? #twitjc -9:07 PM northern_doctor Checking out now everyone - thanks for an interesting debate! #twitjc -9:07 PM doctorblogs nooooo! RT @fidouglas Should individuals receiving preventive treatment be considered patients? #twitjc -9:07 PM adriamarilla I couldn't agree more! #twitjc -9:08 PM davecurtis314 Prevention of one premature death from cervical cancer through vaccination costs about 200,000. #twitjc -9:08 PM fidouglas @endless_psych A person treated for slightly elevated blood pressure isn't ill. Should they assume the patient role? #twitjc -9:08 PM anaestheticdoc @amcunningham @anaestheticdoc no #twitjc -9:08 PM davecurtis314 Taking a pill every day makes you a patient. #twitjc -9:08 PM kevfrost @fidouglas: Should indivls receiving preventive treatment be considered patients? #twitjc <<< sell it as "to avoid you becoming a patient"? -9:09 PM amitns RT @davecurtis314: Prevention of one premature death from cervical cancer through vaccination costs about 200,000. #twitjc <wow! -9:09 PM GabrielScally We need to unleash the potential of all doctors to change society. Don't spend all their time in hospitals and consulting rooms. #twitjc -9:09 PM petermbenglish RT @davecurtis314: Taking a pill every day makes you a patient. #twitjc As Rose says in his paper! -9:09 PM amcunningham @KP_LD personally I think sociologists at least as important as psychologists when thinking about what determines health behaviour #twitjc -9:09 PM fidouglas @davecurtis314 Lifetime prevalence is about 1/150. And Gardasil costs about 300 or 400. That should work out at about 50k #twitjc -9:09 PM silv24 If true medicalises more of the population as a result RT @davecurtis314: Taking a pill every day makes you a patient. #twitjc -9:09 PM GabrielScally If all the paediatricians campaigned for 'safe routes to school' that would do more to reduce childhood obesity that anything else. #twitjc -9:10 PM petermbenglish RT @davecurtis314: Prevention of one premature death from cervical cancer through vaccination costs about 200,000. #twitjc <I'd check this -9:10 PM themattmak @davecurtis314 Not always! Plenty of people take multivitamins or cod liver oil. Not necessarily a patient. #twitjc -9:10 PM fidouglas @davecurtis314 I'm not sure. Is someone on the contraceptive pill a patient? #twitjc -9:10 PM davecurtis314 @fidouglas Disagree, but can't be bothered to argue now. Can revisit later. #twitjc 9:10 PM amitns RT @amcunningham: @KP_LD personally I think sociologists at least as important as psychologists when thinking about what determines health behaviour #twitjc -9:10 PM shanemuk RT @GabrielScally: "No mass disorder afflicting mankind has ever been brought under control or eliminated by attempts at treating the individual" #twitjc -9:10 PM

amcunningham @carlylou somehow or other we need to do more to draw more attention to this without compromising patient confidentiality #twitjc -9:10 PM endless_psych @fidouglas I think the patient role in some cases can be harmful. see variations of Stanford prison Exp. Run in wards #twitjc -9:10 PM EverythingVHost @fidouglas If so, we all are at least one way (e.g. water fluoridation), so nah, guess thats the split in treating risk vs disease? #twitjc -9:10 PM anaestheticdoc @fidouglas @davecurtis314 isn't that life time prevalence not mortality rate #twitjc -9:10 PM JoTreharne @davecurtis314 hi interested how much does HPV vacc cost vs. Cancer treatment? Also what is #TwitJC ?? Pls? Interesting discussion!:) -9:10 PM amcunningham RT @GabrielScally: If all the paediatricians campaigned for 'safe routes to school' that would do more to reduce childhood obesity that anything else. #twitjc -9:10 PM EverythingVHost RT @amcunningham: @KP_LD personally I think sociologists at least as important as psychologists when thinking about what determines health behaviour #twitjc -9:11 PM endless_psych @fidouglas Being a patient associated with feelings of a loss of agency and the like. #twitjc -9:11 PM fidouglas @anaestheticdoc @davecurtis314 Ah, yes, my mistake. #twitjc -9:11 PM petermbenglish RT @GabrielScally: If all the paeds campaigned 4 'safe routs 2 skool' that wld do more 2 reduce childhd obesity than anything else. #twitjc -9:11 PM cardio_matters RT @GabrielScally: If all the paediatricians campaigned for 'safe routes to school' that would do more to reduce childhood obesity that anything else. #twitjc -9:11 PM davecurtis314 