Dear Aubrey Bristow, I do not live in UK, but my comments are correct. As a matter of fact, UK - I don´t say UK doctors, but UK State - indeed has withdrawn enteral nutrition from comatous patients - read the English version of my article at https://revistabioetica.cfm.org.br/revista_bioetica/article/view/1498/1882 Moreover, we have here read from newspapers about British complex sick children to whom experimental treatments overseas were denied; their devices were shut down. They may be just a few cases, but they do have occurred in UK from time to time. 

Dario you may not live in the UK but your comments are wrong. The decisions are made by the Family Division of the High Court by lawyers not doctors. However they take the opinion of doctors and in the main the limitations you raise are the advice of the medical team. So they have nothing to do with assisted dying

This article makes many assumptions of the role of doctors. We are hoping when a patient raises the request that their consultant and GP will provide a diagnosis and medical history but we can circumvent that as we can obtain electronic notes without the doctor. It is expected there will be a panel of doctors that will be able to review notes, and provide assurance the legislation is met. I am not sure we need a doctor to even prescribe as it is assumed the drug dispensing will be by a pharmacist if an order is given and the order is not a prescription and may come from eg a social worker or lawyer or even a judge.

Furthermore other countries allow self administration at home and also administration by nurses. I do not see you need a doctor to mix up drugs and offer them. I accept many doctors will not want to be seen to be assisting death while still practicing but we are talking of 5 cases per 100,000 population so a small number and even if doctors are needed some will be willing and also retired doctors are being considered.

It will be obvious I believe the small number of patients who cannot be adequately helped by palliative care should have a choice. It seems to me much of the opposition comprises those trying to impose their beliefs or views on others or those claiming it cant be done. Australia and New Zealand show it is practical and safe.

Dear John,

In reply to your request for comments about the medical system in the US - I feel I am fairly qualified to comment as I lived and worked there from 2012-2019.

In a word - it is 'broken'. Certain segments are magnificent - especially in the field of trauma and reconstruction - but other areas are simply out of control.  The stranglehold that Medicare, Insurance Companies and corporatised medicine holds - makes it all but impossible for individuals to practice freely and intuitively.

Add to this the 'legal vultures' - from both sides - the prosecutors of 'malpractice' - countered by the defenders of 'class actions' - make a total mockery of what care should all be about.

A brief Google search of fines and criminal convictions in the pharmaceutical industry should be enough for any thinking person to pause - and take heed of what is actually going on.  It is a headlong lemming-like dash to be the first to release the latest 'silver bullet' - and make Wall Street and the Investors rub their hands in glee.

One thing however does comfort me - and that is a very small percentage of the world practices Western Medicine'.  As large as it looms in our lives - less than 20% of the world's population practices the Latino-Greco complex identification of diseases so that equally complicated 'pharmaco-babble' can be employed to confuse things further.

It would be wise to put things into perspective.  Western Medicine is but a babe in the world of health.  It came into being around 1910 as a result of the Flexner Report - commissioned by Carnegie and Rockefeller - largely outlawing practitioners and  remedies that had been proven effective over thousands of years.  

To think that I have been around for 84 of those 114 years certainly puts things into perspective.

1.3 billion Indians use Ayurveda, 1.4 billion Chinese use TCM, Japan uses Kanpo, over 1 billion Africans still use tribal medicine, many parts of Europe still use herbalism and homeopathy - so it is not such a big deal after all.

The reality though is that this 20% generates THREE TRILLION DOLLARS a year and the US has the worst of all health outcomes in all of the OECD countries.

We think we are living longer.  The reality is that we are actually dying longer.

Yet - I still live in hope.

Dear Dr Bookbinder

thank you for your comment.  Below is an abstract of the paper from which my comments originated.  Admittedly it is a cross sectional study.  I may not have the appropriate information.  Can you share your references which provide a rational for spinal xray in this patient’s case.  

Plain lumbosacral X‐rays for low back pain: Findings correlate with clinical presentation in primary care settings

Mohammed AlAteeq1,2, Abdelelah A. Alseraihi2, Abdulaziz A. Alhussaini2, Sultan A. Binhasan2, Emad A. Ahmari2

1Family Medicine Department, Ministry of National Guard ‐ Health Affairs, Riyadh, Saudi Arabia, 2King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

2020 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer - Medknow 6115

How to cite this article: AlAteeq M, Alseraihi AA, Alhussaini AA, Binhasan SA, Ahmari EA. Plain lumbosacral X-rays for low back pain: Findings correlate with clinical presentation in primary care settings. J Family Med P

AbstrAct

Background: Low back pain (LBP) is a common disabling condition frequently seen and managed in primary care. LBP is considered to be the most common health problem for which general practitioners order an imaging test. Objective: To correlate radiological findings of plain lumbosacral X-rays with the initial clinical presentation of patients with back pain. Materials and Methods: This is a descriptive cross-sectional retrospective chart review study, conducted for 384 adult patients, with back pain who had plain lumbosacral X-rays, at three primary healthcare centers at King Abdul-Aziz Medical City (KAMC) in Riyadh, Saudi Arabia, in the period from 1 Jan 2017 to 31 Dec 2018. Results: The majority of cases had either normal lumbosacral X-rays (32.8%) or incidental findings that were nonspecific. The most abnormal findings were degenerative changes such as spondylosis (osteophytosis) and narrowing of the intervertebral foraminal space (45.3%). The vast majority of cases of chronic back pain was associated with abnormal findings on a plain lumbosacral X-ray, which constituted most cases with abnormal findings among subjects. Conclusion: Lumbosacral X-ray findings in the vast majority of cases do not correlate with clinical presentation and do not justify routinely ordering imaging studies for nonspecific back pain in a primary care setting

comments 1

Yes polygraphs are pretty worthless but lets put this in context. This isnt about lie detectors for doctors so much as the investigatory process for drug abusers who work in healthcare. The US has a pandemic of healthcare workers stealing drugs at work whereas ASAIK in the rest of the world this is very rare and most illegal drugs are purchased outside the healthcare setting.

