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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. 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: Diagnosis and management of complex post-traumatic stress disorder (C-PTSD)
Re: Diagnosis and management of complex post-traumatic stress disorder (C-PTSD) Joanne Stubley, Beverley Chipp, Marta Buszewicz. 388:doi 10.1136/bmj-2024-079458

Dear Editor,

A key population group omitted from this article are the parent carers of children with complex medical needs. Multifaceted components to their lives and context not only heighten their risk of complex PTSD but reduce their potential to seek support. Parent carers for life-limited and medically complex children are repeatedly exposure to witnessing their child face life threatening complications and frequent encounters with an often-traumatic health and social care systems.

A recent working group noted that parent carers face the inescapable reality of repetitive small ‘t’ trauma when caring for their disabled children and can, as a result, experience past, present and predicted future trauma as they process life threatening events, face complicated and challenging systems of care as well as fearing an unknown future (Griffin et al, 2023).

Not only the parent carers, but children with profound and multiple learning disabilities face increased risk of medicalised trauma by undergoing invasive often painful medical treatments without the ability to cognitively understand what is happening, or the communication skills to express feelings, fears or needs. Both children and their parents are then further subjected to Systems Generated Trauma which not only observes and measures the child’s development and behaviours but judges and can contribute to disempowering the parent carers’ authority.

Caring for a disabled or serious ill child is a highly emotive, challenging and often relentless experience of love, devotion, isolation and powerlessness. Recent research shows the mental health impact of being a parent carer leads to an increased risk of thoughts of suicide with 4 in 10 experiencing suicidal thoughts and behaviours while caring for a disabled or chronically ill child (O’Dwyer et al, 2024). Yet without parent carers being a data collection point, the actual levels are difficult to measure.

Parent carers also face a level of fear that expressing suicidal thoughts might lead to safeguarding concerns and rather than lead to additional support, result in additional scrutiny. Key for this population is the additional complexity that healthcare systems, and the clinicians who work within them, have been identified as potential sources of Systems Generated Trauma (Clements, 2024).

It is vital clinicians not only identify this high-risk population who they frequently encounter but also reflect on the ways their personal interactions and service delivery might be contributing to the parent carer experience of complex PTSD. Their actions might not only identify those at risk but enable a non-judgemental, safe and supportive space for parent carers to express their trauma and seek help.

1 Griffin, J. et al, (2023) Difficult parent or traumatised parent. British association of Counselling and Psychotherapy Children Young People and Families, December 2023
2 O’Dwyer, S. et al, (2024). Suicidal Thoughts and Behaviors in Parents Caring for Children with Disabilities and Long-Term Illnesses. Archives of Suicide Research, 1–18. https://doi.org/10.1080/13811118.2024.2363230
3 Luke Clements. Systems Generated Trauma. 15 June 2024.

Competing interests: No competing interests

03 April 2025
Rachel Wright
Nurse, Founder/Director Born at the Right Time
Southend
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World’s first computerised records in general practice
Re: Jeremy Bradshaw-Smith: GP who pioneered computerised medical records and is thought to have produced the world’s first printed prescription Anne Gulland. 387:doi 10.1136/bmj.q2702

Dear Editor,

In your obituary of Jeremy Bradshaw-Smith (March 2025) you rightly report he is thought to have achieved a world first when he gave a patient a computer printed prescription.

However, the world first of having all the registered patients in a general practice with a computerised medical record was achieved a few years earlier by John Preece (1928-2021), then a single-handed GP, in the Whipton Practice in Exeter. He entered all medical records himself and first authored an academic publication reporting it. (Preece J et al. 1971).

References
Gulland A. Jeremy Bradshaw-Smith. Obituary. BMJ 2024; 387 :q 2702
Preece JF, Gillings DB, Lippmann ED et al. An on-line record maintenance and retrieval system in general practice. Int J Biomed Comput 1970; 1(4) :329-37

Competing interests: No competing interests

03 April 2025
Denis J Pereira Gray
Consultant
St Leonard's Research Practice
Exeter
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Re: Approaches to children’s smartphone and social media use must go beyond bans
Re: Approaches to children’s smartphone and social media use must go beyond bans Gilson Schwartz, Miranda Pallan, et al. 388:doi 10.1136/bmj-2024-082569

Dear Editor

In the introduction to their paper Goodyear et al report that the overall health effect of smartphones and social media on children is “not clear cut” [1]. They seem to imply that the standard of the criminal justice system of “beyond reasonable doubt” needs to be achieved before public health intervention rather than the more usually applied civil judicial threshold of “balance of probabilities”[2].

