William Pickles

This month in the BJGP, the editor, Roger Jones, reviews open access publishing. There are lots of issue around open access and these are well summarised in the article. In general, open access is regarded as A Good Thing. I wouldn’t disagree.

Organisations such as the Wellcome Trust, the Research Councils UK, and National Institute for Health Research all have plans, or at least aspirations, to make the research that they fund open access. However, there are clear financial implications for some journals with the risk they could go to the wall if they don’t manage their income. Personally, I’m not sure that’s necessarily a disaster – arguably, there are far too many journals publishing too many papers of dubious quality.

The BJGP have analysed their papers from the past 2½ years. They reckon around 50% would have had APCs (article-processing charges) in their research grants. However, 50% wouldn’t and 38% were from outside the UK. Clearly, there is a risk that this research wouldn’t have made it into publication.

The current range for APCs in medical publishing is around £1000-2500 per article; not a large fraction of a major research grant, but a very significant sum for research that is not externally funded or which has been conducted with no funding at all.

I’ve been recently involved in a piece of ad-hoc research. It’s been through peer review and accepted by an open-access journal and we are now trawling around various departments in the university in a bid to find some funding. It’s a problem.

General practice has a rather proud tradition of research in the community. William Pickles, the first president of the College, came to light for his epidemiological work in Wensleydale. And I admire the work of Doug Jenkinson – a now retired GP who studied hundreds of cases of pertussis in his own practice over a long career. Perhaps there is no room for the amateur (not that I would classify the quality of work as amateur in those cases) in research these days but it would be a shame if an unintended consequence of open access was to close off these avenues. It isn’t necessarily desirable that community and primary care research becomes confined to academic silos.

So, I wonder if some kind of hybrid model may be most appropriate for the BJGP. I’ll watch with interest.

Roger Jones (2012). Open access publishing: a new direction for medical journals BJGP, 62 (603), 514-515 DOI: 10.3399/bjgp12X654830

I’ve had a couple of articles in the BJGP in recent months.

I wrote a piece on tobacco and the role of harm reduction. I’ve written on this before (here is one of my old Northern Doctor posts on the subject) and it seems to stir up some good discussion. I know NICE are consulting on this – I think it could become a hot topic in the next year or two. So, I thought it might provoke a little controversy but I’ve not heard a peep. Interestingly, I did get an email from Big Tobacco asking me if I would meet them to discuss my work. I haven’t followed up on that.

I also wrote a book review for Margaret McCartney’s The Patient Paradox. I’m sure you’ve read it already. You can buy it from Pinter & Martin here. I’ve just noticed that P&M are using a quote from my review.

The arguments are measured and well-referenced; the conclusions are distressing… Read this book. But don’t expect to be able to practice medicine in the same way again.

The article on bibliometrics, Making an impact: research, publications and bibilometrics in the BJGP, delves into the often bewildering world of bibliometric indices. The 2010 Impact Factor (IF) for the BJGP is 2.070 so it holds its position as the second most highly-cited journal of general practice and primary health care. Some GPs might wonder about the value of this but it highlights some important issues about the BJGP and its purpose. If you think the journal is simply for British GPs and it is essentially an RCGP mouthpiece then I think you are in for a disappointment.

I suspect that the majority of non-academic GPs would prefer an accessible, educational BJGP than one that was striving for the highest possible impact factor. The new publishing strategy of paper short:web long certainly helps the editor achieve this balance. Rob Atenstaedt’s article, Word cloud analysis of the BJGP, was also published this month (click on the frontcover image to see it in more detail). This was an analysis, using Wordle, of the entire 2011 content of the BJGP – some 600,000 words. Interestingly, Atenstaedt noted that the word ‘education’ was completely missing from the 100 words used in the BJGP’s word cloud. He also suggested that, if anything, the inclusion of words such as NHS, UK and London, suggested that the BJGP wasn’t meeting its stated objective of being an international journal.

The increasing use of web technology is likely to have a major impact on the way in which scientific research is published and accessed in the future.

The future is garlic bread open access and post-publication review – both fundamentally about web access, but at the moment the BJGP has very little in the way of a web presence. (Currently a Google search for the BJGP brings my website up as the fourth highest – and it was only three weeks since I started this site.) There are no blogs, the ‘Discussion Forum’ section of the BJGP is behind a paywall on the dismal RCGP site, and lacks any real facility to engage. It is struggling to shake off the impression it is a dumping ground for letters that don’t make the print version. The average spam pornbot on Twitter has more followers than @BJGPjournal.

