But data on use, frequency, and consequences for NHS incomplete and haphazard
Currently impossible to fully understand risks of opting for surgery abroad, warn researchers

The postoperative complications of medical tourism may be costing the NHS up to £20,000 per patient, suggest the findings of a rapid review of the available data, published in the open access journal BMJ Open.

But data on the use, frequency, and consequences for the NHS are incomplete and haphazard, making it currently impossible to fully understand the risks of opting for surgery overseas, warn the researchers.

The number of medical tourists has risen steadily over the past several decades, a trend that shows no sign of abating, note the researchers. And treatment of any postoperative complications usually falls to the home country’s health service and can be further complicated by inadequate information about the initial surgery, they add.

Amid an absence of systematically collected data, the researchers wanted to gauge the costs and savings to the NHS of medical tourism as well as the type, frequency, and complications involved, plus any subsequent treatment, care, and use of NHS resources.

They reviewed research databases for relevant studies as well as ‘grey literature,’ such as conference proceedings, discussion papers, editorials, and government, industry, and institutional reports, published between 2012 and December 2024.

Studies that described cases of emergency and urgent surgery abroad; treatment for cancer, infertility, and dentistry; and transplant surgery were excluded from the analysis.

In all, 90 full text articles were selected for review, of which 38 reports describing 37 studies, were eligible for inclusion: 19 described complications due to metabolic/bariatric surgery; 17 complications due to cosmetic surgery; and one complications arising from eye surgery.

The case series and case reports included 655 patients treated by the NHS between 2011 and 2024 for complications arising from metabolic/bariatric (385), cosmetic (265), or eye (5) surgery tourism.

Twenty three studies reported the destination country. Overall, 29 countries from every continent were reported, but Turkey was the most common destination (61%). Most patients were women (90%), and the average age was 38, but ranged from 14 to 69.

The most commonly reported procedures were sleeve gastrectomy–removal of part of the stomach to create a smaller ‘sleeve’–breast surgery enlargement, and ‘tummy tuck’ (abdominoplasty).

Twenty two studies (371 patients) reported some details on complications. No deaths were reported in the included studies, but at least 196 patients (53%) experienced moderate to severe complications.

Treatment for these was not clearly reported in most of the studies, however, and only 14 studies reported on the associated costs, which ranged from £1058 to £19,549 per patient in 2024 prices.

Eight studies (159 patients) reported length of hospital stay for the treatment of complications from metabolic/ bariatric surgery tourism. The combined average length of stay was just over 17 days; the longest was 45 days.

The combined average length of stay for the treatment of cosmetic surgery complications was just under 6 days; the longest was 49 days. For eye surgery tourism, over 50 outpatient appointments and 4 surgical procedures were reported.

Very few studies reported on the use of other resources, such as day case procedures, surgery time, clinic appointments or number and type of diagnostic tests.

The certainty of the evidence obtained from most of the studies was low, primarily because most of the studies were retrospective, with data obtained from medical notes, which can be incomplete or wrongly coded; few studies included demographic details or previous medical history; and not all outcomes were reported by all the studies, explain the researchers.

But this suggests that both the complications arising from medical tourism for elective surgery and the associated costs are likely to be underestimated, they add.

“There are areas of the UK, such as Wales and the South West of England, which are almost unrepresented [in published evidence]. We did not identify any studies that related to other surgical specialties, such as orthopaedic surgery, and we did not identify any eligible studies conducted in primary care or that considered longer-term follow- up,” they point out.

“We still do not know how many people resident in the UK go abroad for elective surgery or how many people subsequently experience complications. Without these data, we cannot fully understand the levels of risk that people seeking surgery abroad are taking,” they emphasise.

“A systematic approach is needed to collecting information on the number of people who travel abroad for elective surgery and the frequency and impact on the UK NHS of treating complications,” they insist.

“Awareness-raising campaigns and interventions are warranted to inform members of the public in the UK considering going abroad for surgery about the potential for complications.” they add.

“Those seeking medical treatment abroad should be made aware of which complications the NHS is responsible for treating, and costs for which the patient may be potentially personally liable, including non-emergency treatment,” they suggest.

13/01/2026

Notes for editors
The authors have previously posted a non-peer reviewed, unedited version of this study for feedback from the research community, on a recognised preprint server.
Research: Complications and costs to the UK National Health Service due to outward medical tourism for elective surgery: a rapid review Doi: 10.1136/bmjopen-2025-109050
Journal: BMJ Open

External funding: Health and Care Research Wales Evidence Centre

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf  

Externally peer reviewed? Yes
Evidence type: Rapid review
Subjects: People

The post Postoperative complications of medical tourism may cost NHS up to £20,000/patient first appeared on BMJ Group.

Associations apparent for any, exclusive, and cumulative (at least 1 year) breastfeeding

Breastfeeding may lower mothers’ later life risks of depression and anxiety for up to 10 years after pregnancy, suggest the findings of a small observational study, published in the open access journal BMJ Open.

The observed associations were apparent for any, exclusive, and cumulative (at least 12  months) breastfeeding, the study shows.

Breastfeeding is associated with lower risks of postnatal depression and anxiety, but it’s not clear if these lowered risks might persist in the longer term, say the researchers.

