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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.

From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.

The word limit for letters selected from posted responses remains 300 words.

Re: Junior doctors’ strikes: it’s time to stop the walkouts and start negotiations Fraz A Mir. 381:doi 10.1136/bmj.p813

Dear Editor

The moral obligation to strike and the temptation of extremism

Fraz Mir argues that the recent industrial action by junior doctors put patients in harm’s way, endangered them by compromising their safety, created hardship for thousands (if only in the short term) and was likely to have eroded public trust in the medical profession (1). Presented in this way, industrial action by doctors looks like a definitive moral wrong.

However, much of the argument about the ethics of industrial action by doctors runs in the opposite direction. In a socialised health care system concrete circumstances promoting conflict between doctors and the State must be considered, alongside general ethical principles. Toynbee and colleagues (2) point out that the change to a shift-based system has decreased the number of junior doctors on site at any given time, whilst intensifying their workload and eroding the quality of care. Junior doctors have largely lost control of their training which they experience as inflexible, impersonal and overly specialised (just when the NHS needs generalists). All of this was rewarded by a 15% real term reduction in salaries between 2009 and 2014. It is hardly surprising that junior doctors have opted for industrial action.

Limited short-term industrial action seems unlikely to be harmful to patients (2) and emergency care may even improve (3). The erosion of the quality of care poses a longer-term risk to the public. Davies argues that “If the conditions that doctors work under put patients at risk, then (on balance) they are morally obliged to strike” (4) .

Roberts (5) offers some ethical conditions for legitimate industrial action: strikes should be proportionate, not obviously futile, a last resort, organised through a body with a legitimate claim to represent medical interests and announced in advance. Health services should nonetheless ensure that emergency care is made available during walkouts, and that junior doctors “avoid the temptation of extremism by protecting the weak and the vulnerable during their quarrels with their employer” (4).

1) Mir FA Junior Doctors’ strikes: it’s time to stop the walkouts and start negotiations BMJ 2023:381:p813
2) Toynbee M, Al-Diwani AAJ,Clacey J, Broome MR J.Med Ethics 2016;42: 167-170
3) Metcalfe D, Chowdhury, Salim A What are the consequences when doctors strike? BMJ 2015;351: h6231
4) Davies M Is it ethical for doctors to strike? BMJ 2015; 351:h5597
5) Roberts AJ A framework for assessing the ethics of doctor’s strikes J Med Ethics 2016;42(11) 698-700

Competing interests: No competing interests

16 April 2023
Steve Iliffe
Emeritus Professor of Primary Care for Older People
University College London
London NW2 3BP
Re: Rammya Mathew: Helping patients off the conveyor belt of interventions Rammya Mathew. 381:doi 10.1136/bmj.p761

Dear Editor

Rammya Mathew’s powerful, and moving, description of the disruption caused by overuse of tests and reminders deserves much wider readership -- for example, by every specialist group seeking to add yet another nudge to clinical practice. The call by the Chief Medical Officers and other leaders in the first editorial of the 2020s -- responding to the challenge of multimorbidity -- has had little impact and it is up to GPs to practise Cluster Medicine for people like me, with four diagnoses and eight pills, who are not fortunate enough to be supported by Geriatric Medicine.

The General Practitioner needs time for empathy and time to focus in those precious minutes of the consultation without even more low value prompts for action. I was recently informed I had ‘pre-diabetes’, with a body mass index of 23, adding yet more time required for a doctor or nurse to explain what pre-diabetes is thought to be.

The people called patients also have a part to play. They need to be prompted to think more clearly before they arrive at the consultation -- for example, about what is actually bothering them most and about what questions they want to ask. They also need to be given reading and learning about, for example, HbA1C or how to manage anxiety about their conditions. This obviously requires a digital wellbeing service for better self care, and for digital groups to meet with others with the same problem who are there 24/7. Many people are not yet online but this is changing and everyone will have ‘the internet’ for a ‘mains’ knowledge service just as they have mains electricity and water.

Rammya Mathew’s analysis needs its own editorial linked back the CMO’s editorials on multi morbidity and on secondary prevention

Competing interests: We are developing a digital self care service

16 April 2023
Muir Gray
director of the Optimal Ageing Programme
Re: BMA and NHS leaders call on government to engage with arbitration service to end junior doctors’ pay dispute Abi Rimmer. 381:doi 10.1136/bmj.p844

Dear Editor,

The government fails to come to the table at its peril.

Having supported junior colleagues on picket lines in 2016 and 2023, it is obvious that the public are very much on the doctors' side this time round.