The difficulty in analysing scale of risk and harm, especially in children, is the issue of biological and psychological heterogeneity as well as balancing the level of the benefit against the severity of the harm. In addition to this social media is a rapidly evolving and changing landscape with both new products appearing and new features being added to existing products. For example the Royal Society for Public Health’s (RSPH) report [3] into this topic in 2017 did not include “Tik Tok” which by 2023 had become the second most popular site used by UK children (53%) [4].

A recent household survey conducted by the Central Statistics Office (CSO Ireland) showed that amongst 18-29 year olds, 64% felt social media had a negative effects on their mental health as opposed to just 6% who reported a beneficial effect [5]. So while some reported benefit this is overwhelmed by those reporting harm.

The commonly reported health benefits of social media are accessing information, support, identity expression and wellbeing [3] which are thematically similar to what the authors quote. However the harmful impacts are often of a categorically higher degree of severity such as sexual exploitation [6], suicide [6], mental health disorders [6] and an increase in disordered eating behaviours [7] amongst others. This difference in outcome between benefit and harm is exacerbated by the fact that most of the benefits could be achieved through non algorithmically-driven digital platforms (i.e. web-sites) or off-line (help-lines), while the harms are mostly unique to the technology of social media.

The exposure of youth to pornography is a paradigmatic exemplar. While a number of adolescents may report it provides entertainment the associated increase in harmful sexual attitudes and behaviours surely outweigh this trivial benefit irrespective of the numbers on either side [8].

Finally, as a paper grounded in a rights based framework it is astounding that they authors do not acknowledge that the engagement of a child with commercial, profit driven, algorithmic-enabled social media should remain a choice and not the accepted default position. There are a number of valid reasons that an individual might not wish to use social media, such as “poor use of time, preference for other forms of communication, preference for engaging in other activities, cyber-safety concerns, and a dislike of self-presentation online” [9].

In my opinion the greatest infringement upon the human rights of children today is experienced not by restrictions imposed by adults but social norms imposed by peers upon those that force unwilling participants into the “influence of peer groups who socially compel addictive behaviours” [10]. Too often the avoidance of FoMO” (Fear of Missing Out) [3] is benignly seen as a valid reason or benefit of social media usage rather than the glaring example of peer group coercive control that it is.

Goodyear et al are right in asserting that digital technologies are here to stay and for children to prosper they need digital literacy skills. It is possible to stay connected, informed and productive on line without exposing oneself to the significant harms of algorithmically-controlled social media sites and this should be the focus of public policy and education. As Thomas Paine once wrote “A long habit of not thinking a thing wrong, gives it a superficial appearance of being right”.

References:

