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General practitioners and occupational health
professionals
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A correction has been published for this article. The contents of the correctionhave been appended to the original article in this reprint. The correction is available online at: To order reprints of this article go to: appears to have no serious side effects.11 Tamoxifen Previous studies of tamoxifen on physiological gynaecomastia appears to be successful, safe, and avoids operation and Tamoxifen
on present evidence should be regarded as the first line dose (daily
Duration
Success No/
dose in mg)
(months)
patients
total (%)
Hamed N Khan clinical research fellow RW Blamey emeritus professor of surgery Nottingham City Hospital, Nottingham NG5 1PB McGrath MH, Mukerji S. Plastic surgery and the teenage patient. J Pediatr Adolesc Gynecol 2000;13:105-18.
Carlson HE. Gynecomastia. N Engl J Med 1980;303:795-9.
Yang WT, Whitman GJ, Yuen EH, Tse GM, Stelling CB. Sonographic fea- placebo,5 but adverse effects such as weight gain limit tures of primary breast cancer in men. Am J Roentgenol 2001;176:413-6.
Plourde PV, Kulin HE, Santner SJ. Clomiphene in the treatment of ado-lescent gynecomastia. Clinical and endocrine studies. Am J Dis Child The use of tamoxifen for gynaecomastia has been studied previously in several centres. The table shows Jones DJ, Holt SD, Surtees P, Davison DJ, Coptcoat MJ. A comparison ofdanazol and placebo in the treatment of adult idiopathic gynecomastia: the various published studies on the use and efficacy of results of a prospective study in 55 patients. Ann R Coll Surg Engl tamoxifen for physiological gynaecomastia in the Eng- Ting AC, Chow LW, Leung YF. Comparison of tamoxifen with danazol in lish literature.6–9 Only two of these studies6 9 have more the management of idiopathic gynecomastia. Am Surg 2000;66:38-40.
than 10 patients and both showed resolution of lump Parker LN, Gray DR, Lai MK, Levin ER. Treatment of gynecomastia withtamoxifen: a double-blind crossover study.
and pain in 80% of cases. A recent study from our own McDermott MT, Hofeldt FD, Kidd GS. Tamoxifen therapy for painful unit in 36 cases confirms this figure (83% resolution of idiopathic gynecomastia. South Med J 1990;83:1283-5.
lump).10 Ting et al also found tamoxifen to be more Alagaratnam TT. Idiopathic gynecomastia treated with tamoxifen: a pre-liminary report.Clin Ther 1987;9:483-7.
efficacious than danazol.6 Importantly only minor and 10 Khan HN, Rampaul R, Blamey RW. The use of tamoxifen for reversible side effects were reported. This confirms gynaecomastia at Nottingham Breast Unit. Br J Surg 2003;90(s1):100.
11 Ribeiro G, Swindell R. Adjuvant tamoxifen for male breast cancer (MBC).
findings that tamoxifen used in male breast cancer General practitioners and occupational health
professionals
Consensus statement to improve interaction is timely and welcome
OccupationalMedicine(thejournaloftheSociety Vocationalrehabilitationisanimportantissue.In of Occupational Medicine) recently published Britain it is estimated that some 2.7 million people are currently economically inactive and receiving state inca- between general practitioners and occupational health pacity benefit.6 The issue has recently received increased professionals in their roles in vocational rehabilitation.1 attention from several organisations,7 8 and all in health This was derived by using a Delphi technique to solicit care have seen the damage that ensues from losing a job the views of interested and influential individuals from and income as a consequence of ill health. Successful industry, insurance, academia, representative organisa- vocational rehabilitation has the ability to promote tions, government departments, and universities.2 3 The health and limit the financial burden on the state and statement emphasises the potential benefits of work and pension funds. It is important that it is done well.
