THINKING ALLOWED - CONVERSATION WITH A CHESTCRACKER

Too many still do not yet Get it!

2013-05-08T18:00:00.000+01:00

Lessons from patients’ journeys | BMJ
This is a fascinating article marking the 10 years since the series of patients' journeys was first published in the British Medical Journal. I have read most of them and find them extremely useful. After what has happened in the National Health Service over the past 12 months (Midstaffs, Francis report etc etc), I think that this kind of account must be required reading for all clinical staff however junior or senior and for all managers - well anybody anywhere who works in the health service.
My experience of being a patient over the past 2 years has certainly been eyeopening .
In this account of the 10 years experience by the BMJ's patient editor, I am struck but probably not surprised by his conclusions that doctors still do not really understand or empathise sufficiently with patients. The rise of the internet as an increasingly important source of information has not come quick enough for many. The accounts also suggest that the traditional nihilistic approach doctors in the UK take when dealing with cancer are not in keeping with most patients' expectations.

The Perfect Human Valve Substitute ?

2013-05-07T18:01:00.000+01:00

The quest for the perfect heart valve substitute goes on. This article in recent edition of the Circulation journal shows how little has changed in the 50 years we have been implanting prostheses to replace diseased human aortic valves. Patients who have mechanical heart valves still require anticoagulants and are at greater risk of strokes or anticoagulant related haemorrhages. The new anticoagulants have not and will not change that reality. Patients who receive biological valves are at higher risk of requiring reoperations due to degeneration of the prosthesis. The cut off age for the use of mechanical prosthesis used to be 70 years. (Below 70 mechanical, above biological). Over the past decade, it has drifted downwards first to 65 then to 60. Although the rate of bioprosthetic degeneration does slow with age (possibly related to calcium turnover) the main determinant of whether degenerative changes become clinically significant is years of life with the prosthesis in situ I.e. longevity or prognosis. As life span of both women and men has increased rapidly over the past 20 years, the cut off age should in my opinion, be going up and not down. This downward drift in cut off age has not occurred because of new evidence or because of dramatic new developments in the design or manufacture of biological valve prosthesis. What has driven this change is marketing and the advent of TAVI (Transcutaneous Aortic Valve Implantation) or valve on a catheter. This device ( which is essentially a biological prosthesis that is collapsed around a catheter ) can be used to treat a stenosed native aortic valve or a degenerating surgically implanted prosthesis without the need for open surgery. A TAVI device inside a degenerating biological prosthesis is a very imperfect solution for many people who might still have 10 or more years of like ahead of them. What is needed and what has not yet been invented is a biological valve that does not degenerate over time or a mechanical valve that is completely non-thrombogenic. The advent of stem cell technology and the emerging concept of using acellular valves that get seeded by autologous cells suggest that the former I.e. a perfect biological valve is more likely to be invented than the latter. I won't however be holding my breath.

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It just seems so Logical Now.

2013-04-27T17:55:00.001+01:00

A few years ago, I would have thought that this idea was nuts. Now it just seems a logical thing to do. Anyone on Facebook and Twitter are life loggers.

why does every Vimeo or YouTube video that accompanies a piece of tech or a new app always has an American speaking? This is a European (Swedish) product, and it should have a European doing the voice over - someone like Stephen Fry or Harry Hill !

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An Entertaining Viewpoint

2013-04-27T16:49:00.001+01:00

STOOPIDTALL - CICLAVIA 2013 - LA BIKE CULT from Richie Trimble on Vimeo.

Amazing how a slightly different viewpoint of an otherwise normal scene becomes so entertaining

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NHS England and Mitraclip - Room for Improvement

