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BMJ. 2007 August 4; 335(7613): 0.
PMCID: PMC1939775
Editor's Choice

Questioning fondly held assumptions

Jane Smith, deputy editor

An important part of the BMJ's business is to question assumptions. Mostly this is done in a well mannered way, but sometimes we hit a raw nerve and emotion breaks through.

This happened last week over our head to head debate on whether there should be a boycott of Israeli academic institutions. The associated poll produced an unprecedented number of votes and the flavour of the debate can be gauged in our Observations section, together with the editor's response on why we published the debate (doi: 10.1136/bmj.39294.443264.59). Most of the correspondents quoted have engaged with the arguments, but others in rapid responses and in direct emails have not, choosing to focus on our right to host the debate.

In contrast, our editorials this week illustrate the careful unpicking of evidence on issues that also are or have been controversial. Each is commenting on an article in this issue and each exemplifies the role of such an editorial, setting the context for the article and broadening the discussion around it. The oldest controversy is probably that on hormone replacement therapy. The WISDOM trial, reported by Madge Vickers and others (doi: 10.1136/bmj.39266.425069.AD), was stopped prematurely once the results of the US women's health initiative study showed that HRT did not have the beneficial effects expected on coronary heart disease and indeed showed increased risks of breast cancer, stroke, and venous thromboembolism. Even with fewer than planned participants and limited follow up the WISDOM trial confirms this: the groups receiving HRT had significant increases in cardiovascular and thromboembolic risk. In her editorial Helen Roberts says that HRT has come full circle (doi: 10.1136/bmj.39272.445428.80): it “was originally used to treat menopausal symptoms, and now the indications for use are again hot flushes, night sweats, and vaginal dryness.” The hope that HRT could also prevent chronic disease is dead.

The debate over abstinence only programmes for preventing HIV should also be dead after this week's systematic review by Kristen Underhill and colleagues (doi: 10.1136/bmj.39245.446586.BE). The review shows that they don't seem to affect the risk of HIV infection in the developed world as measured by self reported biological and behavioural outcomes. In their editorial Stephen Hawes and colleagues bring this evidence together with the rather sparser evidence from the developing world to advocate programmes that promote condom use, which do reduce the risk of acquiring HIV (doi: 10.1136/bmj.39287.463889.80). This message matters more in the US, where some government funds for AIDs prevention can be used only for abstinence programmes. Here is some clear evidence for policymakers. Will they follow it?

There's more evidence for policymakers in the third paper-editorial pair. In his analysis paper Jonathan P Weiner questions the recent call by the American Association of Medical Colleges for an expansion of US medical students by 30% (doi: 10.1136/bmj.39246.598345.94), drawing on evidence showing little relation between more doctors and better health outcomes. But his article also undermines the belief that UK has far fewer doctors per person and a far higher percentage of generalists than the US: “the total number of active and trainee doctors …is only 16% higher in the US than in England” and the proportion working as generalists (33%) is actually lower than in the US (35%). In his editorial David Goodman says that the question about doctor shortages shouldn't be answered simply by projecting today's healthcare system into the future but by asking how to improve the health of growing populations with limited national funds (doi: 10.1136/bmj.39265.448715.80). In that context improving the delivery of care and implementing evidence based interventions may be sounder investments than expanding the medical workforce.


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