Having overseen just 4 cases in over 30 years working in large hospital bodies, my take is that these people need help. In the UK we have a concept called the three wise men; three senior doctors not connected to the hospital who manage the individual. This depends on the individual admitting their drug takling. The individual can then retrain in the NHS with no loss of salary. Three out of the four have returned to medicine albeit not in a specialty that has unsupervised access to controlled drugs. Hence I am not so sure why the US system needs lie detectors ie why in the US our colleagues are less willing to admit their addiction and seek help. Is it because they are accused of theft rather than being seen as addicted? Comments from our US colleagues welcome.

Dear Cecilia Parish, I am really enjoying all the photos in these comments, thank you for sharing! 

Thank you for the reminders (allergies and insurance). Very important and insurance I really didn't think of! Is it a special type?

Dear Letitia Muresan, I am really enjoying all the photos in the comments here! Thank you!!

I agree with previous comments. I have never experienced any misbehaviour in the opereating theatre, however, I have been told stories describing some old professors, whose superiority complex influenced their attitude towards their younger and less experienced colleagues in a negative way. I understand that stress may cause people to lose temper, but, I think that poor behavior is very unprofessional and it shoud be a relic of a bygone era.

Goodness what is going on over there? Rudeness and inappropriate comments are very very rare in all the countries I have worked in. In my hospital any 'poor behaviour' results in tea and biscuits without biscuits with the head of department or in the case of a consultant the responsible officer. Any recurrence leads to disciplinary action leading to dismissal. 

I for one dont like bits of paper stuck on my theatre walls - I dont do it in my home - and certainly not signs saying rudeness exists here

Dear Teresa Wood, This is a great site and we try not to attack each other and use words like offensive. I hope that continues. I see nothing offensive in any post. The world is watching Canada with ever greater disbelief, including the recent announcement (as reported in the UK press - please correct me if inaccurate) your country intends to punish or lock up people not for what they have done but solely on the belief they may in the future say something others find offensive. So your use of the word is of significant importance.

I have worked with transgender patients for 20 years and find them some of the nicest patients I treat. They tell me transitioning changed their lives out of all recognition BUT historically the numbers were so low that in the UK just a couple of units managed a population of 55m. We have to ask why after decades of transgender clinics open to all and with spare capacity have the numbers deciding they need to change gender risen exponentially. Why are we seeing so many children and claims 4 year olds need medical treatment. The comments above reflect society and the medical profession worried we may be helping a few but harming many others.

Are they on treatment for adhd.  I have seen the dopamine boost of stimulants uncover psychosis in a patient (50 yo cis male). But I can’t find evidence either way for your question about testosterone.  Our patient was started on low dose abilify and switched from Dexedrine based adhd management to Concerta with rapid stabilization.  

I’m deeply sorry for offensive comments from colleagues who have not yet considered that genetic diversity has been here since the dawn of time just like hair color diversity and snowflake diversity and calling it a delusion assumes they know more than their God does about sex differentiation diversity at cellular, hormonal, neuro transmitter or other places.  Doctors egos in the face of rising evidence for normal variation in nature (as always) never ceases to amaze me!  

I hope a modification of the ADHD meds helps.  If it was the T, that would be the first I’ve heard of it, whereas there is data for Dexedrine stimulants and hyper dopaminergic states. 

The previous comments are valid.  I think it depends on how the medical scheme works in your country.  I have never had that concern expressed but as an academic physician in a university health care centre I am salaried; I have heard this from time to time from colleagues who are in fee for service practice.  I suspect the comment is more to do with frustration at the pace of recovery than with your practice model, though

The situation here in Brazil is a mix of the other comments shown. Here, one thing is a lawsuit. The other is the final judgment. At first, here, this patient would never win (or difficultly would) as to judically extort money from the doctor. The first question to be made is: did the patient die? Complicated? Had to go to ICU? No? Then, don´t bother me. However, a lawsuit is considered a right of the patient, especially when minors are involved. The patient makes the accusation, the doctor/hospital defends. The difference regarding USA is that here, the judge will name a doctor to be his/her professional assistance. This doctor will be the one who will save or condemn the sued doctor, by saying to the judge if there was negligency or medical error. The sued doctor may present his/her own professional assistance. Also, here in Brazil, since the doctor worked in a hospital, the hospital must be accused together. So, here the system did not flunk totally because indeed it works in a way to extort money from the doctors to the lawyers, not to the patients. Overall, the main judical strategy here is to slow down the process as much as one can, so the patient takes too long to receive money, if any, in a example to other patients to not go sueing freely, or even less for such finickies. Anyway, as a private clinic reaches some size, a group of lawyers must be hired, since the harassment of patients for money never ends. 

Free speech especially where there is reasonable medical uncertainty is one thing, medical misinformation is another - I point to Andrew Wakefield, whose comments have led to preventable deaths - not OK; a breech of professional responsibility

Thank you for comments 

There’s no storage , I keep this in mind 

I agree with the comments.  I think a family meeting would help with consent from the patient and give you a chance to explain that all the contacts are interfering with your care of other patients.  It gives you the chance to tell them that you understand that communicating with the family is necessary and you want to help them.  This gives you an ethical reason to limit the calls.  The limits will be an important part of the discussion and I think that agreeing to one discussion of a limited amount of time I.e. 15 minutes/ day is reasonable.  I would tell them that when you speak they should have prepared questions for you.  You might also try to help them understand that talking to so many in the family may potentially interfere with effective communication and that this would stress the patient and interfere with their recovery.