2013-04-23T17:30:00.000+01:00

MitraClip passes FDA hurdle | theheart.org
Mitraclip is a device that can be used to treat a leaking mitral valve, which is one of the valves in the heart.. The main advantage of this device is that it can be inserted percutaneously without the need for open surgery. The gold standard treatment for mitral regurgitation is surgery. However not all patients are suitable or fit for open surgery. Mitral regurgitation is also an epiphenomenon of heart failure and when present is associated with repeated need for hospitalisation. This type of mitral regurgitation is very rarely dealt with surgically. Use of the mitraclip therefore has the potential to decrease many admissions to hospital due to heart failure. More than 4000 of these devices have been inserted into patients in Europe since 2008 when the CE mark was awarded. The American FDA, who traditionally are very conservative when it comes to approving devices has finally given a stamp of approval through one of its expert advisory panels. These panels consist of cardiologists and cardiac surgeons who are recognised experts in the field of mitral valve disease and related heart failure. The proceedings of these panels are open and transparent.
In the UK, there is no equivalent of the FDA. Devices are approved as being safe with a CE mark granted by the European Union. There is no requirement for them to be effective. As one can imagine, the bar for CE marking is set pretty low. Mitraclip has had a CE mark for several years. The NHS commissioning board or as it is now known NHS England are responsible for commissioning of specialised procedures and devices. In recent weeks it has published guidelines on the commissioning of specialised procedures. It has decided that the NHS will not routinely commission Mitraclip. It will however 'Commission through Evaluation". This process is described on NHS England's website - ‘Commissioning through Evaluation’ enables treatments or procedures to be commissioned initially on a limited basis whilst further evaluation is carried out to determine whether a substantive commissioning policy should be developed for future use'.
I am not sure that this position NHS England have decided to adopt is logical. It certainly is vague. There is no doubt that the Mitraclip reduces mitral regurgitation in a safe fashion and there is no doubt that it does so in a less traumatic & less invasive fashion when compared to surgery. That surely is the only evidence one requires before commissioning. The decision as to whether the patient is treated percutaneously, surgically or medically should be taken by the patient's physician or Heart Team. It is this decision that will be determined by emerging evidence.

Robert Francis Has a Point

2013-04-18T13:00:00.000+01:00

Two points in this article resonate with me, and I am sure with many of my peers - the first is the one that makes it to the title of the piece - every patient needs ONE hospital doctor who is responsible for their care.
My instinctive response to this is 'absolutely. It's the way it used to be before the wretched European Union stuck their oar in'. The contrary argument is that doctors need to go home or go on leave sometimes, but patients still need looking after. although the system clearly failed at Mid staffs it did not in countless other hospitals in England. The broader point is that the current norm, i.e. the involvement of many junior doctors and consultants in the care of a patient, carries risks. It is also clear to me where the risks originate from - inadequate handover. Sort handovers out (and technology has an important part to play here), and the risks will diminish. The increased use of MDT working in the management of patients may also be associated with a dilution of accountability and responsibility - here Robert Francis has a point.
The other part of the article that really resonated with me was Robert Francis's observation that 'in the NHS, nothing gets done because nobody has been told to do it' - or words to that effect. This must surely be the greatest weakness of the current model that has been chosen for the NHS - the top down, central control model. The QC is absolutely right - nothing gets done, unless there is a carrot or a large stick dangled in front of managers. It seems to me sometimes that NHS organisations have lost the power of independent thought. They only look upwards for guidance, and yet it is patients and their own staff that probably hold the key to the future. This way of working also makes a mockery of all the efforts of the NHS to develop leaders. Progressive patient empowerment will mean the current model is doomed to fail, eventually.

The Difficult Problem that is Aortic Dissection.

2013-04-17T18:00:00.000+01:00

There is no other cardiothoracic procedure that is as challenging as the management of a patient with type A aortic dissection.
Untreated, the immediate mortality rate is 1% per hour. The surgery to repair a type A dissection is extremely challenging, patients are very sick, and coagulopathic and the dissected vascular tissues are incredibly friable and difficult to work with. To make matters worse, the average on call surgeon dealing the majority of these cases will only operate on a very small number of aortovascular cases per year. The operative mortality in most countries of the world for this procedure is around 25-30%.
I have come across this excellent video presented recently by the American Society of Thoracic Surgeons on some of the very difficult issues surrounding the operative management of these patients.
It is worth a share!

Off Pump Coronary Surgery (OPCAB) and the Evolution of My Pragmatism!

2013-04-15T18:00:00.000+01:00

I have been observing and then performing coronary artery surgery since 1988. It was in 1992 when I first heard of Subramanian's first published accounts of LIMA to LAD coronary bypass done off pump i.e. without the aid of a heart lung machine.