the importance of vocational rehabilitation in restoring General practitioners have an important role. They an optimal lifestyle to individuals recovering from illness exercise an enormous influence during the treatment and recovery of their patients, but their role in Anecdotally, examples of excellent communication assessing fitness for work and facilitating return to between general practitioners and occupational health work may be handicapped by a limited knowledge of professionals exist, but poor or non-existent communi- their patients’ work and a lack of access to workplaces cation is common. At times the relationship may and managers. There is often an apparent conflict become adversarial, with the patient unable to between the general practitioner’s role as a patient’s understand the respective roles. This has an impact on advocate and the requirement to provide objective patients’ rehabilitation to useful work. Poor communi- information to an employer while maintaining cation is not restricted to the United Kingdom and has patients’ confidentiality. General practitioners act been shown to act as an impediment to rehabilitation successfully as case managers for their patients in so elsewhere.4 5 The consensus statement implies a role many areas, but loyalty to patients can be perceived as for occupational health professionals as case manag- potentially affecting their impartiality when consider- ers, coordinating efforts from healthcare providers, ing employment and benefit entitlement.
employers, and other agencies in facilitating a return to Occupational health professionals, who do not work. It ends with an exhortation for better communi- have continuing responsibilities for family care, may be cation from all to help establish interdisciplinary better placed to adopt an objective and proactive collaboration for the ultimate benefit of patients.
approach to vocational rehabilitation. Occupational BMJ VOLUME 327 9 AUGUST 2003
health professionals have a better knowledge of the care doctors who participate in minimising their workplace. They are also motivated and ethically patients’ disability achieve better health outcomes as bound to help their patients.9 Unfortunately large sec- well as greater patient satisfaction.11 The consensus tions of the United Kingdom’s population do not have statement is a timely reminder of the importance of access to an occupational health service.10 Thus at both the issue of vocational rehabilitation, and the present occupational health professionals are too few quality of communication between different healthcare in number to adopt the role of case manager or certi- providers, and should be applauded.1 The worthwhile fier of ill health and disability for all who require this objectives in the consensus statement will require con- help. Better communication between general practi- siderable change in resources, attitudes, and systems tioners and occupational health professionals has to be before they are optimally achievable.
the way forward in the short term to facilitate improve- Notable barriers to this communication remain.
Department of Public Health Sciences, University of Alberta,Edmonton, Alberta, Canada T6G 2G3 ([email protected]) Occupational health is not a well understood specialty,occupational health services are many and varied, and confusion remains about their role and position in a Occupational Health, Glasgow Primary Care Trust Glasgow G3 8H5 modern healthcare system. There is much unfounded Competing interests: None declared. JB is an assistant editor of suspicion about the impartiality of occupational health services. Occupational health professionals are oftenemployed by the “business” and may be perceived as Beaumont D. Rehabilitation and retention in the workplace—the interac- biased in favour of their paymasters. This perception is tion between general practitioners and occupational health profession-als: a consensus statement. Occup Med 2003;53:254-5.
not restricted to workers and their representatives.
Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CFB, Managers may also anticipate a certain opinion, but Askham J, et al. Consensus development methods, and their use in clini-cal guideline development. Health Technol Assess 1998;2:1-88.
they will be disappointed if they expect only an Beaumont DG. The interaction between general practitioners and occu- opinion that is helpful to the business to the neglect of pational health professionals in relation to rehabilitation for work. OccupMed 2003;53:249-53.
Pransky G, Katz JN, Benjamin K, Himmelstein J. Improving the physician The inadequate and unequal development of occu- role in evaluating work ability and managing disability: a survey ofprimary care practitioners. Disabil Rehabil 2002;24:867-74.
pational health services in the United Kingdom and Verbeek J, Spelten E, Kammeijer M, Sprangers M. Return to work of can- the confusion over their role has inevitably led to diffi- cer survivors: a prospective study into the quality of rehabilitation byoccupational physicians. Occup Environ Med 2003;60:352-7.
culties in communication between occupational health Department for Work and Pensions. Pathways to work: helping people into professionals and other healthcare professionals.
employment. London: Stationery Office, 2002.
Confederation of British Industry. Business and healthcare for the 21st Acting as case manager in vocational rehabilitation is a legitimate and worthwhile role for occupational health Trades Union Congress. Restoring to health, returning to work. London: professionals, and improving communication between Guidance on ethics for occupational physicians. London: The Faculty of a general practitioner and occupational health profes- Occupational Medicine, Fifth Edition, 1999.
sional is essential to this process. There are good 10 McDonald JC. The estimated workforce covered by occupational physicians in the UK. Occup Med 2002;52:401-6.
reasons for general practitioners to participate.
