EIGHTIES MEDIC

BAD SCIENCE (reporting)

noreply@blogger.com (Anonymous) — Wed, 20 Apr 2011 19:37:00 +0000

New heart attack jab even more effective than statins - Telegraph

Read this story in the Daily Telegraph, a major UK newspaper, and you would be forgiven if you thought that this piece reports a new treatment for patients with coronary artery disease and that this treatment has been compared in a randomised controlled trial with statins and that most of the work was done in Leicester, UK.

In actual fact, this story is based on this paper published very recently in the Proceedings of the National Academy of Sciences (PNAS). This was a study using knock out mice and used various models of ischaemia reperfusion to demonstrate that inhibition of mannan-binding lectin-associated serine protease-2 (Masp2) is protective after an ischaemic insult. The authors come from all over the world and many have shares in the Seattle based start up company that is trying to commercially produce the monoclonal antibody that inhibits this enzyme. In the most optimistic best case scenario, a treatment that benefits humans will not be available for 5 to 10 years at least and will probably be unavailable to most NHS patients . Treatments that have reduced the size of myocardial infarcts in mice are plentiful. Most however have come and gone (mice are just not human being one very important reason). I really hope that this works but the odds suggest this treatment will go the same way and disappear forever into the sunset. Professor Wilhelm Schwaeble certainly seems to have done a fine job selling the story. This however is no excuse for this example of shoddy journalism.

STAND UP AND BE COUNTED

noreply@blogger.com (Anonymous) — Tue, 19 Apr 2011 17:38:00 +0000

I really liked this quick response letter to an anonymously authored piece recently published in the BMJ. The subject is the lack of teaching for junior docs. I had to reproduce it in full.

Do we have the appetite for a Medical Reformation?
Christoph C Lees, Consultant Obstetrician
NHS University Teaching Hospital, Cambridge
The anonymous author of this piece has hit the nail on the head, but what are we to do?
Rather than pontificate in prose, I'll put down a series of key phrases that most of us will recognise as going some way to redressing the balance: Consultant teaching rounds, on call rotas (as opposed to elaborately constructed shifts), resurrecting the firm structure, team cameraderie, supervision, steep learning curve, rapid acquisition of clinical skills, apprenticeship, renounce EWTD, bedside teaching.
To move towards such a world would require, as happened in the late Middle Ages in Europe (then in a religious context), nothing less than a Reformation. It would require that the Royal Colleges regain their primacy in determining standards and directing postgraduate education; it would require that Doctors renounce their corporate allegiances as de facto civil servants. And it would require the GMC to tear iself from its comfortable position as a Department of health quasi-quango.
Are Doctors willing to stand up and be counted, as the President of the RCS and some other brave souls have recently done-or to push the analogy even further, as Martin Luther did in Wittenberg in 1517? The prize would be an independent profession-and the beneficiary would be our patients.
Competing interests: None declared

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RESURRECTION OF MEDICAL RESEARCH

noreply@blogger.com (Anonymous) — Mon, 18 Apr 2011 11:48:00 +0000

I apologise for the imagery used during this Holy Week but I felt it was apt.

For a while, I have meant to write something about this article and others on the Wakefield affair which were published in a dedicated BMJ edition earlier this year.

In the UK, large amounts of tax dollars are (rightly) invested into medical R&D and the amounts have, until recently, been increasing every year. The problem is that an increasing large portion of this dosh goes to support draconian governance processes that would have done ABSOLUTELY nothing to stop the MMR farrago occurring. As the total amount of money will undoubtedly drop over the next few lean years, the obscenely large fractions being used to hire people whose main aim in life seems to be to construct barriers to research , must fall even faster. With junior doctors spurning research, the future of medical R&D in the UK looks bleak to me. If the government really wants to achieve more with less, an urgent review of how medical R&D is conducted in the UK is required. This must include the role of research in the training of all doctors. An expensive course in research methodology is no substitute for the real thing.

Since the NHS reforms are now in 'pause' mode and according to the PM and deputy PM everything is up for grabs, would it not be great if someone could bring the state of British medical research and required solutions to the table.

THE NHS SALAMI SLICER

noreply@blogger.com (Anonymous) — Sun, 03 Apr 2011 18:18:00 +0000

I am taking a big risk here and I am about to write something in favour of the NHS reforms. Will the British Medical Association ban me from their bosom and send me back my £400 plus? Highly unlikely!