I have observed more pipping, tinging, smiling, thumbs up, power salutes, clapping and waving than in 2016. There are more positive comments and fewer snide ones. People have been dropping off refreshments that they are donating. Groups who are not supposed to toot their horns, such as the police, have told us that they still support the action.

These are the folks who will be voting in forthcoming local and general elections. Those currently in power need to buck their ideas up if they want to stay that way.

Competing interests: No competing interests

15 April 2023
Rachel L Hooke
Freelance Writer, Trainer and Translator
Re: Despite historic bans, south Asia still struggles with pesticide suicides Sonia Sarkar. 381:doi 10.1136/bmj.p678

Dear Editor,

As expected, our country contributes significantly to the suicide numbers by pesticides. As a GP in the city I do see very frequently youngsters, both boys and girls of adolescent age, committing suicide with the available pesticides. Along with the pesticides other agents like floor & bath room cleaning agents, paint thinners, etc, are commonly used. Many of these suicides are for reasons such as - boy and girl involved in love across different religions and caste, anger with the parents for not getting pocket money or not sending them out with other friends, not getting the desired dress, etc. Husband and wife arguing with each other for silly reasons is also common. Unable to meet the financial commitments, financial loss in enterpreneurship wherein whole family yields to the method of consuming chemicals. Very sad but is there another way out? There is a distress call service - psychiatric help may help a few, but in these present cruel competitive times I am not sure we will be able to help.

And some of the newer agents do not have antidotes. There should be bold display of the same and also pictures - like on cigarette packs.


Competing interests: No competing interests

15 April 2023
mohan devegowda
613 2nd main first stage indiranagar bengaluru 560038
Re: India’s struggle with medical malpractice Kamala Thiagarajan. 381:doi 10.1136/bmj.p632

Dear Editor

Here is one of the multiple scenarios that happen in India. A patient becomes sick in a small nursing home/ hospital, where the patient’s attendant creates chaos, threats, abuses, and sometimes manhandles the treating doctors. Strict law is rarely enforced. Unfortunately, the mob ransacks the smaller nursing home or hospital if the patient dies. The patient's attendants protest on the roads and attract media attention. The case is filed under section CrPC 174, but there are certain circumstances, like Dr. Archana Sharma, who was charged with IPC 302 (murder) without a medical team expert opinion.

Rarely are there instances where attendants influence district collectors to instruct the local medical college deans and the forensic department to find medical negligence. Whole-body CT scans, X-rays of the deceased body, and VIDEO recordings of the postmortem are done to find the cause, which happens only in rare situations. Indian doctors have been harassed to a maximum extent that all laws in India will be used to find a cause to make them medically negligent, even if not.

In recent times India has witnessed the unethical and atrocious behavior of a few journalists, papers, and online media where the nursing home/ hospital and the treating doctors are named in their news without evaluating the truth and waiting for the medical expert committee's opinion. This flares more wrong information and false impressions about the Indian doctors and the hospital to the common man’s perception. There is no control over this now.

There are windows for the attendants where a criminal complaint can be made to the police commissioner, DIG, and the local police station, repeatedly pressuring them to recharge the complaint 174 to IPC section 302. Higher up on the ladder, the patient’s attendant complains to the state health minister and health secretary. India has no proper protocol and system where the medical grievances redressal mechanism functions and addresses the calls.

Further, in a democratic country, courts are always the savior. The patient’s attendants file many petitions under different constitutional powers masking the truth and demanding the arrest of the treating doctors under section 302. Also, there are various forums, such as the state medical council, Director of health services, and family and rural health services, where the petitioner can make a complaint. The doctors and the hospital face enquiry in all these forums for the petitioner's complaint.

In some situations, a state medical council clears the doctor and team of no negligence. Still, the case is being held in the criminal courts, state health, and rural service departments without being aware of the medical expert team's opinion of the medical council. The Joint directors or directorate of the state should be educated about medical negligence and errors of judgment. Error in judgment is not medical negligence. They should be unbiased, bold, and informative in dealing the medical negligence cases. A prompt inquiry by a medical expert team and a timely decision save the doctor from harassment, abuse, mental unwellness, and despondence. The complications, untoward incidents during surgery or after, not conducting a few tests, finding faults in clerical errors, and expecting the imaginary best healthcare are not medical negligence.

The saviors and frontline warriors of dreadful COVID-19 cannot be portrayed as criminals in untoward incidents. India needs a renaissance and a colossal change in handling medical negligence, and I pray through this letter that justice prevails for doctors. Pushing them to halt the minds of saving the patients because of harassment will be a national loss; no doctor will take any risk. This will bring a monumental catastrophe to Indian healthcare.