11 Radosevich DM, McGrail MP Jr, Lohman WH, Gorman R, Parker D, Returning to work is a part of many patients’ complete Calasanz M. Relationship of disability prevention to patient health statusand satisfaction with primary care provider. J Occup Environ Med recovery, and there is evidence to indicate that primary Speak up!
Can patients get better at working with their doctors?
Amother brings her daughter to the general thingsmighthaveturnedoutdifferently.“Easiersaid practitioner with a chest cold. She is mainly than done,” say patients. This is a guiding assumption seeking reassurance that the infection will go behind “Working with your Doctor,” an online course by itself. She hopes to avoid antibiotics unless they are we have designed for patients to complement absolutely necessary. Her general practitioner assumes BestTreatments, the BMJ Publishing Group’s website for she is there for a prescription and so writes one out for US patients and doctors.1 The course teaches patients amoxicillin. The mother assumes the prescription simple things to do before, during, and after a visit to means that the infection is serious and so keeps her their doctor to help them get what they want from the preferences quiet. After the consultation the general The antibiotics scenario described above is true. It mother’s body language that she was unhappy about comes from a qualitative study of patients’ unvoiced taking a prescription for antibiotics. He admitted they agendas in consultations with their general prac- titioner.2 Researchers asked patients about their ideas, This consultation would have gone so much better, concerns, and expectations for their visits. After the you might say, if the doctor had simply explained what consultation only four of the 35 patients had managed he was thinking. This is true, but the cliché about com- to raise all the issues they wanted to when face to face munication applies even in medicine—it is a two way with their doctors. Nearly half of the 35 consultations street. If the mother had said what was on her mind, had “problem outcomes” such as major misunder- BMJ VOLUME 327 9 AUGUST 2003
15 Heller RF, McElduff P, Edwards R. Impact of upward social mobility on population mortality: analysis with routine data. BMJ 2002;325:134.
16 Walker A, O’Brien M, Traynor J, Fox K, Goddard E, Foster K. Living in Summary points
Britain 2001: health survey for England 2001. London: Stationery Office,Office for National Statistics, 2002.
17 Marang-van de Mheen PJ, Davey-Smith G, Hart CL. The health impact of Methods of communicating health risks to health smoking in manual and non-manual social class men and women: a test of the Blaxter hypothesis. Soc Sci Med 1999;48:1851-6.
18 Department of Health. Health survey for England 1998: cardiovascular dis- ease. London: Stationery Office, 1999.
Decision makers require easily understandable 19 Kannel WB, Neaston JD, Wentworth D, Thomas HE, Stamler J, Hulley SB, measures that show the impact of risk factors for et al. Overall coronary heart disease mortality rates in relation to majorrisk factors in 325,348 men screened for MRFIT. Am Heart J allocation of resources according to local health 20 Chen Z, Peto R, Collins R, MacMahon S, Lu J, Li W. Serum cholesterol concentration and coronary heart disease in populations with low chol- esterol concentrations. BMJ 1991;303:276-82.
21 Rose G. Sick individuals and sick populations. Int J Epidemiol The population impact number of eliminating a 22 Murray CJ, Lauer JA, Hutubessy RCW, Niessen L, Tomijima N, Rogers A, risk factor (PIN-ER-t) is “the potential number of et al. Effectiveness and costs of interventions to lower systolic blood pres- disease events prevented in your population over sure and cholesterol: a global and regional analysis on reduction ofcardiovascular-disease risk. Lancet 2003;361:717-25.
the next t years by eliminating a risk factor” 23 Ezzati M, Lopez AD. Measuring the accumulated hazards of smoking: global and regional estimates for 2000. Tobacco Control 2003;12:79-85.
24 Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality from The PIN-ER-t can be used to show the impact of a tobacco in developed countries: indirect estimation from national vital range of risk factors in different populations and statistics. Lancet 1992;339:1268-78.
25 Walter SD. Prevention for multifactorial diseases. Am J Epidemiol to compare the potential benefits of individual 26 Morgenstern H, Bursic E. A method for using epidemiologic data to esti- mate the potential impact of an intervention on the health status of a tar-get population. J Community Health 1982;7:292-309.
27 Heller RF, Page JH. A population perspective to evidence based medicine: “evidence for population health.” J Epidemiol Community Health2002;56:45-7.