To find out, they tracked the breastfeeding behaviour and health of 168 second time mothers who were originally part of the ROLO Longitudinal Birth Cohort Study for 10 years.

All the women had given birth to a child weighing under 4 kg and they and their children had check-ups 3 and 6 months, and 2, 5, and 10 years after birth by which time the mothers’ average age was 42.

At each check-up, the mothers completed a detailed health history questionnaire. This asked whether they had been diagnosed with, and treated for, depression/anxiety. They also provided information on potentially influential factors, including diet and physical activity levels.

At the check-ups, the mothers provided information on: whether they had ever breastfed or expressed milk for 1 day or more; total number of weeks of exclusive breastfeeding; total number of weeks of any breastfeeding; and cumulative periods of breastfeeding of less or more than 12 months.

Nearly three quarters of the women (73%; 122) reported having breastfed at some point. The average period of exclusive breastfeeding lasted 5.5 weeks and that of any breastfeeding for 30.5 weeks. More than a third (37.5%; 63) reported cumulative periods of breastfeeding adding up to at least 12 months.

Twenty two (13%) of the women reported depression/anxiety at  the 10-year check-up, with a further 35 (21%) reporting depression or anxiety at any time point.

Those reporting depression/anxiety at the 10 year check-up were younger,  less physically active, and had lower wellbeing scores at the start of the study than those who didn’t report this. Those women reporting depression and anxiety at any time point differed only by age at the start of the study.

Analysis of the data showed that women experiencing depression and anxiety 10 years after pregnancy were less likely to have breastfed and had shorter periods of any or exclusive breastfeeding over their lifetime.

Each week of lifetime exclusive breastfeeding was associated with a 2% lower likelihood of reporting depression and anxiety, after accounting for potentially influential factors, including alcohol intake.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that participants were relatively few in number, not ethnically or socially diverse, and that the study relied on personal recall rather than objective measures of depression/anxiety.

Nevertheless, they write: “We suggest there also may be a protective effect of successful breastfeeding on postpartum depression and anxiety, which in turn lowers the risk of maternal depression and anxiety in the longer term.”

They explain: “The likelihood is that the association is multifactorial, as many socioeconomic and cultural factors influence both breastfeeding and mental health in addition to the impact of health history.  Additionally, women with a prior history of depression and anxiety are at risk of lower breastfeeding success, compounding the association but in the reverse direction.”

They conclude: “We know that improving breastfeeding rates and duration can improve lifetime health outcomes, reducing population level disease burden and resulting in significant healthcare savings.

“The possibility that breastfeeding could further reduce the huge burden of depression on individuals, families, healthcare systems and economies only adds to the argument for policymakers to improve breastfeeding support.”

08/01/2025

Notes for editors
Research: Breastfeeding and later depression and anxiety in mothers in Ireland: a 10- year prospective observational study Doi: 10.1136/bmjopen-2024-097323
Journal: BMJ Open

External funding: Health Research Board, Ireland; Health Research Centre for Health and Diet Research; National Maternity Hospital Medical Fund; European Commission Seventh Framework Programme; Children’s Health Ireland

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf  

About the journal
BMJ Open is one of 70 journals published by BMJ Group.
https://bmjopen.bmj.com

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: Mothers

The post Breastfeeding may lower mums’ later life depression/anxiety risks for up to 10 years after pregnancy first appeared on BMJ Group.

80% of respondents’ children exposed to skin bleaching products were under 2 years old
Aesthetic preferences trumped knowledge of health risks, responses indicated

A significant proportion of under 5s in Nigeria may be being exposed to skin lightning products, if the results of a semi-urban community survey are indicative, suggests research published in the open access journal BMJ Open.

Most (80%) of the respondents’ children exposed to skin bleaching products were under 2 years old, and despite good knowledge of the health risks of the practice, these were trumped by aesthetic preferences for lighter skin tones, the survey responses show.

The cosmetic use of skin lightening products has become increasingly common globally, with very high rates among women of reproductive age in Africa, note the researchers. And while the practice used to be associated only with poverty, youth, and female sex, this is now no longer the case, they add.

Of particular concern is the increasing trend of mothers using skin lightening creams on their young children who are especially vulnerable to the side effects of these products, explain the researchers.

This is because of their higher ratio of body surface area to weight, which increases systemic exposure, and their thinner and more permeable skin, which heightens the risk of absorption, they add.

And skin lightening products often contain endocrine system disruptors, such as liquorice, resveratrol, steroids, as well as heavy metals, such as mercury, they point out.

To better understand the prevalence and motives for the practice and inform policy to safeguard children’s health, the researchers surveyed 369 mothers with at least one child under 5 in Ile-Ife, Osun State, Southwestern Nigeria.

The mothers were all attending community immunisation and infant welfare clinics in three government-owned primary healthcare centres.

The questions aimed to find out how many of them used skin lightening creams, soaps, or lotions on their young children and to explore their knowledge, attitudes, and perceptions of the pros and cons of these products.

Potentially influential factors, such as age, marital status, religion, income, occupation, cultural beliefs, educational attainment, personal skin colour and use of skin lightening creams, perceived social factors, and access to media were all taken into account.