Competing interests: No competing interests

15 April 2023
Terrence Jose Jerome
Orthopaedics, Hand and Reconstructive Microsurgeon
Olympia Hospital and Research Centre
47,47A, Puthur High Road, Trichy-620017, Tamilnadu, India
Re: Intercalation helps to develop doctors with a more holistic approach to medicine Reagan Lee, Oscar Han. 380:doi 10.1136/bmj.p577

Dear Editor,

I would caution the authors not to put intercalated degrees on a pedestal; there are many ways to develop more holistic approaches to medicine that are more inclusive than an intercalated degree.

Pertaining to the suggested benefits of intercalated degrees outside of clinical practice. Publications, conference posters, and forming a good professional network are examples of ways in which low-income students are differentially disadvantaged when applying for competitive training posts. Highlighting these benefits of an intercalated degree demonstrates how low-income students and trainees are excluded from conversations about career advancement.

Holistic development must include an appreciation of the factors which contribute to differential attainment at all levels in medicine. More work must be done to make intercalated degrees more accessible, and to provide all students and trainees with opportunities to produce research and build professional networks. Making recommendations without the resources to support participation may further existing disparities in training.

Competing interests: No competing interests

14 April 2023
Daniel J Chivers
Junior Doctor
Barnsley Hospital
Barnsley Hospital
Re: Rammya Mathew: Helping patients off the conveyor belt of interventions Rammya Mathew. 381:doi 10.1136/bmj.p761

Dear Editor,

Dr Rammya clearly illustrates the sense of over-whelm most clinicians feel when consulting with real world patients, who often have many complex conditions and bring both physical and social issues to a long-awaited but short consultation.

When guidelines are viewed in totality, it is very clear that we have lost the wood for the trees, have forgotten the person behind the disease and are failing to address the root causes of the symptoms we are seeing.

Basic science is now painting a clearer picture of a common underlying pathology to all these long-term conditions from cancer to neurological disease, autoimmunity and metabolic disease; that of immune dysregulation resulting in chronic systemic inflammation. The key driver of this dysfunction is often environmental and lifestyle factors influencing gene expression and our microbiome amongst others.

Our current medical model is based on a dated, reductionist and deterministic view of disease that stems from the era of genetic discoveries, this has fostered a pervasive belief that diseases exist in isolation and we are powerless victims without medicine and medications.

This is not the case, if we take a step back from the relentless assessment, quantification and labelling of disease and spend more time addressing their root causes, we may be able to support people to reverse or at least improve or delay these conditions. For example, this can be done through supporting better nutrition, sleep, social connection, increased activity and so on.

What I and Dr Mathews are seeking is fewer guidelines and assessments for more Public Health measures outside the consulting room and more Lifestyle Medicine approaches in it. Lifestyle Medicine is a discipline that is aware of the social drivers of behaviour, acknowledges the difficulties people might be facing and uses person-centered techniques that can support people to make lifestyle changes to improve health.

In my own practice as a GP with training in Lifestyle Medicine, I now ask people what matters most to them, where they would like to start and work with them to address the root causes of their symptoms. With patients agreements, we often stop medications and I’ve seen reversal of Type-2 diabetes and hypertension many times now.

This approach isn’t new, nor is it controversial - being the first step in all major long-term condition guidelines. But it is neglected, the funds for creating good quality education and evidence-base, are sorely lacking and need a mind-set and policy level change. The hardest behaviour to change however, is not that of our patients but that within medicine itself.

Competing interests: Consulting work with the NHS Type-2 Diabetes LCD programme (supporting remission through weight loss)

14 April 2023
Ellen S V Fallows
Vice-President of The British Society of Lifestyle Medicine
Re: Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis Matt Sutton, Bruce Guthrie, et al. 380:doi 10.1136/bmj-2022-072098

Dear Editor

The paper by Morales et al. (1), falls into the trap of measuring the impact of the Quality & Outcomes Framework against itself. The remit and overall quality of General Practice is far broader than this relatively narrow and transactional set of measures, and yet the impact of QOF on overall quality is not explored. This is a missed opportunity.

The impact of incentivised external motivators is mentioned in passing, but warrants further exploration. The work of Daniel Pink and others on what motivates individuals and teams is very clear; external motivators such as targets and financial incentives are powerful de-motivators and reduce overall performance in all but the simplest of tasks. (2). Against this knowledge, the current General Practice contracting arrangements are well placed to demotivate an entire profession.

With 33.4% of General Practitioners report a high chance of leaving the profession in the next 5 years (3) 43% of GPs who have left citing burnout as a reason for leaving (4), and with public satisfaction with General Practice falling dramatically (5), we are going to need all the internal motivation we can get if UK General Practice is to reverse the current crisis.