Railways will pay 100-200K to prevent each death. #twitjc -9:11 PM danjrharvey @fidouglas think you're onto something there. medicine only becomes secondary when aim is social! (also weight loss, hair gain etc,) #twitjc -9:11 PM doctorblogs no! But are they "service users"or customers or clients?RT @endless_psych Should patients be considered patients? #twitjc -9:12 PM anaestheticdoc @fidouglas @anaestheticdoc @davecurtis314 still you can knock the cost of that treatment off the vaccine to! #twitjc -9:12 PM davecurtis314 @JoTreharne Just follow #twitjc and you'll see all gory detail. -9:12 PM carotomes patient role referred to assumes consensus/compliance... in reality more negotiation. Patients aren't always passive! #twitjc -9:12 PM petermbenglish Greater emphasis on healthy living cd help. But hard to make it happen. #TwitJC 9:12 PM danjrharvey @davecurtis314 Airlines pay about $3million I think. Industry's risk aversion directly related to population trust/fear/expectation #twitjc -9:12 PM dean_jenkins Would you offer a better reference for smoking cessation and reduction in CVD? @dean_jenkins @amcunningham #twitjc -9:13 PM amcunningham @dean_jenkins i'm just pedantic... of course it is sensible for people to stop smoking- I just though MRFIT was interesting choice! #twitjc -9:13 PM shanemuk RT @GabrielScally: If all the paediatricians campaigned for 'safe routes to school' that would do more to reduce childhood obesity that anything else. #twitjc -9:13 PM

carlylou @amcunningham yes, recognition of inequalities often leads to frustration when its outside your role to be able to do much about it #TwitJC -9:13 PM petermbenglish HPV vax is way off topic! Perhaps another time... #TwitJC -9:13 PM fidouglas @carotomes I do think there has been a shift away from medical paternalism. #twitjc -9:13 PM Trisha_the_doc @silv24 And that's NOT a good thing. (Medicalising healthy people). #twitjc -9:13 PM davecurtis314 If you smoked (I don't and hate it) how much would you want to be paid to stop smoking? #twitjc -9:13 PM alijmbacon @endless_psych which patients lose agency in which situation is person specific though #twitjc -9:14 PM doctorblogs what on earth characterises "patient role"? MT @fidouglas person treated for blood pressure isn't ill.Shld they assume patient role? #twitjc -9:14 PM danjrharvey Right really am off now.#twitjc. Will try to get back to the summary later ! We need a threaded twitter feed, anyone know of such ? #TwitJC -9:14 PM Trisha_the_doc @fidouglas Though supposedly if we get it right we can empower people to look after their own health more? #twitjc -9:14 PM endless_psych @KP_LD Most probably, things are changing however. Patient role and doctors role vastly changed over last 50 years or so #twitjc -9:14 PM endless_psych @doctorblogs People? #twitjc -9:14 PM fidouglas @doctorblogs What it says on the tin really, but from quite a paternalistic viewpoint. #twitjc -9:15 PM dean_jenkins @amcunningham what would be your choice of reference for our friend the psychiatrist on smoking cessation and CVD? #twitjc -9:15 PM petermbenglish @danjrharvey Tweetdeck. Have a column for #TwitJC search. -9:15 PM endless_psych @alijmbacon Indeed. #twitjc -9:15 PM carlylou @davecurtis314 does it? Think the concept of patient is v nebulous. Diff ppl decide they are pt at diff points #TwitJC -9:15 PM davecurtis314 I think there's a real conflict between risk/benefit to the individual and to society/NHS. #twitjc -9:15 PM Trisha_the_doc @fidouglas Perhaps go back to the concept of partnership with our patients? Doesn't work for everyone! #twitjc -9:15 PM GabrielScally Look at the great medical campaigning in Cardiff to introduce shatterproof glasses in pubs. That's doctors doing prevention! #twitjc -9:15 PM NHS_GP @carotomes I don't think patients are ever passive in #1care. #TwitJC -9:15 PM dean_jenkins @northern_doctor @Trisha_the_doc yes that's a good figure so what's the upper age limit for prescribing them then? #twitjc -9:16 PM endless_psych @doctorblogs Historically submissive and there to be told what will happen #twitjc -9:16 PM carlylou @davecurtis314 probably more on a Saturday night than a Sunday morning! #TwitJC -9:16 PM