The average age of the mothers was 30, and nearly all had attained at least secondary level education. Most (87%; 320) reported low household income. Between them, they had 792 children, ranging in age from 1 to 59 months.

Around 1 in 5 (19.5%;72) of the mothers said they used skin lightening creams on their children. Of these, 90% (65) applied the products routinely; the rest used them intermittently.

Infants and young children were the primary recipients. Over three quarters (81%; 58) of those exposed to these products were under 2 years old, with just over half (51.5%; 37) 6 months or younger.

Children under 2 were twice as likely to be the recipients of skin lightening attempts as older children.

The most frequently used agents were hydroquinone-based creams (60%; 43), followed by powerful topical steroid creams (29%; 21).

Three quarters (76.5%; 55) of the mothers who used skin lightening products on their children self-identified as light skinned, and a similar proportion (75%; 54) expressed a preference for lighter complexions.

Most of these mothers (89%; 64) said they had used skin lightening creams on their own skin. But only just over half of them (56%; 40) perceived lighter skin as conferring social or economic advantages over darker skin tones.

The most frequently cited reasons for the use of skin lightening products were to improve the child’s complexion (61%; 50) and to preserve or maintain what was described as the child’s natural skin colour (79%; 65).

Less than half (43%; 31) of the mothers cited specific perceived benefits of skin lightening, including the treatment of blemishes (8%; 6), enhancement of beauty (19.5%;14), or prevention of darkening from sun exposure (6%; 4).

Almost all the respondents (97%) were aware of the health risks associated with these products, and most (81%;58) of those using them on their children were aware of at least one serious systemic side effect associated with use.

One in three, (34%; 24) acknowledged the potential presence of toxic substances in some of these formulations. But they were around 4 times less likely to acknowledge specific dangers or identify complications than those who didn’t use these products.

“The observed disconnect between awareness of risks, recognition of specific danger and skin lightening practices indicates that social expectations and perceived advantages can outweigh safety concerns,” note the researchers.

Mothers who had used skin lightening creams on themselves were 15 times more likely to use them on their own children than those who didn’t report personal use, while perceiving light skin as more attractive or socially advantageous nearly doubled the odds of early childhood exposure.

And having a family member who practised skin lightening was also associated with a doubling in the likelihood of using one of these products on a child.

This is an observational study and, as such, can’t establish cause. And the researchers acknowledge that relying on survey data risks recall bias and possible under reporting through fear of judgment. And they only included mothers’ perspectives, precluding the potentially influential views of other caregivers or household members.

But they point out: “Beyond physical health implications, these practices also transmit colourist ideals, positioning lighter skin as a marker of beauty, self-worth, and social acceptance.”

They add: “Such early internalisation may adversely affect self-concept and identity, reinforcing intergenerational cycles of dissatisfaction with natural skin tone, stigma, and harmful cosmetic norms that persist across the life course.”

And they conclude: “The dual risk of toxic exposure and early internalisation of colourist ideals from childhood skin-lightening carry profound public health implications. While risk awareness may contribute to reducing the practice, cognitive dissonance may undermine its impact.

“Addressing this requires policy measures that go beyond individual risk education to challenge cultural narratives and normative pressures, alongside stronger regulatory oversight to ensure accurate labelling and restrict hazardous formulations.

“Culturally sensitive strategies, such as integrating skin health education into maternal child health services, leveraging immunisation visits, and engaging trusted community leaders, may offer effective avenues for change.”

20/11/2025

Notes for editors
Research: Early childhood exposure to skin-lightening products in Nigeria: prevalence, maternal perspectives, and predictors from a cross- sectional study Doi: 10.1136/bmjopen-2025-105631
Journal: BMJ Open

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf  

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post High prevalence of artificial skin lightening in under 5s, Nigerian survey suggests first appeared on BMJ Group.

Professional background linked to 6-fold greater likelihood of becoming a doctor than working class background
Greater efforts needed to boost social mobility of medical school applicants, say researchers

Large social and economic inequalities persist among UK doctors, with those from a professional background 6 times more likely to become a medical practitioner than those from a working class background, reveals a 10 year study, published in the open access journal BMJ Open.

Greater efforts are needed to boost the social mobility of medical school applicants and better understand the effects of these inequalities on patient care, say the researchers.

National data from 2014 show that only 4% of practising doctors came from lower-income working class backgrounds. And despite concerted efforts over the past 20 years to redress the balance in the UK their impact on medical school admissions has been limited, note the researchers.

Yet the British Medical Association has long held that doctors should be as representative as possible of the society they serve to provide the best possible care to the population, and this remains an explicit aim in the latest workforce plans from the NHS in England, they add.

The researchers therefore wanted to gauge how socioeconomic background might affect the likelihood of working as a doctor in the UK between the 1960s and the 2010s.

To do this, they pooled 10 years of data (July 2014 to September 2023) from the nationally representative UK Office for National Statistics Labour Force Survey for 358,934 respondents, aged at least 23 and in work.

Since 2014, each July–September wave of this survey has captured information on the household composition, main wage earner, and their occupation when the respondent was 14 as well as the respondent’s current occupation.