In 1995, when I was senior registrar (Chief resident) at the Queen Elizabeth Hospital in Birmingham, UK, Jim Fonger, an American cardiac surgeon, was invited by Bruce Keogh (who was still a plain old Mr. then and a Consultant cardiac surgeon at the QE) to come to Birmingham to operate on a Jehovah's Witness who required redo coronary surgery . Dr. Fonger performed an off pump gastroepiploic artery bypass to the right coronary off pump through a small upper abdominal incision - it was impressive stuff. The patient did very well and the case was reported in the local paper. A few months later another surgical team arrived from Italy and operated on 6 patients with isolated disease in the left anterior descending coronary artery. Two things seem quite extraordinary now - finding so many patients with single vessel coronary disease requiring surgical bypass and enabling foreign surgeons to operate on NHS premises - both are virtually impossible now! Anyway, back to Birmingham, these 6 patients did not do as well as was expected and most suffered one or other complication - I was not impressed and my skeptic attitude towards off pump CABG returned. Moving on to 1998 and a publication from South America changed the scene. Buffolo et al described a very large series of patients undergoing multivessel coronary artery bypass surgery without the aid of a heart lung machine. This study was significant because until now only single vessel bypass had been performed in this way. Now here was a operation that was applicable for the majority of patients with coronary disease requiring surgical revascularisation. The operation was christened OPCAB - off pump coronary surgery. Industry became interested and the turbo boosters were lit! What followed was massive non-evidence based expansion in practice in the usual optimistic way which seems to be so characteristic of surgical procedures. I was swept up by the enthusiasm, went on courses, learned the technique and soon more than 50% of the cases I was operating on were done without the aid of a heart lung machine. Over the ensuing 8 years, paper after paper eschewing the benefits of OPCAB surgery were published. Most of these papers were large retrospective series. There were some small randomised trials that suggested that despite the findings of the retrospective case series, the differences between on pump and OPCAB were negligible . The justified criticism aimed at these studies were that they were small and trial subjects did not include the type of patients who were likely to benefit from OPCAB - the high risk patient. I stated as much in a leader in the European Heart Journal.
During the past three years, the findings of a number of randomised controlled studies have now been published - here, here, here and here. The truths surrounding the OPCAB vs on pump CABG debate are now emerging from the mists of uncertainty.
Patients require less transfusion after OPCAB
Patients are less likely to suffer postoperative atrial fibrillation after OPCAB
Early and probably late mortality rates are NO different after OPCAB in all (even higher risk) patients
Vein grafts are less likely to be patent after one year in patients undergoing OPCAB
As a consequence, patients are more likely to suffer angina recurrence and need coronary revascularisation at 1 year after OPCAB (still much lower than percutaneous coronary intervention).

There are 2 further truths that all surgeons would also accept - 1. manipulation of an ascending aorta that is known to be diseased is tantamount to criminal behaviour because of the known high risk of cerebral emboli. 2. The only way to avoid touching the aorta during a coronary artery bypass procedure is to perform an OPCAB procedure using pedicled arterial grafts such as the internal mammary artery grafts with any further grafts attached proximally to these pedicles. The alternative, if the disease in the aorta is not diagnosed until after the chest is opened, is a surgical bailout. In the presence of severe coronary disease, this option could be quite hazardous.
The age of the patients undergoing coronary surgery is increasing all the time. Operating on an octogenarian is now not as rare as it used to be. The chances of coming across a diseased ascending aorta is therefore higher than it has ever been.
Despite the lack of evidence for its superiority and the fact that OPCAB surgery is technically harder and certainly more stressful for the operating surgeon, it represents a valuable addition to a coronary surgeon's armamentarium. As it is a technically harder operation, surgical competence must depend on the surgeon performing an adequate number of procedures.
These are pragmatic rules I have devised therefore for choosing OPCAB when performing a coronary bypass operation:
all patients with any evidence of a diseased ascending aorta requiring surgical coronary revascularisation
When putting the patient on the heart lung machine is hazardous - e.g. heparin resistance,
If performing the same operation is quicker and easier if the heart lung machine (or Pump) is NOT used e.g. LIMA to LAD

These rules mean I can perform OPCAB often enough to remain proficient in the technique and I am not caught out if required to perform coronary surgery without a pump in an emergency.
OPCAB remains the procedure of choice in many cardiothoracic centres including the majority in India where OPCAB is king. Evidence however suggests that this might not be the right thing to do.