We have reported that individual clinicians are not 28 Heller RF, Edwards R, McElduff P. Implementing guidelines in primary as influenced by the presentation of risk in population care: can population impact measures help? BMC Public Health 2003;3:7.
http://www.biomedcentral.com/1471-2458/3/7 terms as they are by relative risk (Heller et al, submitted 29 Nexoe J, Gyrd-Hansen D, Kragstrup J, Kristiansen IS, Nielsen JB. Danish for publication), while others have found that the GP’s perception of disease risk and benefit of prevention. Fam Pract “number needed to treat” statistic (which also relies on 30 Kristiansen IS, Gyrd-Hansen D, Nexoe J, Nielsen JB. Number needed to measures of absolute risk) is poorly understood by treat: easily understood and intuitively meaningful? Theoretical doctors and lay people.29 30 It remains for us to examine considerations and a randomised trial. J Clin Epidemiol 2002;55:888-92.
(Accepted 19 August 2003) whether new measures of population impact like PIN-ER-t can be more easily understood and used in healthpolicy related decision making than traditionalmethods of communicating risk. We are developing aresearch programme to explore this further.
Contributors and sources: The authors work at the Evidence forPopulation Health Unit, aiming to develop a public health Corrections and clarifications
counterpart to evidence based medicine. The measuredescribed here is one of a series of population impact measures Parathyroid hormone alone is as effective as combination developed to use evidence combined with routinely collected data to provide local context to measures of risk and benefit and We enthusiastically added a reference to this news support public health policy decision making.
article by Scott Gottlieb to help readers locate the study being reported (27 September, p 700).
Unfortunately, although we got the year and Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data volume of the New England Journal of Medicine into meaningful pictures. BMJ 2002;324:827-30.
right, we published the wrong page numbers. The Fahey T, Griffiths S, Peters TJ. Evidence based purchasing: understanding correct reference is 2003;349:1207-15.
results of clinical trials and systematic reviews. BMJ 1995;311:1056-9.
Last JM. A dictionary of epidemiology. Oxford: Oxford University Press, ABC of subfertility: male subfertility McPherson K, Britton A, Causer L. Coronary heart disease. Estimating the Two errors crept into in this article by Anthony impact of changes in risk factors. London: Stationery Office, National Heart Hirsh (20 September, pp 669-72). Firstly, we incorrectly inserted an extra word in the caption to Schoenbach VJ. Relating risk factors to health. Epidemiolog.net 2002.
the figure on page 670; the caption should read: www.epidemiolog.net/evolving/RelatingRiskFactorstoHealth.pdf “Autosomal Robertsonian translocations may be Gail MH, Benichou J. Encyclopaedia of epidemiologic methods. Chichester: associated with poor sperm quality and subfertility.” Secondly, we made a dog’s dinner of the caption to Cook R, Sackett D. The number needed to treat: a clinically useful meas-ure of treatment effect.
the figure on page 671. The photograph in fact Milward L, Kelly M, Nutbeam D. Public health intervention research: the evi- shows a “microsurgical vasovasostomy for dence. London: Health Development Agency, 2001.
Levin ML. The occurrence of lung cancer in man. Acta Unio Int ContraCancrum 1953;19:531.
General practitioners and occupational health 10 Walter SD. Choice of effect measures for epidemiological data. J Clin Epi- 11 Miettinen OS. Proportion of disease caused or prevented by a given We inadvertently typed the word “health” instead of exposure, trait or intervention. Am J Epidemiol 1974;99:325-32.
“medicine” when we inserted the competing 12 Armitage P, Berry G, Matthews JNS. Statistical methods in medical research.
interests for one of the authors of this editorial by 13 Heller RF, Dobson AJ, Attia J, Page JH. Impact numbers: measures of risk Jeremy Beach and David Watt (9 August, pp 302-3).
factor impact on the whole population from case control and cohort Professor Beach is in fact an assistant editor of the studies. J Epidemiol Community Health 2002;56:606-10.
journal Occupational Medicine.
14 Department of Health. Compendium of clinical and health indicators 2001.
London: DoH, 2002. (http://nww.nchod.nhs.uk) BMJ VOLUME 327 15 NOVEMBER 2003

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