In all, nearly 1% (2772) respondents were currently working as doctors. A much higher proportion of them came from professional backgrounds than other job holders (69% vs 32%), while a significantly lower proportion originated from working class backgrounds (13% vs 43%).

Those from professional backgrounds were, respectively, 3 and 6 times more likely to become doctors than those from intermediate and working class backgrounds, the data showed.

Around 1 in 7 (14%) of respondents who came from a household where the main earner was a doctor when they were 14, were currently working as a doctor themselves, compared with less than 1% of the whole sample.

And they were 15 times more likely to report working as a doctor themselves than respondents who didn’t come from a doctor household. They were also between 3 and 100 times more likely to be working as a doctor than respondents where the main earner when they were growing up worked in other specific occupation groups.

Respondents whose main earner worked as a cleaner, home carer, security guard, fork-lift truck, taxi, or bus driver, or in a warehouse were among the least likely to be doctors, with adjusted average probabilities of doing so only around 1 in 500 to 1 in 1500.

Adjusting for survey year, the year the respondent turned 18, sex, country of birth and ethnic group, the likelihood of being a doctor varied principally by socioeconomic background.

And stratified analyses suggested socioeconomic inequalities remained highly stable over time among respondents who turned 18 between the 1960s and the 2000s, followed by weak evidence of increasing socioeconomic inequalities between 2010 and 2018.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that the number of doctors in the sample represents just 1%–2% of the total workforce and so the findings may not be applicable to all working doctors.

They conclude: “Doctors from professional backgrounds are highly overrepresented within medicine, in particular those coming from households where the main earner was also a doctor, resulting in a workforce of doctors that is highly unrepresentative of the general population in terms of socioeconomic background and occupation.

“This inequality mirrors previous observations within medical school populations over the last 60 years in the UK and internationally.

“Unlike other studies to date, this analysis is the first to show the persistence and rigidity of these socioeconomic inequalities among working doctors over a timespan of 50 years within a single, nationally representative sample.”

It’s not clear what impact this equality gap might be having on patient care, they add, and therefore comprehensive data on doctors’ socioeconomic backgrounds needs to be collected and made available for research.

Collection of this information could be incorporated into the national databases of the UK General Medical Council or NHS England, both of which already record characteristics protected in the UK Equality Act, they suggest.

09/09/2025

Notes for editors
Research: Socioeconomic diversity of doctors in the United Kingdom: a cross-sectional study of 10 years of Labour Force Survey social mobility data doi:10.1136/bmjopen-2024-097178
Journal: BMJ Open

External funding: None declared

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: Doctors

The post Large social and economic inequalities persist among UK doctors first appeared on BMJ Group.

Higher volume prescribers more likely to receive payments; and recipients more likely to prescribe that company’s drugs, especially if payments were larger, sustained, and recent

Nearly 80% of US neurologists prescribing drugs for multiple sclerosis (MS) received at least one pharma industry payment, with higher volume prescribers more likely to be beneficiaries, finds a 5 year analysis of Medicare database payments, published in the open access journal BMJ Open.

And those in receipt of these payments were more likely to prescribe that company’s drugs, especially if the sums involved were larger, sustained, and recent, the findings indicate.

Because of the lifelong nature of MS, effective therapies are usually continued indefinitely unless a patient’s clinical response changes, explain the researchers. And MS drug prescriptions are Medicare’s largest neurological drug expense despite making up a relatively small portion of total claims, they add.

While previously published research indicates that industry payments are associated with increased prescribing of marketed products, none of these studies focused on a market as competitive as the MS drugs market, say the researchers.

They therefore set out to characterise industry payments to neurologists prescribing MS drugs and find out if the receipt of such payments might be associated with the likelihood of the preferential prescribing of that company’s drugs.

They used publicly available data on payments made by pharma companies to doctors from the Centers for Medicare & Medicaid (CMS) Open Payments platform from 2015 to 2019.

Payments are classified as: research payments; ownership and investment interests; and general payments. The researchers focused on general payments to neurologists, linking these to Medicare Part D data, which covers prescription drugs, using National Provider Identification numbers and drug names.

Their analysis included 7401 neurologists who had prescribed disease modifying therapies (DMTs) for at least 1 year, issuing a minimum of 11 prescriptions, and 20 DMTs manufactured by 10 companies.

In all, 5809 (78.5%) neurologists received 626,290 distinct industry payments from at least one drug company, totalling US$163.6 million between 2015 and 2019; 4999 (67.5%) neurologists received payments from two or more companies.

The average individual amount received was US$779, but 10% of recipients amassed US$155.7 million between them—95% of the total sums received–which suggests that drug companies may selectively target high-volume prescribers, say the researchers.

Higher prescription volumes were associated with a greater likelihood of receiving any payment type, particularly for consulting services, non-consulting services, such as speaking at an event, and travel/accommodation; the highest number of discrete payments was made for food and drink.

The amount received was positively associated with prescription volume. Compared with those who received no payments from a company, those who did, were 13% more likely to prescribe that company’s drugs.

The strongest association between industry payment and prescribing tendencies was observed for non-consulting services. These neurologists were 53% more likely to prescribe that company’s drugs.