There are parts of the bill that I do fear - the power of the unelected NHS commissioning board that is likely to be involved in the commissioning of my specialty - cardiac surgery. As in many parts of the bill the devil will be in the detail.
What I would point out to opponents of the reform bill is to consider the alternative. This, I fear, is even less palatable than what Lansley is offering. People are conflating the needs for £20 Billion cuts and the reforms. The cuts will occur whatever happens to the reforms. The current form of the NHS with its associated cost is just unsustainable. Without the reforms, the NHS will revert to type and resort to an bloody orgy of top slicing. This is really disruptive and demoralising. That is why as a medic who wants the NHS to survive, I just have to support the reforms.
I wish Lansley would be courageous enough to explain this to everyone.

CONFLICT OF INTEREST ITALIAN STYLE

noreply@blogger.com (Anonymous) — Mon, 21 Mar 2011 19:32:00 +0000

This news article from a recent BMJ is a good example how a conflict of interest between acting in the best interest of a patient and acting in the best interests of 'finances' can end up in the courts. It is not inconceivable that this might happen here in the UK to GPs running consortia. Devolving responsibility downstream also means devolving blame and liability.

SAME OLD SAME OLD

noreply@blogger.com (Anonymous) — Mon, 21 Feb 2011 18:47:00 +0000

BBC News - Device 'could revolutionise blood pressure monitoring'
Good story but why does it take a foreign startup company to develop the fruits of British research and the investment of British taxpayers? I suspect that British patients treated by a cash strapped NHS will not even benefit from this technology.

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RISING TENSION

noreply@blogger.com (Anonymous) — Thu, 17 Feb 2011 13:53:00 +0000

This recent article in the New England medical Journal about the future of medical education has caught my eye. The authors quote from another article entitled Cottage Industry to Postindustrial Care — The Revolution in Health Care Delivery' which appeared in an earlier edition of the NEJM - doctors, they state,

must shift from viewing themselves as 'nonintegrated, dedicated artisans who eschew standardization' to become leaders of a system that values 'wise standardization, meaningful measurement, and respectful reporting'. Aren't wise, meaningful and respectful useful adjectives!

As a practising doctor in the UK, two thoughts occur to me - In the US, patient autonomy and influence is increasingly viewed by those on the left as a liability and one of the major drivers of the huge cost of healthcare there. In England, one of the stated aims of the impending NHS reforms is to increase patient autonomy and influence - the 'Nothing about me without me' philosophy - to have more 'local cottage industry' and less Stalinist centralisation. In view of the American experience, does this mean costs will be driven upwards at a time when we are supposed to save £20 billion?

The second thought relates to the first article on medical education mentioned above - what kind of hospital doctors do we need in the future and how should the medical training system be altered to acheive this? The British consultant position, especially in the surgical specialities, has been more 'dedicated independant sometimes nonintegrated highly trained artisan' and less, small compliant cog in the giant wheel of healthcare delivery. Are we seeing the beginning of the end of the traditional system that will be replaced by one that sees the service run by a number of semi experienced doctors (subconsultants maybe!!) led by one compliant individual with shiny new MBA in medical leadership?

The fact is that patients want to be treated and managed by individuals not systems. This tension, that is becoming increasingly apparent to me in the new NHS is unsustainable and something will have to give. I predict that cost containment will trump patient satisfaction .

WHAT DOES IT ALL MEAN?

noreply@blogger.com (Anonymous) — Sat, 12 Feb 2011 16:17:00 +0000

A beautiful poem with video from a nurse who has had enough of being 'medicalised.'

THE ITALIAN WAY

noreply@blogger.com (Anonymous) — Sun, 06 Feb 2011 20:39:00 +0000

I was in Italy recently on a scholarship observing minimally invasive heart valve surgery. Observing practice in other units both at home and abroad is always very educational and should be encouraged. I spent quite a bit of time in the operating room and one thing (amongst many) that struck me was the Italian attitude to cross infection. Once you got beyond the changing room, everyone had to have a orthopedic type full hat on with a mask. If you did not, you were quickly and courteously reminded to cover yourself up. In theatre, every drop of blood that was spilt, whether on the floor or on a surgical instrument was immediately cleaned.
Now I am sure that there are those over here who would argue that this is overkill and that there is no evidence for such a strict regimen. There may not be evidence FOR the practice (because probably the study has not been done yet) but there is no evidence AGAINST the practice. Intuitively one would expect such a practice to diminish the incidence of wound infections. The SSI (modern speak for wound infection) rate in this unit is indeed very low. Now I"m not a mouth piece for top down directives but the same applies to the 'bare below the elbows' policy. There may not be evidence in favour of it but it probably helps - especially if there is a problem with cross infection.
I am old enough to remember Italian type regimen in the operting theatre in the UK. Things were also pretty strict on the wards and nurse in charge was really in charge and enforced such practices. But time moves on, and attitudes change. It reminds me one of the themes of Pope Benedict's speech at the palace of Westminster when he visited these shores. In reference to moral values he said 'If the moral principles underpinning the democratic process are themselves determined by nothing more solid than social consensus, then the fragility of the process becomes all too evident' - the same applies to our modern attitudes to the control of cross infection - the result - dimishing effectiveness of antibiotics, spending of millions on employing people to persuade staff to do what they should have never stopped doing and more top down directives and targets.
The Tuscan food, wine and hospitality were also pretty memorable!