1 Goodyear VA, James C, Orben A, Quennerstedt M, Schwartz G, Pallan M. Approaches to children’s smartphone and social media use must go beyond bans. https://doi.org/10.1136/bmj-2024-082569
2 Williams CR Burdens and Standards in Civil Litigation. Sydney Law review 2023 accessed on 02/04/2025 https://posh.austlii.edu.au/cgi-bin/viewdoc/au/journals/SydLawRw/2003/9....
3 Royal Society for Public Health. #StatusofMind Social media and young people’s mental health and wellbeing. 2017. https://www.rsph.org.uk/static/uploaded/d125b27c-0b62-41c5-a2c0155a8887c...
4 Ofcom Children and Parents: Media use and Attitudes. 2023. https://www.ofcom.org.uk/siteassets/resources/documents/research-and-dat...
5 Central Statistics Office COVID-19 Our Lives 5 Years On Social Impact. 2025. https://www.cso.ie/en/releasesandpublications/fp/fp-c19si/covid-19-ourli...
6 Ghai S, Magis-Weinberg L, Stoilova M, Livingstone S, Orben A Social media and adolescent well-being in the Global South. Curr Opin Psychol 2022; 46:101318. doi:10.1016/j.copsyc.2022.101318 pmid:35439684Negata JM, Zamora G, Al-Shaoibi AAA,
7 Dahlgren CL, Sundgot-Borgen CS, Kvalem IL, Wennersberg AL, Wisting L. Furher Evidence of the association between social media use, eating disorder pathology and appearance ideals and pressure: a cross-sectional study in Norwegian adolescents. Journal of Eating Disorders 2024 https://doi.org/10.1186/s40337-024-00992-3
8 Government Equalities Office, Women and Equalities Unit. The relationship between pornographt use and harmful sexual attitudes and behaviours: literature review. 2021. https://www.gov.uk/government/publications/the-relationship-between-porn...
9 Baker RK, White KM In their own words: why teenagers don’t use social networking sites. Cyberpsychol Behav Soc Netw 2011 https://doi.org/10.1089/cyber.2010.0016
10 Adjorjan M, Ricciardelli R. Smartphone and social media addiction: Exploring the perceptions and experiences of Canadian teenagers. Canadian review of Sociology 2021 https://doi.org/10.1111/cars.12319

Competing interests: No competing interests

02 April 2025
Matthew A Sadlier
Associate Clinical Professor & Consultant Psychiatrist.
Mater Misericordiae University Hospital, University College Dublin.
Mater Misericordiae University Hospital, Eccles St., Dublin 7, Ireland.
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Boosting team morale - Recognise wins and spread joy
Re: How can I boost team morale? Abi Rimmer. 388:doi 10.1136/bmj.r444

Dear Editor

We thank Abi Rimmer and contributors for their important piece on boosting team morale.[1]
We particularly appreciated Divpreet Sacha’s suggestions, and have two additional recommendations for teams to spread positivity and recognise achievements.

First, Moments of Joy. Team members share recent moments of joy (from wherever - home and family life, work, social life, their leave) with their team. Examples might include a compliment from a friend or praise from a patient, a relaxing day off, or a pet’s latest antics. Even when times are tough, moments of joy can be found. Sharing these moments with the team helps build stronger connections as people learn more about each other and what is meaningful to them. Moments of joy could be added to a whiteboard as a way to share joy with others and brighten a challenging shift. Moments of joy can also be used as a way to positively start meetings - particularly suited to one-to-one meetings. For example between supervisor and resident doctor, with both sharing their moments of joy, helping establish a flat hierarchy.

Second, Win of the Week. Team members share their win of the week at work with the wider team. Alternatively (or if someone is struggling to think of their own ‘win’), colleagues can suggest a win of the week for each other. Depending on the work environment, win of the shift/rota/month or another system may work better. Reflecting on ‘wins’ helps resident doctors or new consultants or General Practitioners recognise and celebrate the progress they are making. Often, the most satisfying wins for patient care stem from effective teamwork and communication and so sharing wins helps strengthen bonds and boost team morale. The latest NHS Staff Survey reveals that only around half (54%) of NHS staff in England were satisfied with the recognition they get for good work [2] - initiatives like Win of the Week could redress this.

Moments of Joy and Win of the Week can complement positive reporting systems (known as “Learning from Excellence”,[3] such as ‘greatix’). By normalising reflection and sharing of positivity and achievements in the workplace, simple tools like Win of the Week and Moments of Joy may lead to improvements for both staff and patients. For example, when achievements and best practice are recognised, techniques like Appreciative Inquiry can focus on and build upon ‘excellence’ and inspire Quality Improvement (QI) efforts.[4]

Moments of Joy and Win of the Week both align with recommendations from the Institute for Healthcare Improvement (IHI) on ensuring a joyful, engaged workforce.[5] This IHI white paper makes for interesting reading for those motivated to boost team morale.

Implementing and encouraging Moments of Joy and Win of the Week demonstrates compassionate leadership through fostering supportive relationships where team members are listened to, understood, and valued.[6] Our suggestions thus promote inclusion and can support wider efforts to foster psychological safety, where everyone feels comfortable asking questions, admitting to, sharing, and learning from mistakes, and challenging problematic behaviours.[7]

Healthcare delivery relies on teams, and team morale is vital to effective teamwork. Let’s recognise wins and spread joy, and boost team morale.