Larger payments were also associated with a greater likelihood of preferential prescribing, rising in tandem with the size of the payment received: US$50 was associated with a 10% greater likelihood of prescribing that company’s drugs; US$500 with a 26% greater likelihood; US$1000 with a 29% greater likelihood; and US$5000 with a 50% greater likelihood.

Longer duration of payments was another seemingly influential factor, ranging from a 12% greater likelihood of prescribing that company’s drugs for one year of payments to 78% greater likelihood for 5 consecutive years.

The recency of payments also seemed to be influential. A payment made 4 years earlier was associated with a 3% greater likelihood of prescribing that company’s drugs, but a 34% greater likelihood when made in the same year.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that their study was limited to the prescribing of Part D drugs, and couldn’t establish the appropriateness of prescribing, nor for which patients more expensive brand-name drugs were most suitable.

A doctor’s decision to prescribe is informed by many different factors, including national guidelines and/or institutional protocols, insurance cover, and patient preferences. These drivers are difficult to assess using publicly available data, but should be considered when interpreting the findings, emphasise the researchers.

Nevertheless their “findings raise concerns about excess pharmaceutical promotion efforts and their implications for physician prescribing for patients,” they suggest.

“Promotional efforts to influence prescribing are especially concerning given the drugs’ substantial costs, particularly if more expensive brand-name drugs are being prescribed instead of appropriate, effective, generically available alternatives,” they point out.

“The Physician Payments Sunshine Act, which led to the creation of the Open Payments Database, was an important step forward in making transparent the financial conflicts of interest among physicians receiving industry payments.

“However, it remains unclear whether increased transparency has mitigated these conflicts of interest and their impact on prescribing behaviour, or simply given the public greater insight into the large scale of industry payments made to prescribers,” they conclude.

26/08/2025

Notes for editors
Research:  Industry payments to US neurologists related to multiple sclerosis drugs and prescribing (2015–2019): a retrospective cohort study Doi: 10.1136/bmjopen-2024-095952
Journal: BMJ Open

External funding: None declared

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf   

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: People (neurologists)

The post Most US neurologists prescribing MS drugs have received pharma industry cash first appeared on BMJ Group.

But women doctors in this attire are often misidentified as nurses or medical assistants
And preferences for doctors’ dress strongly influenced by clinical context/medical specialty 

Patients are still more likely to trust doctors and consider them more professional when they wear white coats, although women doctors in this attire are often misidentified as nurses or medical assistants, finds a review of the available research on the topic, published in the open access journal BMJ Open.

But patient preferences for doctors’ attire seem to be strongly influenced by clinical context and medical specialty, with a growing acceptance of scrubs, especially in emergency or high-risk settings, the findings indicate.

In the 19th century, doctors primarily wore black, because medical encounters were viewed as serious and formal occasions. But with the growing emphasis on hygiene and scientific advancements in medicine, white coats represented cleanliness and professionalism and became standard attire for doctors worldwide in the 20th century, note the researchers.

Since the publication of a previous comprehensive review of the published research on the impact of doctors’ attire at work, which highlighted the significant role this has in patient satisfaction, trust, and adherence to medical advice, healthcare practices and societal expectations have evolved, they explain.

The researchers therefore wanted to update those findings, broadening the scope to include diverse clinical contexts, in a bid to gain a deeper understanding of how doctors’ attire might influence interactions with patients and treatment outcomes.

They scoured research databases for relevant studies published between January 2015 and August 2024. From an initial haul of 724 studies, 32 were eligible for inclusion in the review.

Most of the studies were carried out in the USA (17); two each came from Japan, China, and Pakistan; and the rest were carried out in Indonesia, India, Ethiopia, Korea, Germany, Malaysia, Saudi Arabia, Singapore and Switzerland.

Clinical setting had some bearing on patient preferences. For example, palliative care doctors’ attire didn’t affect patients’ trust, or assessments of the practitioner’s capabilities, but patients preferred emergency care doctors to wear white coats or scrubs. And they were happy for primary care doctors to be dressed casually and to wear white coats.

Specialty also seemed to influence perceptions, with patient preferences for doctors to wear white coats observed in orthopaedics, surgery, dermatology, ophthalmology, and obstetrics and gynaecology, for example.

The included studies indicated a distinct preference among patients for male doctors to wear suits. One study indicated that accessories, such as watches and glasses worn by male doctors significantly enhanced perceived professionalism and trustworthiness, which aligns with the findings of previously published studies, note the researchers.

The UK, however, has implemented a ‘bare below the elbows’ policy, which bans doctors from wearing white coats, watches, ties and long sleeves to minimise infection risks.

And even when male and female doctors wore identical attire, female doctors were still more likely to be misidentified as nurses or medical assistants—a misidentification that was consistently observed across different cultural settings.

But patients preferred white coats over business or casual attire for both male and female doctors, and irrespective of gender, they favoured doctors wearing white coats, perceiving these practitioners to be trustworthy, respectful, skilled, communicative and empathetic.

Notably, male surgeons wearing a white coat over scrubs were looked on less favourably than those wearing a suit with a white coat, scrubs, or just a suit. On the other hand, female surgeons in white coats over scrubs were preferred over those in suits or casual attire.