SLOW DEATH OF MEDICAL RESEARCH IN THE UK

noreply@blogger.com (Anonymous) — Wed, 02 Feb 2011 09:16:00 +0000

BBC News - Pfizer research site closure 'a major blow'
This is a major blow to medical research in general for UK PLC. I do not know why Pfizer have done this - it could be for purely commercial reasons but the fact that the bureaucracy and expense associated with doing research in the UK have become so prohibitive would not have helped.

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BRAVE NEW WORLD OF SURGICAL TRAINING?

noreply@blogger.com (Anonymous) — Sun, 30 Jan 2011 19:02:00 +0000

I was listening to Andrew Lansley this morning on Andrew Marr's show. I was not able to hear the whole
interview but he made a very good point about the use of private providers by the previous administration. As the market was rigged in their favour and as only a minority of trusts had foundation status with limited powers to change, the hope of competition driving up standards in the NHS was NEVER going to be realised.
If (and it's a big if) these changes do have the desired positive effect, I can see surgeons working in multiple hospitals and having several contracts with different employers. As these providers are supposed to support training in their bids for GP consortium work, we might have the situation where junior surgeons might get a significant amount of their training in private facilities. With any luck the hours spent there will not be included in the infernal European Directive total. If that is so who will pay them - i.e. the doctors doing the work AND the private facilities supporting training?
It does have the potential of being just a little messy.

THE END OF THE BROWNIE ?

noreply@blogger.com (Anonymous) — Mon, 24 Jan 2011 19:52:00 +0000

BMA News - Your letters and emails
CEAs (clinical excellence awards) have been in the news continuously now for several months. They have become inextricably associated in people's mind with the financial crisis and with massive overspending in public services. They are the medical equivalent of greedy bankers' bonuses. The narrative is one Alastair Campbell would be proud of and one that will undoubtedly influence the review that is taking place and that is due to be published in the summer. This article and letters in various BMA publications suggest that the strength of feeling amongst doctors in the UK is predominantly against CEAs. This alone will ensure that CEAs in their present form or even maybe in any form will not survive. Whether this is a good or bad thing as far as what a consultant could or should accomplish is for another post.

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DEFENSIVE OR DEFENSIBLE ?

noreply@blogger.com (Anonymous) — Sun, 23 Jan 2011 19:25:00 +0000

Casebook Volume 19 Issue 1

Interesting article in this month's Casebook magazine - the MPS's (medical protection society) mouth piece.
It makes a valid differentiation between defensive (bad) and defensible (good) medicine. Defensible medicine should be evidence based and therefore any treatment decision could be justified. Obvious examples of defensive medicine are over-investigation and risk avoidance behaviour. Risk averse behaviour is seen as a possible byproduct of the reporting of individual cardiac surgeons' outcomes in the UK.
As unnecessary investigations carry side-effects of their own and as patients become better informed and empowered, defensive medicine will ironically come to carry a significant risk of litigation of its own.
Anyway a very good read !

WHAT'S SUITABLE FOR THE GOOSE IS NOT ALWAYS SO FOR THE GANDER

noreply@blogger.com (Anonymous) — Tue, 18 Jan 2011 16:46:00 +0000

Automated External Defibrillators and Survival After In-Hospital Cardiac Arrest, November 17, 2010, Chan et al. 304 (19): 2129 — JAMA

This interesting JAMA paper published online recently is an extreme example of the deleterious effect of over protocolisation of a procedure/response. I can only assume that AED use was associated with a worse outcome because those attending the cardiac arrest relied too heavily on the device to tell them what to do resulting in loss of seconds/minutes in a situation when seconds really matter. These protocols were surely designed for members of the public when the alternative is no response - unlike in a hospital where the users have expert knowledge of resuscitation. So always remember who your target population is when designing a protocol!