A BJGP web presence that presented and discussed papers could have considerable appeal to the majority of GPs. Articles could be boiled down to their pragmatic clinical residue, providing much needed educational value, and it wouldn’t do any harm to the journals overall academic aims either.

Jones, R., Green, E., Hull, C., Niesner, E., & Schofield, P. (2012). Making an impact: research, publications, and bibliometrics in the BJGP British Journal of General Practice, 62 (596), 157-159 DOI: 10.3399/bjgp12X630214

Atenstaedt, R. (2012). Word cloud analysis of the BJGP British Journal of General Practice, 62 (596), 148-148 DOI: 10.3399/bjgp12X630142

I hope that that this post will form part of a regular series of BJGP blogposts. My aim is to post at least once per issue with a brief summary of a few articles from that month’s BJGP. I’ll prioritise clinical topics and particularly articles where I think there is a sporting chance they could actually change one’s practice.

The overall theme of the issue is communication and the editorial Calling time on the 10-minute consultation draws together some of the strands from the papers published. Ironically, I found it rather disjointed and difficult to read. The editorial started talking about the ‘medical interview’ which seemed like odd and slightly unsettling terminology but after the first section it was dropped and we were back to the ‘consultation’ again. However, I am in agreement about a couple of the main threads – risk communication and the consultation length. It is deeply alarming how wrong folk get it when it comes to discussions of risk. The concepts of relative risk and absolute risk are schoolboy stuff yet are systematically misused. The editorial suggests this is an educational need and a structural problem with modern consultations needing more time. There needs to be a whole scale shift in our thinking about consultation length. This is particularly the case in practices where minor illness has been diverted to nurse practitioners or the telephone. In my view, the 15-minute consultation should be the standard for GPs – and perhaps only reduced in specific circumstances such as urgent, open-access, or ‘one-problem’ surgeries.

[Curiously, this editorial references a paper yet to be published in the BJGP. Although described as ‘in press’ in the references, it is not, as far as I can see, available to view anywhere as is commonly done in other journals. As a reader this is a fairly irritating piece of BJGP time-travel. I guess within a month or two it will be of no consequence but I hope the editor doesn’t make a habit of it.]

If you haven’t gotten to it yet then the BJGP also provides a quick and dirty summary of the new NICE guideline: Management of hypertension in adults in primary care. One of the big changes is the dropping of the diuretic from first-line treatment. Diuretics are still there, way down the list of options, but the thiazides have now dropped out of favour to be replaced by the relative unknowns, chlortalidone or indapamide. The other major change is the use of ambulatory blood pressure monitoring (ABPM) as the preferred method for diagnosis. Many practices have these ’24-hour’ cuffs but they cost upwards of about £1500. That may be an unwelcome expense for some practices but the old habit of basing decisions on a handful of BPs in the surgery has been shown to be woefully inadequate.

The paper by Helsper and chums, Follow-up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care, is something that could change a GP’s practice. It’s all too easy to bat away mild rises in LFTs – but chronic hepatitis C infection is woefully under-diagnosed (and under-treated for that matter) and if GPs are glossing over mild rises in ALT we are missing a golden opportunity to diagnosis a treatable condition. This Dutch study took anonymised lab samples that had shown a slight rise in ALT and tested them for HCV. The prevalence of chronic HCV was 1.6% and 1.2% in patients with an ALT of 50-70 IU/l and 70-100 IU/l respectively. The anonymity does mean that there is a severe limitation as effectively the denominator is missing – we don’t actually know how many of these people already knew they were HCV positive.

Interestingly, this paper raises the point that the upper limit for normal ALT may have been distorted by the pool of undiagnosed HCV. When you consider that it’s a deeply alarming suggestion; it means that people with a serious, but treatable, disease can be hidden through something as simple as the ‘normal’ limit. It’s easy to think of so-called normal limits as being sacrosanct but like anything they are, to a degree, arbitrary. GPs should test anyone with risk factors but abnormal LFTs remain an important marker to highlight a problem.

But, I digress. The bottom-line from this paper is that even if you think you know why there is a mild ALT rise make sure you have excluded HCV infection.

Silverman, J., & Kinnersley, P. (2012). Calling time on the 10-minute consultation British Journal of General Practice, 62 (596), 118-119 DOI: 10.3399/bjgp12X625102

Helsper, C., van Essen, G., Frijling, B., & de Wit, N. (2012). Follow-up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care British Journal of General Practice, 62 (596), 212-216 DOI: 10.3399/bjgp12X630115

McCormack, T., Krause, T., & O’Flynn, N. (2012). Management of hypertension in adults in primary care: NICE guideline British Journal of General Practice, 62 (596), 163-164 DOI: 10.3399/bjgp12X630232