“This preference aligns with recent evidence indicating that female physicians are often judged more on appearance than their male counterparts. The way female physicians dress significantly influences perceptions of competence and professionalism, highlighting the gendered expectations that patients hold,” write the researchers.

“These gender-specific preferences for surgical attire were each supported by a single study and warrant further validation… None the less, gender-related perceptions of physician attire were consistently reported across studies with a low risk of bias, supporting the robustness of this theme,” they add.

A few studies explored doctors’ attire during the COVID-19 pandemic, when numerous doctors reported a preference for wearing scrubs to prioritise hygiene and ease of movement.

These studies consistently reported a shift in patient preference towards practical and hygienic attire, such as scrubs and face masks, reflecting heightened sensitivity to infection control, say the researchers.

The researchers acknowledge various limitations to their findings, in particular the fact that most of the included studies were carried out in the USA, there were none from South America, and only a few from European, Asian, and African countries. Many of the studies also relied on self-reported data, and none included children or patients with mental health issues.

“While the traditional white coat is seen as a symbol of professionalism and trust, patients have increasingly accepted scrubs, especially in emergency or high-risk settings,” they write.

“The expectations regarding attire are often gendered, particularly affecting the recognition and respect given to female physicians, which highlights the importance of institutional initiatives aimed at reducing bias and fostering equitable perceptions among patients,” they add.

Medical institutions should consider adopting flexible dress codes that align with patient preferences for different clinical environments and medical specialties, they suggest.

12/08/2025

Notes for editors
Research: Patient perception of physician attire: a systematic review update Doi: 10.1136/bmjopen-2025-100824
Journal: BMJ Open

Externally peer reviewed? Yes
Evidence type: Systematic review
Subjects: People

The post Patients still view doctor’s white coat as symbol of professionalism and trust first appeared on BMJ Group.

While often not immediately obvious, its effects may be no less damaging or protracted
Prevalence of verbal abuse has risen substantially while that of physical abuse has halved

Experiencing childhood verbal abuse shows a similar impact to adult mental health as physical abuse, suggests a large intergenerational study, published in the open access journal BMJ Open.

While often not immediately obvious, the effects of verbal abuse may be no less damaging or protracted, the findings indicate. This large retrospective study of more than 20,000 participants examining birth cohorts from the 1950s onwards showed reductions in childhood physical abuse but increases in childhood verbal abuse.

Globally, an estimated 1 in 6 children endures physical abuse from family and caregivers. As well as the immediate physical trauma, physical abuse can exert lifelong effects on mental and physical health and wellbeing, note the researchers.

This can manifest as higher levels of anxiety and depression, problematic alcohol and drug use, other ‘risky’ behaviours, violence towards others, and serious health issues, such as cardiovascular disease and diabetes, they explain.

Like physical abuse, verbal abuse is a source of toxic stress, which may affect the neurobiological development of children. It is thought that around one in three children around the globe is subjected to it, they add.

But despite its high prevalence, policies and initiatives to prevent violence against children have tended to focus on physical abuse, often overlooking the potential impact of verbal abuse, they point out.

To better glean the long-term effects on adult mental health of childhood physical and verbal abuse, separately and combined, the researchers pooled the data from 7 relevant studies, involving 20,687 adults from England and Wales, and published between 2012 and 2024.

The studies had all involved questions on childhood physical and verbal abuse using the validated Adverse Childhood Experiences (ACE) tool, and the short Warwick-Edinburgh Mental Wellbeing Scale to measure individual and combined components of adult mental wellbeing.

The survey asked participants how often over the past 2 weeks they had been: feeling optimistic about the future; feeling useful; feeling relaxed; dealing with problems well; thinking clearly; feeling close to other people; and able to make up their own mind about things.

Responses were scored from 1 (none of the time) to 5 (all of the time), and added up. Low mental wellbeing was considered as being more than one standard deviation below average scores (equivalent to around 1 in 6 of the sample).

Analysis of all the data showed that experience of either physical or verbal abuse as a child was independently associated with a similar significant increase (52% and 64%, respectively) in the likelihood of low mental wellbeing as an adult.

And experience of both abuse types more than doubled this likelihood compared with no exposure to either type.

Even when physical abuse was part of a person’s childhood experiences, those who had also experienced verbal abuse as a child faced an additional risk, with the prevalence of low mental wellbeing rising from 16% with no abuse to 22.5% (physical abuse only), 24% (verbal abuse only) and 29% (both physical and verbal abuse).

Individual components of mental wellbeing also showed similar associations, with the prevalence of never or rarely having felt close to people in the preceding fortnight rising from 8% for neither abuse type, to 10% for physical abuse alone, to just over 13.5% for verbal abuse alone, and to just over 18%  for both types, after adjusting for potentially influential factors.

Those born in or after 2000 had higher likelihoods of all individual poor mental wellbeing components as well as overall low mental wellbeing. And men were more likely to report never or rarely feeling optimistic, useful, or close to other people, while women were more likely to report never or rarely feeling relaxed.