UK CANCER SURVIVAL RATES

noreply@blogger.com (Anonymous) — Fri, 14 Jan 2011 18:19:00 +0000

BBC News - Early testing at heart of survival cancer drive
So, poor access by GPs to investigations, the reason for worse cancer survival figures in the UK, ?

Well I'm not a GP and therefore not ideally placed to answer this question but I cannot help but think that this is only part of the reason for late presentations and poor outcomes. Everyone agrees that early diagnosis is key to successful treatment of patients with cancer. However if the patient with lung cancer (to use an example) ignores his/her haemoptysis for weeks before presenting himself/herself to the GP or if the GP has spent weeks treating the persistent cough with antibiotics for months than a day here or there waiting for a CT is not going make a difference. In these specific examples, what would be needed is education on a massive scale. If on the other hand access to investigations is an issue, than only an oversupply of imaging services will ensure that every request is dealt with 'just in time' (toyota speak for immediately.) This means a huge investment in staff and equipment at a time when the NHS is trying to shed £20 billion. Does anybody know the real reason for the UK's poor outcomes ? Whatever the cause, the solutions will cost money. So don't expect any big changes in outcomes soon.

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CHIM CHIM CHEREE

noreply@blogger.com (Anonymous) — Mon, 03 Jan 2011 13:25:00 +0000

During this holiday period, I watched a re-mastered Mary Poppins on a 55 inch HD telly. It was marvellous !! And doesn't Dick Van Dyke, the original mockney, and his chimney sweep mates move well. Amazing considering a number of them would have had pulmonary anthracosis and ulcerating squamous carcinoma of the scrotum!

SUCCESSION WARS

noreply@blogger.com (Anonymous) — Mon, 20 Dec 2010 20:32:00 +0000

New oral anticoagulants: How do they compare? | theheart.org

This article is a good synopsis of what is proving to be a battle to take over the anticoagulation crown from warfarin. As the dose of these drugs are fixed, measurement of INR to help determine the dose of warfarin, is not necessary. Although as with all newly developed drugs, these will be expensive, their cost will be offset by the fact that anticoagulant clinics, an NHS staple for decades , will no longer be necessary. Go figure - drugs causing unemployment! In addition to these savings, thousand of bed days will also be saved. In cardiac surgery, my specialty, the main reason for prolonged inpatient stay after heart valve surgery , is initiation and stabilization of warfarin therapy. I can't wait for the day when warfarin will relegated to the dustbin of history.

WHAT GOES AROUND, COMES AROUND

noreply@blogger.com (Anonymous) — Fri, 17 Dec 2010 18:15:00 +0000

Decisions and the Financial and Human Costs of Medical Care

A good piece by an anaesthetist in the NEJM today. What I found interesting was the fact that there used to be a chapter on surgical judgement
and on when not to operate in the 1960 edition of a major surgical textbook. The chapter had disappeared by 1972. As surgical and anaesthetic techniques improved, the scope for surgical intervention was extended to sicker and older patients. Now the emphasis on cost containment in a world that is broke and on patient reported outcomes is beginning to apply the brakes on that hubristic approach. It is however that kind of approach that frequently plays an important part in the advancement of medicine. With much greater scrutiny on doctors' performance, that kind of approach has now become increasingly socially and some might say morally unacceptable.

FLY FLY AWAY

noreply@blogger.com (Anonymous) — Wed, 08 Dec 2010 19:15:00 +0000

I used to be a consultant in the west Midlands and lived in a sleepy Warwickshire village
which just happened to be a 15-20 minutes drive away from Birmingham airport. I now live in a suburb in the south west corner of Sheffield and therefore when I need to fly for pleasure or business I have a choice of airports which I can use. All involve a drive of at least 90 minutes. The commonest airport I do use is Manchester. It is larger with a greater choice of destinations (therefore no need for stressful changes.) Anyone who lives in Sheffield knows that there are 2 transpennine routes to get you to Manchester airport from South Yorkshire. Having crossed the Pennines, you need to get sequentially onto the M67, M50 and M56 before you arrive at t'airport, As you drive along these fine motorways, you cannot help but notice the names of the suburbs that lie at the end of the exits. Two stand out - the first is Hyde - place of practice of one who (apart from murdering more than 200 elderly innocents) did more than any other individual to provide governments with the authority and excuse to subjugate and 'villianify' the medical profession . The second is Denton where the Chief Inspector of ITV's finest would have smelt a rat in the neighbouring borough decades ago and maybe life for docs in today's UK might have been a wee bit less complicated.