The Emotion of Transplant Surgery

2013-04-01T16:00:00.000+01:00

I watched this episode of Horizon recently on BBC iplayer - it featured 40 years of coverage of progress in transplant science and surgery on the BBC. The programme brought back so many memories and emotions about transplant surgery related events that have occurred during my training as well as the great people who I have had the privilege to work with and/or meet on the way - people like the late great Norman Shumway, Michael Debakey, Joel Cooper, Roy Calne, Terence English, John Wallwork, Randy Morris and David White. It also made me think a great deal of how so much has changed in medicine - not only the medical and surgical progress that has occurred over the past 30 to 40 years but also the bigger changes that have influenced HOW we practice medicine i.e the advent of MDTs, guidelines and evidenced based medicine and our relationship with patients and the effect of the world's fiscal situation which whether we like it or not will be a major determinant of progress over the next 30 years.
There is no doubt that doctors (surgeons usually) did things that would today lead them to be struck off and imprisoned (in the UK at least ). Will this mean in the future progress will be slower or just different?
The scene featuring the girl with cystic fibrosis brought a lump to my throat - it reminded me of a patient who I looked after and who featured on one of the programmes in this special called Knife to the Heart.
A final point I would like to make is that this work is a Clinical Ethical minefield e.g. shortening the lifespan of a patient with immunosuppressive drugs (including steroids) for cosmetic reasons (hand/face transplant) or performing surgery (living related lung or liver transplant) that has a potential 300% mortality are issues I would have difficulty dealing with today.

Is this A Dangerous Precedent ?

2013-03-30T16:36:00.000Z

I really cannot tell whether suspending paediatric cardiac operations at Leeds General Infirmary was the right or wrong thing to do - I just do not have the facts to make a judgement .
What I can tell for sure is that Sirs Bruce Keogh and Roger Boyle, both of whom I know and greatly respect, have set a precedent on how to deal with adverse surgical outcomes.
From April 1st, Bruce Keogh promised that outcomes of a number of surgical procedures performed in England will be published. There will be surgeons and units with mortality rates that are double the national average.
Are we therefore going to see a whole host of closures and investigations started before the month of April is up?

Let's Save the Dead Tree Press

2013-03-30T15:08:00.001Z

It is early morning, I am on a train speeding towards the capital for a day course at the Royal College of Surgeons in Lincolns Inn Field. I have the paper copy of the latest edition of the British Medical Journal with me to read on the train. As with many journals now, there are a number of different ways one can consume the output of the BMJ, digitally on a computer or an IPad and the age old traditional paper version.
I have an IPad and the machine faithfully downloads the BMJ every week. I am not sure why but I hardly ever read it - I still prefer the paper version. I am no technophobe - on the contrary, compared to my peers I am very geeky. I am not sure whether this penchant for paper is because the IPad BMJ is not the greatest app on the planet (IMHO it urgently needs an upgrade) or whether I am old fashioned at heart and still enjoy handling paper. One often hears prognostications about the death of paper journals and newspapers. I cannot see it myself, not unless there is a dramatic change in the quality of the experience of reading from a device. Today, the one huge advantage of reading digital material over stuff on paper is the ease with which it can be shared - stuff that cannot be shared is obsolete in a blink of an eye and obsolescence equals death. As I read my paper BMJ, I have come across stuff I would like to share but can't.
There is however a way now to make paper stuff shareable - the QR code. Just scan the code (which is printed on paper) with your phone and in a 3 or 4G instant you have the digital page on your browser which you can than share. In truth, many journals do use QR codes but usually have just one for the whole edition. Journals need to make more use of these infinitely available modern black and white marvels. Every single item that can be shared, whether it is a research article, editorial, item of news or even advert needs to have its own code. They could be the saviour of the paper industry.
Reading stuff on an smart phone or pad is common, reading paper is cool - that's the message we need to promulgate. I think I will contact all the editors of the paper journals I normally read to give them a piece of my mind- whether they will listen is something else although Fiona Godlee (BMJ ed) seems like a good egg!