The prevalence of child physical abuse halved from around 20% among those born between 1950 and 1979 to 10% among those born in 2000 or later. But the reverse was true of the prevalence of verbal abuse, which rose from 12% among those born before 1950 to around 20% among those born in 2000 or later.

Reported physical and verbal abuse were both highest among those who lived in areas of greatest deprivation.

This is an observational study, and as such, can’t establish cause and effect. The researchers also acknowledge that the study relied on the retrospective recall and report of verbal and physical abuse, so inaccuracies may have crept in.

Nor were they able to measure the severity of either type of abuse, the age at which it had occurred, or how long it had gone on for, all of which might be highly influential, they suggest.

But they nevertheless conclude: “Verbal abuse may not immediately manifest in ways that catch the attention of bystanders, clinicians, or others in supporting services with a responsibility for safeguarding children. However, as suggested here, some impacts may be no less harmful or protracted.

“In an increasing range of countries, parents, caregivers, teachers, and others are in roles where legislation now prevents the physical abuse of children, regardless of whether the intent would previously have been considered abusive, punitive, or educational. This leaves a potential void which should be filled with instructional advice and support on appropriate parenting, discipline, and control of children.

“Without such support, and in an absence of public knowledge of the damages caused by child verbal abuse, measures to reduce the physical punishment of children risk simply swapping one type of harmful abuse for another, with equally long-term consequences.”

05/08/2025

Notes for editors
Research: Comparative relationships between physical and verbal abuse of children, life course mental well-being and trends in exposure: a multi-study secondary analysis of cross-sectional surveys in England and Wales Doi: 10.1136/bmjopen-2024-098412
Journal: BMJ Open

External funding: UK Prevention Research Partnership

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf   

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Childhood verbal abuse shows similar impact to adult mental health as physical abuse first appeared on BMJ Group.

But figures based on 2020-21 data and don’t include all indirect costs
Societal and financial impacts of increasingly common condition “gravely” undervalued 

The annual UK cost of the mental health disorder PTSD is likely to top £40 billion, but the figures are based on 2020-1 prevalence rates—the most recently available—and don’t include many indirect costs, such as family support services, finds a cost analysis published in the open access journal BMJ Open.

The societal and financial impacts of this increasingly common condition have been “gravely” undervalued, conclude the researchers.

Post-traumatic stress disorder, more commonly referred to as PTSD, usually develops after witnessing or experiencing a traumatic event or being subjected to a more systematic pattern of trauma or abuse, explain the researchers.

Those experiencing physical violence, life-threatening injury, sexual abuse, active military combat, first responders and aid workers in humanitarian disasters may all be at risk.

Yet, despite an anticipated rise in cases of 77,000 a year, primarily due to the COVID-19 pandemic, PTSD continues to be misunderstood, stigmatised, and often misdiagnosed, say the researchers. Evaluating its economic toll is therefore crucial to inform policymakers about the importance of PTSD and the provision of care, they add.

They calculated an overall lifetime prevalence of around 4% for 2020-21—equivalent to 6,665,000 people who are expected to develop PTSD at some point in their life—from available military and civilian data.

And they searched databases for all types of quantitative studies evaluating the economic and societal costs associated with PTSD, published in English between 1990 and 2023.

Five studies involving millions of people were eligible for the analysis. From these they extracted and pooled direct cost components: hospital stays; drug treatment; family doctor (GP) and specialist (psychiatrist) time; treatment for alcohol and/or substance misuse; costs of counsellors and psychologists.

Similarly, they extracted and pooled indirect cost components: homelessness; disability living allowance; unemployment allowance; lost productivity at work (absenteeism and presenteeism); domiciliary care; social worker costs (mental health); and premature death.

At 2020-1 prices, they estimated the annual average direct excess costs for a patient with PTSD in the UK to be around £1,118, and the annual average indirect costs to be around £13,663, adding up to a total of £14,781, but ranging from around £11,373 to £16,797.

Based on the prevalence figures for 2020-1, this comes to more than £40 billion a year, they calculate.

The researchers acknowledge that PTSD is often present with other mental health conditions, and disentangling the costs due to PTSD alone is difficult. The severity of the condition (and therefore associated treatment costs) also varies.

“Certain costs are hard to measure, such as stigma and discrimination, for which we have provided only a qualitative analysis. These in turn may lead to indirect costs, such as reduced income and higher dependence on social security assistance,” they write.

But they say: “Recognising the hidden costs of PTSD (eg, in criminal justice, family support services and education) for which we were unable to provide estimates, suggests the actual economic burden is higher than estimated here,” adding: “we are gravely underquantifying the cost of this increasingly prevalent condition.”

They suggest: “The UK would do well to consider the need for the collection of high-quality cost data to more accurately assess the different costs associated with this condition. These include the involvement of individuals affected by PTSD in criminal activities, the stigma and discrimination they face, leading to social exclusion, the impact on personal relationships, and the effect on education, potentially limiting future opportunities.”

And they conclude that their findings underscore: “the need for increased awareness of PTSD, the development of more effective therapies, and the expansion of evidence-based interventions to alleviate the substantial disease and economic burden of PTSD in the UK.”