Footnote: Views expressed are the authors’ own and do not necessarily reflect those of their employers. Authors are joint first authors.

References
1. Rimmer A. How can I boost team morale? BMJ 2025; 388 :r444 https://doi.org/10.1136/bmj.r444
2. NHS Staff Survey. National results. www.nhsstaffsurveys.com/results/national-results
3. Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child 2016;101:788-791. https://doi.org/10.1136/archdischild-2015-310021
4. Plunkett A. Embracing excellence in healthcare: the role of positive feedback. Arch
Dis Child Educ Pract Ed 2022;107:351-354. https://doi.org/10.1136/archdischild-2020-320882
5. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017.
https://www.ihi.org/resources/white-papers/ihi-framework-improving-joy-work
6. Bailey S, West M. What is compassionate leadership? The King's Fund; 2022. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/what-is-com...
7. NHS Employers. Top tips for supporting the psychological safety of staff. NHS Employers; 2024. https://www.nhsemployers.org/articles/top-tips-supporting-psychological-...

Competing interests: Both authors use Win of the Week and Moment of Joy in their workplaces.

02 April 2025
Christopher J Graham
Digital Education Manager
Raykal Sim
Royal College of Physicians of Edinburgh
Edinburgh, UK
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Re: Stepwise dual antiplatelet therapy de-escalation in patients after drug coated balloon angioplasty (REC-CAGEFREE II): multicentre, randomised, open label, assessor blind, non-inferiority trial
Re: Stepwise dual antiplatelet therapy de-escalation in patients after drug coated balloon angioplasty (REC-CAGEFREE II): multicentre, randomised, open label, assessor blind, non-inferiority trial Yanmin Xu, Wenxia Jia, Ping Yang, Yuquan He, et al. 388:doi 10.1136/bmj-2024-082945

Dear Editor

Gao et al. 2025 investigate the efficacy and safety of a stepwise de-escalation strategy for dual antiplatelet therapy (DAPT) following drug-coated balloon (DCB) angioplasty. This study addresses a pertinent clinical query regarding the optimization of antiplatelet therapy pot-DCB angioplasty [1]. Finding the equilibrium of thrombotic risk reduction and minimizing bleeding remains a key principle of Evidence-based practice (EBP). Moreover, the multicenter, randomised, assessor-blind approach enhances the study's generalizability.

However, the following areas are critical considerations. First and foremost, the open-label methodology facilitated participants’ awareness of their treatment which inherently influences their adherence and overall engagement [2]. Also, clinician knowledge often affects treatment decisions and the intensity of monitoring. The bias highlighted here can affect the internal validity of the study outcomes.

Additionally, the duration of follow-up remains a significant limitation. There is a high chance of cardiovascular effects occurring beyond the period covered by the research. Moreover, late stent thrombosis and recurrent ischemic events often manifest months or years after the intervention [3]. Thus, longer follow-up would be necessary to determine the proper risk-benefit balance of the stepwise de-escalation stratagem. Lastly, the absence of a standardised DAPT de-escalation protocol across different regions provides leeway to introducing variability in adherence and implementation [4]. Such variations often compromise the external validity of the study.

References
[1] Gao C, Zhu B, Ouyang F, Wen S, Xu Y, Jia W, et al. Stepwise dual antiplatelet therapy de-escalation in patients after drug coated balloon angioplasty (REC-CAGEFREE II): multicentre, randomised, open label, assessor blind, non-inferiority trial. BMJ. 2025 Mar 31;e082945.
[2] Lord-Bessen J, Signorovitch J, Yang M, Georgieva MV, Roydhouse J. Assessing the impact of open-label designs in patient-reported outcomes: investigation in oncology clinical trials. JNCI cancer spectrum [Internet]. 2023 Jan 20;7(2). Available from: https://academic.oup.com/jncics/article/7/2/pkad002/6994189
[3] Matteau A, Yeh RW, Camenzind E, Steg PG, Wijns W, Mills J, et al. Balancing Long-Term Risks of Ischemic and Bleeding Complications After Percutaneous Coronary Intervention With Drug-Eluting Stents. The American Journal of Cardiology [Internet]. 2015 Jun 6 [cited 2025 Apr 2];116(5):686–93. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4670082/
[4] Kereiakes DJ, Yeh RW. DES and DAPT in Evolution. КАРДИОЛОГИЯ УЗБЕКИСТАНА. 2022 Feb 1;15(3):278–81.