We need a much more sophisticated, broader, and longer-term understanding of General Practice quality that must include the experience of patients and the wellbeing of our workforce. Without this wider view we will continue to reap the unintended consequences of well-meaning but narrow and short-sighted improvement tools.

1. Morales DR, Minchin M, Kontopantelis E, Roland M, Sutton M, Guthrie B. Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis. BMJ. 2023;380.
Available from:
2. Pink D, Drive: The Surprising Truth About What Motivates Us. Canongate Books 2010
3. Odebiyi B, Walker B, Gibson J, Sutton M, Spooner S, Checkland K. Eleventh National GP Worklife Survey Policy Researh Unit in Commissioning and the Heathcare system. 2021,
Available from:
4. Royal College of General Practitioners. Fit for the Future: Retaining the GP workforce. Sept 2022.
Available from:
5. NHS England. GP Patient Survey 2022.
Available From:

Competing interests: No competing interests

14 April 2023
Ian J. Lawrence
Clinical Director for Integration & CCIO
Derbyshire Community Health Services
Re: Jiang Yanyong: surgeon and whistleblower who reported China’s first SARS outbreak to the media John Illman. 381:doi 10.1136/bmj.p733

Dear Editor,

The leader of the World Health Organization stated on Mar 17th that he expects the organization to declare an end to the COVID-19 pandemic later this year [1]. However, a week later, three Chinese doctors published a correspondence letter to describe the situation of Chinese medical staff after the COVID-19 pandemic. The letter was soon retracted [2], once again, following the retraction of a letter requesting international assistance from two nurses at the beginning of the pandemic [3].

During the past three years of the COVID-19 pandemic, Chinese medical staff have faced unprecedented pressures, including unfulfilled medical needs, contagion risks, pandemic prevention measures, and lack of public support, as the Chinese government adhered to the “zero covid” policy. The physical exhaustion and mental health burnout resulting from this policy caused significant impairment, and Chinese medical staff experienced higher rates of burnout than medical staff in developed countries [4]. However, this issue has received little attention from the international community. Despite the language barrier confronting the authors who may be interested in knowing more [5], the difficult situation faced by Chinese medical staff is an undeniable fact. While the world has seen doctors in the UK, US, or Germany striking for their professional wellbeing, few voices have emerged from China, and it seems that these voices are being further silenced. When communication with the international community is blocked, the situation of medical staff will undoubtedly become even more challenging.

As other countries and governments start to summarize the lessons learned and move forward at the dawn of the end of the global pandemic, the Chinese government is trying to forget and erase the vestiges of the "zero covid" policy [6], which has irreversibly affected millions of people's lives. However, we must not forget the wellbeing of Chinese medical staff and ensure that it remains a critical priority, and their voice not to be silenced.

1 Virtual press conference on COVID-19 & Other Global Health Emergencies 2023. Available at: Accessed April 12, 2023.
2 Sun L, Jia H, Yang T. Chinese medical personnel after the COVID-19 pandemic. The Lancet 2023;401(10381):1000. (23)00394-X/fulltext#back-bib1.
3 Zeng Y, Zhen Y. Chinese medical staff request international medical assistance in fighting against COVID-19. The Lancet Global Health 2020;0(0). doi:10.1016/S2214-109X(20)30065-6 [published Online First: 24 February 2020].
4 Zheng Q, Yang K, Zhao R-J, et al. Burnout among doctors in China through 2020: A systematic review and meta-analysis. Heliyon 2022;8(7):e09821. doi:10.1016/j.heliyon.2022.e09821 [published Online First: 28 June 2022].
5 "I really want to know what the medical staff think when the zero-covid is released"?(in Chinese) - Zhi Hu 2023. Available at: Accessed April 12, 2023.
6 Hong N, Wang Z (2023). China Moves to Erase the Vestiges of ‘Zero Covid’ to Deter Dissent. The New York Times, 28 February 2023. Available at: Accessed April 12, 2023.

Competing interests: No competing interests

14 April 2023
Zhi Qu
research scientist
Hannover Medical School
Carl-Neuberg-Straße 1
Re: Rammya Mathew: Helping patients off the conveyor belt of interventions Rammya Mathew. 381:doi 10.1136/bmj.p761

Dear Editor

Goliath was weighed down by his heavy armour

Professor Sir William Ferguson Anderson ('Fergie' - first Professor of Geriatric Medicine at Glagow) used to say that the only reason for measuring blood pressure was to check for hypotension. Too much information makes it difficult to get to the essence. We surely must find a way to use the lessons from the past.

Competing interests: No competing interests

14 April 2023
David Jolley
Retired Psycho-Geriatrician
Previously The University of Manchester