23/07/2025

Notes for editors
Research: Economic burden of PTSD in the UK: a systematic review and economic analysis Doi: 10.1136/bmjopen-2024-084394
Journal: BMJ Open

External funding: Supporting Wounded Veterans; The Veterans Foundation

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Systematic review; cost analysis
Subjects: People

The post Annual UK cost of mental health disorder PTSD likely tops £40 billion first appeared on BMJ Group.

The post Cold sore viral infection implicated in development of Alzheimer’s disease first appeared on BMJ Group.

Adding this test to usual care yearly or every two years could improve patient outcomes

A single blood test, designed to pick up chemical signals indicative of the presence of many different types of cancer, could potentially thwart progression to advanced disease while the malignancy is still at an early stage and amenable to treatment in up to half of cases, suggests a modelling study published in the open access journal BMJ Open.

Incorporating the test, formally known as a multi-cancer early detection test, or MCED for short, either yearly or biennially, could therefore improve outcomes for patients by intercepting disease progression, suggest the researchers.

Currently, only a few cancers can be reliably screened for—those of the breast, bowel, cervix (neck of the womb), and lung for those at high risk. While effective at lowering death rates from these diseases, these screens can also result in false positive results and overdiagnosis, say the researchers.

The optimal interval at which screening will pick up the most cancers at an early stage (I and II) while at the same time avoiding unnecessary testing and treatment still isn’t clear.

To inform future clinical trials, the researchers drew on a previously published disease progression model for many different cancers. They used this to predict the impact of regular screening with an MCED test on the time of cancer diagnosis and patient death for different screening schedules among 50-79 year olds in receipt of usual care.

The screening schedules modelled ranged from 6 months to 3 years, but with an emphasis on annual and biennial screening for two sets of cancer growth scenarios. These were  ‘fast’, where tumours remain at stage I for between 2 and 4 years before progressing; and ‘fast aggressive’ where tumours remain at stage 1 for between 1 and 2 years, with decreasing periods of time for progression to successive stages.

Cancer types included were those of the anus; bladder; breast; cervix; bowel/rectum; food pipe (oesophagus); gallbladder; head and neck; kidney; liver/ bile-duct; lung; ovary; pancreas; prostate; sarcoma (soft tissues/bone); stomach; thyroid; urothelial tract, and uterus, as well as leukaemia, lymphoma, melanoma, blood cancers (myeloid neoplasm, immune cell cancers (plasma cell neoplasm).

The researchers drew on MCED test characteristics from a recently published report and patient outcomes from population cancer data from the US Surveillance, Epidemiology and End Results (SEER) programme.

Their analysis showed that all MCED screening intervals had more favourable early-stage diagnostic rates than usual care alone. There was a larger impact on stage shift for tumours with ‘fast’ growth than for tumours with ‘fast aggressive’ growth.

But annual MCED screening under the fast tumour growth scenario was associated with a higher number of diagnoses: 370 more cancer signals were detected per year per 100,000 people screened, with 49% fewer late-stage diagnoses, and 21% fewer deaths within 5 years than usual care.

While biennial MCED screening was able to shift the stage at diagnosis and avert deaths, it was not as effective as annual screening: 292 more cancer signals were detected/year/100,000 people screened; 39% fewer late-stage diagnoses; and 17% fewer deaths within 5 years than usual care.

Annual MCED screening prevented more deaths within 5 years than biennial screening for the fast tumour growth scenario. But biennial screening had a higher positive predictive value: 54% compared with 43%. In other words ,it picked up more cancers for each completed test.

And it was more efficient at preventing more deaths within 5 years per 100,000 tests—132 compared with 84, although it prevented fewer deaths per year, so was less effective.

Given that 392 people are diagnosed each year with an aggressive cancer that would kill them within 5 years, earlier diagnosis through biennial MCED screening could have averted 54 (14%) of these deaths. But annual MCED screening could have avoided 84 (21%) fewer deaths, say the researchers.

“Based on the performance characteristics from a case control study, both annual and biennial screening with an MCED test have the potential to intercept 31–49% of cancers at stage I-II that would otherwise present at stage III-IV,” they estimate.

“Of these, approximately equal numbers would be detected at stage I and at stage II: 14% stage I and 16% stage II to 23% stage I and 26% stage II.”

The researchers acknowledge that their estimates assume 100% compliance with the recommended screening schedule and 100% accuracy of confirmatory follow up tests, and so represent the upper bounds of potential benefits of MCED cancer screening.

It is also assumed that a reduction in the number of late-stage cancer diagnoses would automatically reduce death rates from the disease. And they point out: “The optimal choice of screening interval will depend on assessments of real-world cancer survival and the costs of confirmatory testing after MCED screening.

“However, both annual and biennial MCED screening intervals have the potential to avert deaths associated with late-stage cancers when used in addition to current guideline-based cancer screening.”

09/04/2025

Research: Assessment of the impact of multicancer early detection test screening intervals on late-stage cancer at diagnosis and mortality using a state transition model Doi: 10.1136/bmjopen-2024-086648
Journal: BMJ Open

External funding: None declared

Externally peer reviewed? Yes
Evidence type: Modelling study
Subjects: People

The post Blood test for many cancers could potentially thwart progression to late stage in up to half of cases first appeared on BMJ Group.