A Frightening Vision of the Future of Medicine.

2013-03-25T19:00:00.000Z

Outside the medical school of the University of Sheffield (my alma mater) is an attractive stone carving of the words ARS LONGA VITA BREVIS. Apart from the fact that this is the name of an album by the group Nice before Keith Emerson left to form ELP, it is also an aberrant Latin translation of a saying by the Greek father of us all, Hippocrates.
More of this later.

JAMA Network | JAMA | Crossing the Omic ChasmA Time for Omic Ancillary SystemsOmic Ancillary Systems

Interesting article about the 'omic' revolution to come and its implications. The word omic refers to the final 4 letters in 'genomic', metabolomic, and proteomic. I am pretty sure before the decade is through, a few other words ending in omic will join the list. I am also pretty sure that I will be long retired or even gone from this mortal coil before omic medicine is the norm. But the norm is what it will eventually become. It is very difficult at this point to actually visualise what life will be like in medicine and for physicians if they will still exist in their present form that is. Each human is unique and this uniqueness is recognised and recorded digitally in omic medicine. Huge digital vaults as well as enormous analytical powers will be required. Medicine will be truly personalised and randomised control trials and evidence based medicine will be irrelevant and obsolete.
Just thinking and writing about this disconcerts me. This is a future does not really appeal to me and to a certain extent I am glad I will not be part of it. The art of medicine will be dead. Ars Longa Vita Brevis no longer.

Surgical Outcomes Reporting - why we are Missing the Point.

2013-03-23T20:20:00.000Z

JAMA Network | JAMA Surgery | Failure to Rescue Patients After Reintervention in Gastroesophageal Cancer Surgery in EnglandFailure to Rescue in Gastroesophageal Cancer

Although cardiac surgery seems to be very different from other surgical specialties (and cardiac surgeons seem alien to many!) there is a lot I, as a cardiac surgeon can learn from more conventional surgical specialties. I often browse through thoracic and general surgical journals. I even enjoy reading the Annals of my College - the Royal College of Surgeons of England. I stop short however of reading orthopaedic rags - I have never had ANY professional affinity with that lot - no offence boys/odd female!!
I digress. This paper in JAMA surgery (the journal formerly known as Archives of Surgery!) is fascinating. It confirms what has been previously publicized in yet another excellent piece by surgeon racconteur, Atul Gawande in this piece in the New Yorker. Gawande describes the findings of a research study from University of Michigan that demonstrated that a major reason for variation in mortality rates after surgical procedures between different hospitals was not the incidence of things going wrong or morbid events but the ability of the institution to rescue patients once things went pear shaped. This study from England looking at events occurring after (o)esophagectomy replicates these findings. If one thinks about the incidence of morbid events or death after surgery, these findings are perhaps not so surprising. We know from many studies in different surgical specialties that a major contributor to the spread of incidences of complications are the patients themselves - advanced age, co-morbid conditions etc. But how much does the surgeon's ability contribute to variation in mortality between centres after surgery? In any one developed country, the vast majority of surgeons are trained to the same standards -standards which do not vary greatly between schools of surgery. In addition graduates from each school end up working all over the country. Both these factors contribute to the uniformity and narrow standard deviations of surgical ability in any one country. This paper is therefore significant on a number of levels - it confirms the fact on both sides of the Atlantic that variation between surgical outcomes are due predominantly to systemic institutional factors. It is also important because Bruce Keogh, medical director of the National health service in England and ex cardiac surgeon has decided that many surgical specialties should follow the Cardiac Surgeons and publicly report individual surgeons' outcomes. There is a moral case for this - patients are entitled to know what the clinical outcomes of the surgeon who is about to operate on them, are. This paper above, other studies and common sense suggest however that Bruce Keogh and many of the colleges and professional societies who support this stance, are missing the point.