Competing interests: No competing interests

02 April 2025
FP Omullo
Medical Doctor, Medical Researcher
Murang'a County Referral Hospital
P.O. Box 40100
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Re: Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials
Re: Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials Ivan D Florez, Rachel J Couban, Fatemeh Mehrabi, Holly N Crandon, et al. 388:doi 10.1136/bmj-2024-079971

Dear Editor,

On behalf of the ASIPP Board of Directors, we were alarmed when we reviewed Wang and colleagues’ publication of their systematic review and network meta-analysis of randomized controlled trials of common interventional procedures for chronic non-cancer spine pain.

The Rapid Recommendation Guidelines were of such rapid nature that the authorship lacked relevant interventional expertise and what qualified as a “randomized” trial included those with as few as 10 patients, lacked differentiation between high and low-quality studies, what was referred to as a “sham procedure” was pharmacologically or physiologically active, clinically meaningful pain relief was simply dismissed and included studies that followed chronic pain patients for as short as one month while reviewing the treatment arm out of context to current practice of interventional pain medicine.
Interventional spine procedures serve diagnostic and therapeutic purposes and are part of an interdisciplinary approach to patient care. They form part of the interpreted workup similar to imaging workup that tends to be overly sensitive and nonspecific. In addition to appropriate diagnostic utilization, the effectiveness of the reviewed interventional procedures is dependent on proper patient selection, duration of underlying pathology, and proper technique based on the location of pathology (e.g., foraminal vs. central, unilateral vs. bilateral), after which interventional treatments are utilized as a part of a multimodal plan of care that may include physical, pharmacological and behavioral therapy coupled with lifestyle changes and expectation setting.

The reviewed interventions enjoy some of the lowest number of needed to treat (NNTs) in chronic pain for clinically meaningful pain relief relative other treatments. In appropriately selected patients, reviewed interventions offer substantial relief, improve function, enable physical therapy, allow performance of activities of daily living, maintenance of work or return to work, prevent detrimental effects of immobilization, reduce number of emergency department visits, and may delay or obviate the need for surgical interventions or long-term reliance on opioids.

The article’s conclusions diverge from a well-established body of high-quality research that supports the efficacy of interventional procedures, particularly with appropriate patient selection. The authors either completely discounted, misinterpreted or simply ignored several publications and peer reviewed data that demonstrate clinically meaningful relief that will be addressed in a subsequent publication.

The weaponization of the BMJ “Rapid Recommendation” against chronic pain sufferers notwithstanding, the article has the potential to impede access so that a meaningful duration of pain relief can be provided to sufferers of, for example, subacute or chronic cervical and lumbar radiculopathy and mitigate pain, suffering and chronification, contributing to unbalanced care that compensates by relying on peripheral and central analgesics with their adverse effects on a range of end organs and unmatched morbidity and mortality.

The Guideline, in sum and substance, states that such standard interventional procedures for chronic non-cancer spine pain are ineffective, should not be available to patients, and a financial reordering of their compensation is in order to bring how pain medicine was practiced back to the 1990s with endless failure of pharmacological and nonpharmacological therapies.

To be clear, the interventions need to be utilized as part of an interdisciplinary approach and applied appropriately based on the correct diagnosis. They are not intended for everyone with spinal pain. However, creating a nihilistic guideline that effectively denies appropriately selected patients for interventions does a great disservice to chronic pain suffers, and the outcome of treatment denials, unfortunately, may be pharmacological and surgical overutilization or persistence of avoidable pain and suffering that serves to promote chronic pain. The BMJ author’s message to spinal pain sufferers is that if a trial of conservative management fails, go for something riskier or suffer, will contribute to limiting patient care and choice, contributing to further deterioration of chronic pain outcomes, a metric that guidelines aim to improve, not antagonize.