danjrharvey @petermbenglish yep, got that, but need something to summarize the conversation after wards in readable format #TwitJC -9:16 PM carotomes @anaestheticdoc not Q of privatisation, but motivation. Short-term benefits should be promoted eg self esteem, social approval #twitjc -9:16 PM Trisha_the_doc @anaestheticdoc Excellent point! #twitjc -9:16 PM amcunningham @dean_jenkins not quite primary prevention as they already have chd http://is.gd/j9pnde #twitjc -9:16 PM endless_psych @doctorblogs Now very much awareness of multiple "patient roles" and many far more equal #twitjc -9:16 PM fidouglas Thanks everyone for joining, I think we'll officially bring things to a close, but feel free to keep chatting. #twitjc -9:17 PM GabrielScally It took Rose years to actually start campaigning on cardiac prevention. Stepping away from medical way of doing things is not easy. #twitjc -9:17 PM welsh_gas_doc You can't save people from themselves. If they want to smoke, drink, take drugs etc they will. No about of education will stop them #TwitJC -9:17 PM amcunningham @dean_jenkins this really is about primary prevention http://is.gd/b5O9pA benefits of smoking cessation #twitjc -9:18 PM fidouglas (Don't want to run too late). We've yet to decide on next week's paper, but will do so this evening & tweet & blog to let you know. #twitjc -9:18 PM psweetman It's easier to change society if you are paternalistic & society listens. Much harder to get grassroots opinion driving change #twitjc -9:18 PM twitjournalclub Thank you all for an informative and extremely interesting discussion - it has been excellent yet again #twitjc -9:18 PM themattmak @fidouglas @silv24 Congratulations again on a great #twitjc. Definitely more controversial and debate generating than last week's! -9:18 PM Assidens RT @GabrielScally: Look at the great medical campaigning in Cardiff to introduce shatterproof glasses in pubs. That's doctors doing prevention! #twitjc -9:18 PM carotomes RT @GabrielScally: If all the paediatricians campaigned for 'safe routes to school' that would do more to reduce childhood obesity that anything else. #twitjc -9:18 PM davecurtis314 Thanks for great job running this. Where do I get my certificate? #twitjc -9:19 PM Trisha_the_doc #twitjc My dinner is ready and footballer husband is home. Signing out to share meal and wine. But we've both done our exercise today! Bye! -9:19 PM twitjournalclub A summary will be posted on the blog like last week and please feel free to comment and continue the debate there #twitjc - ns -9:19 PM danjrharvey @petermbenglish hm, you can get a list out easy, but would be good to organise tweets under "replies" etc to see conversation #TwitJC -9:19 PM carotomes @psweetman starts w/ listening and understanding drivers/barriers/perceptions and motivations. Social marketing has a lot to offer #twitjc -9:19 PM amcunningham @welsh_gas_doc #twitjc we could try & do something abt the inequalities in society that make poorer ppl more likely 2 smoke/take drugs etc -9:20 PM fidouglas @danjrharvey @petermbenglish That would also be horrendously time consuming for me, I'm afraid. :-( #twitjc -9:20 PM

twitjournalclub The paper for next week will be announced tomorrow (when we have had time to choose one), please keep suggesting papers on the blog #twitjc -9:20 PM danjrharvey WARNING! My mention of diet and hair loss earlier has resulted in Twitter spam avalanche! #twitjc -9:20 PM medicscott @welsh_gas_doc What should role of medics be? To save people from themselves or patch them up to live their life as they want to? #TwitJC -9:20 PM carlylou Thanks it's been really interesting #TwitJC -9:20 PM danjrharvey @fidouglas of course, we need an automated option....software developers listening ? #twitjc -9:21 PM carotomes @welsh_gas_doc nudging is an interesting concept... suggests role of autonomy can be overridden. So you can help people #twitjc -9:21 PM endless_psych @doctorblogs In some, but not all cases, doubt and perceives indecision in a few conditions and for a few individuals bad. #twitjc -9:21 PM psweetman @carotomes Yes, complex but well proven methods exist #twitjc -9:21 PM doctorblogs time for historical change then? MT @endless_psych Patients: "Historically submissive &there to be told what will happen" #twitjc -9:21 PM welsh_gas_doc The Medical Profession can't save society, no matter how much it likes to think that it can. Needs input from SO many more sources #TwitJC -9:21 PM twitjournalclub A transcript will also be posted, thank you all yet again for such a fantastic and interesting discussion #twitjc - ns -9:21 PM