Cardiac Surgeons and the Management of Stroke

2013-03-18T18:06:00.000Z

Atrial fibrillation causes 15% of strokes in the West and the UK. There is evidence to suggest occlusion of the left atrial appendage percutaneously with a device called the Watchman is as effective as warfarin in decreasing the incidence of stroke.
Does the same apply to exclusion of the appendage by surgical/open means? Surgical exclusion can be done inexpensively using prolene sutures or expensively using devices such as the Atriclip or Tigerpaw. Such exclusion is usually performed concomitantly with other cardiac surgical procedures such as CABG (coronary artery bypass grafting) or mitral valve surgery. It is a procedure that is essentially risk free and one that may have life changing benefits for the patients. One wonders how often the appendage is closed off in patients with AF undergoing cardiac surgical procedures?
The fact that percutaneous closure of the appendage is effective at decreasing stroke does not necessarily mean that surgical closure will have the same effect - after all surgery itself has procoagulant effects that may have a negative influence. Trial evidence is needed and if surgical closure is effective at decreasing the incidence of stroke, than this procedure, concomitant or even standalone may very well become more common.

The surgeon with One thumb

2013-03-11T14:43:00.001Z

Did you know that the Larry King has had a history cardiac disease and intervention and has contributed to cardiac medicine as a patient advocate. He was seen in recent days at the Annual American College of cardiology Shindig in San Francisco (tweet below) and introduced the recent annual meeting of the Society of Thoracic Surgeons in LA with an amusing story about a heart surgeon.

I'm at the American College of Cardiology's #ACC13 this AM - getting the first-ever patient advocate award bit.ly/ZreVmN
— Larry King(@kingsthings) March 9, 2013

Should we All have a Robot?

2013-02-21T14:44:00.003Z

JAMA Network | JAMA | Comparative Effectiveness Research on Robotic SurgeryComparative Effectiveness and Robotic Surgery
An interesting leader in JAMA this week about the true usefulness and cost effectiveness of robotic surgery.

As someone who does not routinely practice either 'standard' laparoscopic/thoracoscopic surgery or robotic surgery, I think I am a good person to adjudicate on this. The usual gripe from traditional laparoscopic surgeons (such as Skeptical Scalpel) and others is that the use of a robot in laparoscopic/thoracoscopic procedures results in outcomes that are no better than those outcomes after similar procedures performed without the robot. This edition of JAMA has yet more evidence of this - in patients undergoing hysterectomy. Dissemination of the practice has resulted solely from aggressive monopolistic marketing from Intuitive Surgical, the company that makes and sells the DaVinci Robot. It is curious that all the ire comes from the USA where the free market has always reigned (so far at least) in healthcare rather than the UK where everything is tightly regulated from the centre. I suppose the number of Robots in circulation in the UK is still very small. Anyway I digress - I agree with these arguments against robotic surgery. However, it is clear to me, as a beginner in the art of ...scopic surgery, that the freedom of movements provided by the robotic hands, makes this type of surgery easier to learn, more accurate and safer. Compared to open surgery, standard laparoscopy/thoracoscopy is akin to operating with bilateral frozen shoulders and elbows. If therefore the aim of surgery in general is to extend the scope of keyhole surgery (all patients want this) then robots are here to stay. The obvious problem is the fact that there is only one maker and supplier of surgical robots. As any student of economics will tell you, a free market with a monopoly will result in the worst of all worlds. The world needs multiple manufacturers and suppliers of many different types of cheaper surgical robots. Funnily enough she thinks so!

My Rag

2013-02-19T10:56:00.000Z

Truly Personalised Medicine, #cdom

2013-02-19T10:33:00.001Z

I have posted on the mind boggling potential of 3d printers here. Amazing talk by Lee Cronin on how 3d printers will contribute to the evolution of TRULY personalised medicine.

Pulseless and Alive!

2013-02-15T17:30:00.000Z

In recent years, progress towards the development of the perfect artificial heart to replace a failing one, has been rapid, outpacing progress towards the development of a Xenogeneic transplanted alternative or construction ex vivo of a new organ using stem cells.
A combination of advances in engineering, in pharmacology to develop new anticoagulants, and in battery technology has brought us to this place.
One of the features of these new machines has been continuous flow and the abandonment of pulsatility as a goal for assist devices. Contrary to what we have been led to believe over the past century, circulation does not have to be pulsatile to support human tissue.
This is a great short film full of typical Texan chutzpah recounting the very human story of how one man was brought back to life and how in the process, lost his pulse!