Christopher Gharibo, MD, on behalf of the ASIPP Board of Directors
President, American Society or Interventional Pain Physicians
www.asipp.org

Competing interests: No competing interests

01 April 2025
Christopher Gharibo
Physician
NYU Langone Health
333 East 38th St, NY, NY 10016
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Adolescent Screening
Re: Approaches to children’s smartphone and social media use must go beyond bans Gilson Schwartz, Miranda Pallan, et al. 388:doi 10.1136/bmj-2024-082569

Dear Editor

The topic of social media and its corrosive effect on the minds of teenagers has been brought into sharp focus in the last month with the airing of ‘Adolescence’ on Netflix. The story of a disenfranchised young male whose cultural isolation and vulnerability results in him being preyed upon by the dark forces of the internet to a murderous cost. Look at any group of teenagers in public spaces, how many will be looking around them, how many will be scrunched into their phones?

As a GP our mental health consultations with teenagers and young adults are on the rise. Depression, lack of meaning and body dissatisfaction are part of the main topics. Female teenagers' mental health has especially plummeted in the last ten years with the rise of hospital admissions steeply rising (112.8% in 2021-22) for self-harm and suicidality. (1) Females who have a screen time of more than 5 hours a day are three times more likely to be depressed than those who don’t.

There are louder and louder voices asking the question about whether the rise and availability of smartphones and internet are contributing to this. Studies are finding that 11 year olds can spend up to 9 hours a day on their phones. A Children’s Commissioner Survey found that 27% of British 11 year olds (2) have seen online pornography (without necessarily having actively searched for it) and there have even been tragic accidental deaths from being swept up in the latest online crazes (3).

Long term use of social media can lead to social deprivation, sleep deprivation, attention fragmentation and even addiction. One study in the USA estimates that teenagers receive on average 140 notifications a day. (4) Increasingly monetized, its main priority now seems to be to keep our eyes on screen to allow its adverts to grab our attention. ‘Enrage to engage’ (5) has been coined as an internal strategy to keep us looking. It is known that creating a strong emotional reaction will hold our attention more. Cynically using a Variable – Ratio Schedule of notifications, it manipulates its users to seek ever more feedback.

Jonathan Haidt describes, in his insightful and disturbing book ‘The Anxious Generation,’ (6) that we are raising a generation of children who are overprotected in the physical world and under protected virtually. Children are given less space to roam unsupervised and yet seemingly can go where they want to online. He hypothesizes that this leads to a deep lack of confidence in their ability to make their own decisions but also the constant sense of danger that being online can bring. It is estimated that at least once a day 14 year olds see something that deeply upsets them on social media. (7)

The teenage mental health consultation can often be one of the most unsettling. This can be a result of the difficulty to bridge the age gap to come onto their level, the lack of understanding of their world and pressures both from professional and parent, and the limited options of referral and support due to limited mental health resources. There are many anecdotal stories of young people reporting to actively harming themselves to speed up access to support.

There needs to be a serious debate now about the age of access for social media. Just as in other big profit industries such as Tobacco, Alcohol, Oil and Ultra Processed Food, we know historically that they cannot be trusted to regulate itself. The government needs to make a strong stand on this, or risk a generation of young people utterly failed by those who are entrusted to protect them.

1. Ward JL et al. Admission to acute medical wards for mental health concerns among children and young people in England from 2012 to 2022: a cohort study. Lancet Child and Adolescent Health Volume 9, Issue 2, p112-120, February 2025.
https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(24)00333-X/fulltext#:~:text=Increases%20were%20particularly%20steep%20in,5%25)%20all%2Dcause%20admissions
2. https://www.childrenscommissioner.gov.uk/blog/growing-up-with-pornograph....
3. Lancaster: Inquest into 'social media craze' death of boy opens - BBC News
4. www.statista.com/statistics/1245420/us-notifications-to-social-app-ios-u...
5. Stolen Focus. Hari, Johanne. Bloosmbury 2022
6. The Anxious Generation. Haidt, Jonathan. Penguin 2024
7. https://www.bbfc.co.uk/about-us/news/half-of-children-and-teens-exposed-...

Competing interests: No competing interests

01 April 2025
Giles W Dawnay
GP
NHS
Hereford
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Use Chaos and Complexity Science to better understand uncertainty, improve health and achieve change – from Cos to Cosmos.
Re: Uncertainty of risk estimates from clinical prediction models: rationale, challenges, and approaches Joie Ensor, Rebecca Whittle, Paula Dhiman, Maarten van Smeden, et al. 388:doi 10.1136/bmj-2024-080749

Dear Editor

Responding to Riley and coauthors’ article on uncertainty in risk estimates (1), Chiolero agrees with Riley and coauthors that improving the communication of uncertainty in risk prediction is essential, writing “However, this should be accompanied by the acknowledgement of the complexity of clinical decision-making, emphasizing that, regardless of the level of risk prediction certainty, randomness always plays a role at the individual level” (2).

Randomness is not the only cause of unpredictability, and acknowledgement of complexity should be followed by the need to understand the unusual features of chaos and complexity science and complex systems, for individuals and populations - sensitive dependence on initial conditions, self organization, emergence and uncertainty.

A 2023 BMJ Letter to the Ed (3), suggests that medical schools should teach chaos and complexity thinking to understand uncertainty, and to address complex issues in and beyond medicine, an idea extended to CPD for physicians, health professionals and the general public, to address issues in medicine, health and society (4).

Uncertainty and unpredictability should could lead to action, using chaos and complexity as a powerful tool for creativity and change, described in a free book online – “Tsunami Chaos Global Heart: using complexity science to rethink and make a better world” (5), and in Brian Klaas’ 2025 Book “Fluke: Chaos, Chance and why everything we do matters.”

These ideas were used in health promotion and advocacy for three decades, and in a recent talk “Preventing Premature Heart Disease,” responding to increasing NCDs and premature heart disease, and continuing unexpected unpredicted sudden death globally.

We should go beyond acknowledgement of complexity in clinical decision making, and randomness, to use ideas from chaos and complexity science, to better understand uncertainty and create change to make a better world, from medicine and health to everything else – from Cos to Cosmos (5).
 
References

1 Riley R, Collins G, Kirton L, et al. Uncertainty of risk estimates from clinical prediction models: rationale, challenges, and approaches. BMJ 2025; 388:e080749 doi: https://doi.org/10.1136/bmj-2024-080749 (Published 13 February 2025)
2 Chiolero A. Confusion between population-risk prediction and individual disease. Rapid Response. https://www.bmj.com/content/388/bmj-2024-080749/rr-1
3 Rambihar VS. Medical schools should teach chaos and complexity thinking.
BMJ 2023; 383:p2412 doi: https://doi.org/10.1136/bmj.p2412 available full text as BMJ Rapid Response to Launer J. Living with uncertainty, Opinion. BMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p2052
4 Rambihar VS, Rambihar SP, Rambihar VS Jr. Chaos, Complexity, Complex Systems, Covid19: 30 years teaching health professionals chaos and complexity. 2020 Poster, 10th International Conference on Complex Systems. https://static1.squarespace.com/static/5b68a4e4a2772c2a206180a1/t/5f1f12...
5 Rambihar VS, Rambihar SP, Rambihar VS Jr. Tsunami Chaos and Global Heart: using complexity science to rethink and make a better world. 2005. Vashna Publications. Toronto, Canada.
http://www.femmefractal.com/FinalwebTsunamiBK12207.pdf

Competing interests: No competing interests

01 April 2025
Vivian Rambihar
Cardiologist
Adjunct Assistant Professor of Medicine, University of Toronto
vivian.rambihar@utoronto.ca, Toronto, Canada.
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Re: Development of ROBUST-RCT: Risk Of Bias instrument for Use in SysTematic reviews-for Randomised Controlled Trials
Re: Development of ROBUST-RCT: Risk Of Bias instrument for Use in SysTematic reviews-for Randomised Controlled Trials Romina Brignardello-Petersen, Reed A C Siemieniuk, Dena Zeraatkar, Elie A Akl, et al. 388:doi 10.1136/bmj-2024-081199

Dear Editor

Wang et al. 2025 introduce a critical tool aimed at assessing bias risk in RCTs as far as systemic reviews go. The ROBUST-RCT seeks to attain an equilibrium between methodological rigor with simplicity, thus addressing limitations in existing instruments [1].