The Democratizing Forces that will shape the Future of Healthcare.

2013-02-12T18:00:00.000Z

Patient-centred healthcare, social media and the internet: the perfect storm? -- Rozenblum and Bates -- BMJ Quality and Safety

This is article is a great read and explains to a certain extent the forces that will shape the future of healthcare - determined by patients and consumers - a truly democratic future whether doctors or managers or politicians like it or not!

The Future of Robotics in Surgery

2013-02-07T11:44:00.001Z

Interesting words from the Chief Medical Officer of Intuitive Surgical - the company that makes the DaVinci Surgical Robot

What the Francis Report should say part 2 - breaking out of the bubble #midstaffs

2013-02-05T13:00:00.000Z

Another post on the inevitable.

Yesterday, I was reading the account of @shaunlintern eloquently describing the heart wrenching testimony of those who watched their relatives suffer and die in the face of appalling cruelty by nursing and other staff.
I asked my wife, a senior nurse, why on earth were there so many nurses in this one institution behaving in this fashion? It just beggars belief - it is because, she said, that kind of behaviour became the norm for the whole hospital.
When you live and work inside an impenetrable bubble and have no idea about norms outside that bubble, everyone eventually behaves in a fashion that might seems normal to them but is bizarre and wrong to outsiders. Therein lies the tragedy of Stafford Hospital - there were many people and organisations who entered the bubble, observed odd cruel behaviour, screwed their noses, left and did nothing about it.
The NHS tries to disseminate good practice through specialist web sites and newletters. This clearly is not enough - staff have to physically spend time at places where good practice and srong clinical governance is the norm. Maybe that is what is needed - an NHS wide rotation of staff at all levels so that behaviour like that exhibited by the staff at Stafford hospital never ever again becomes the norm.

What the Francis Report Should say about the NHS #midstaffs

2013-02-04T12:00:00.000Z

This document about the culture Netflix are trying to develop in their company was dubbed as the most important document to come out of the Valley for years.

As I read these slides with admiration and frankly envy, I could not help but think of the NHS and the imminent publication of the recommendations of Robert Francis QC following his investigations of the extraordinarily horrible events that took place at Stafford Hospital over many years and which supposed regulators just ignored.
Events like this result from a top heavy service which often acts as if it despises its most valuable asset - its employees. I just hope that the response is not just another exercise in central command and control.
hat-tip to @88andre (Andre Chow) for the Netflix slides.

Culture (2009) from Reed Hastings

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Why Apprenticeship remains invaluable in Medical Training. #MEDED

2013-02-02T14:30:00.000Z

JAMA Network | JAMA | Attending Physicians on Ward Rounds
Another great study published in JAMA . This unique study by Bob Wachter and Abraham Verghese, both American Physicians, writers and who are always worth listening to, sought the opinion of medical students, and doctors in training on the value of a ward round with a senior doctor.

The main, and possibly obvious message from the findings of the study is that trainees welcome and value the experience of the more senior medic more than the usual evidence based guidelines they are normally expected to use for practice. Spending hours on the coal face with an experienced doctor is not just invaluable and necessary for training in the operating room but applies just as well on the wards.
Medical educationalists, progressive thinkers and European politicians might undervalue the role of apprenticeship and long hours in medical education, but those who matter know better.
Good work B'Abraham!

Pay for Performance and Perversion of Data

2013-02-01T12:30:00.000Z

JAMA Network | JAMA | Tension Between Quality Measurement, Public Quality Reporting, and Pay for PerformancePublic Reporting and Pay for Performance

Excellent demonstration how in the USA, public reporting of outcomes and pay for performance, 2 interventions now being used on this side of the Atlantic, have reduced the reliability of the data itself.

This effect, a consequence of the human condition, I fear, is also seen in coding - the basis for all reimbursement in the modern NHS. If diagnosis A could, with abit of reality stretching be interpreted as diagnosis B, which pays more, guess which diagnosis occurs more frequently?