Moreover, this tool offers simplicity and practicability. The structure and framework are straightforward and remain ideal for users without extensive methodological training. This approach ensures applicability across different systematic review contexts [1]. Also, the article provides a comprehensive development process that improves efficiency and utility.

Nevertheless, the following areas should be considered for improvement. Firstly, this article would benefit from a detailed comparison with existing tools, primarily the Cochrane risk-of-bias tool for randomized trials (RoB 2) [2]. Outlining certain advantages over established instruments would clarify ROBUST-RCT’s unique contributions. Also, empirical data demonstrating reliability is missing. Thus, an inter-rater reliability assessment with other instruments reinforces its credibility.

References
[1] Wang Y, Keitz S, Briel M, Glasziou P, Romina Brignardello-Petersen, Siemieniuk RAC, et al. Development of ROBUST-RCT: Risk Of Bias instrument for Use in SysTematic reviews-for Randomised Controlled Trials. BMJ. 2025 Mar 25;e081199–9.
[2] Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ [Internet]. 2019 Aug 28;366(1):l4898. Available from: https://www.bmj.com/content/366/bmj.l4898
[3] Flemyng E, Moore TH, Boutron I, Higgins JP, Hróbjartsson A, Nejstgaard CH, et al. Using Risk of Bias 2 to assess results from randomised controlled trials: guidance from Cochrane. BMJ Evidence-Based Medicine. 2023 Jan 24;bmjebm-2022-112102.

Competing interests: No competing interests

01 April 2025
Felix Omullo
Medical Doctor, Medical Researcher
Murang'a County Referral Hospital
P.O. Box 40100
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Antiracism in Healthcare Education: Moving from Theory to Practice
Re: Antiracism in medicine: what is it? Aisha Majid. 388:doi 10.1136/bmj.r362

Dear Editor

Antiracism should be an established part of healthcare education - an idea explored in Aisha Majid’s report. (1) Often discriminatory biases perpetuate as seniors pass them down to their trainees and trainees absorb them as truth.

For example, an occasionally recycled discriminatory bias is of pain tolerances varying amongst patients of different ethnicities. This can sometimes be seen playing out on labour wards - consider the various accounts of patients from ethnic minority backgrounds reporting that their requests for painkillers were denied or delayed because health professionals ‘dismissed or minimised’ their reports of pain. (2) Now consider that these professionals charged with caring for these patients are likely to be/have been responsible for educating and influencing students training under them - perpetuating this sort of bias. Minimisation of patient experiences compromises individual care, but more systemically erodes trust in our healthcare systems.

I appreciate Dr. Onwochei's colleague's assertion that she understood what was happening was not right but did not quite know what to say - a common and human reaction. Perhaps if we were proactive in acknowledging this common response, rather than admonishing it as some are wont to do, we might be better able to nurture empathetic discourse on practical ways to challenge such rhetoric. Many want to challenge racism but lack the tools, and therefore, the confidence to do so.

A questioning approach can sometimes be effective: "Why do you believe black people don't like cycling?" or "Are you suggesting this applies to all black people?’ This method guides reflection without confrontation.

More healthcare educational institutions could take example from Anglia Ruskin University in this regard - embedding antiracism training empowers future healthcare professionals to recognise and challenge discriminatory practices.

References
1. Majid, A. (2025). Antiracism in medicine: what is it? BMJ, pp.r362–r362. doi:https://doi.org/10.1136/bmj.r362.

2. Waters, A. (2022). Racism is ‘at the root’ of inequities in UK maternity care, finds inquiry. BMJ, [online] 377(377), p.o1300. doi:https://doi.org/10.1136/bmj.o1300.

Competing interests: No competing interests

01 April 2025
Chelsea C Omeni-Nzewuihe
Medical Registrar
Frimley Health NHS Foundation Trust
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