Monthly Archives: July 2008

There is an interesting and worrying piece in the New York Times about dermatologists in the US. The charge is that patients attending with medical skin complaints are treated as second class compared with those patients seeking cosmetic interventions. The latter make more money for the MDs. The insurance company payout for seeing people with ’ordinary’ medical skin complaints is low, say some dermatologists in defence.

There are lots of reasons why I find this disturbing. The ultimate outcome of demand-based medicine means that the largest dollar shouts loudest. But this does not match who is in need of most medical care. Why on earth should patients with serious skin complaints be dealt with less quickly than those who want a few wrinkles pressed out? Medical magazines in the UK frequently offer courses for doctors or nurses wanting to do a bit of cosmetic botox. Dentists, too, are getting in on the act. Is this really a good use of time and training? 

The other thing that bothers me is our apparant obsession with being wrinkle free. What kind of society is it that proclaims itself to think ageism a terrible thing  – but then spends vast amounts of time and money trying to superficially avoid the signs of maturity?

I consider morale to be a rather important in the smooth workings of the NHS. True, some things in the NHS are done badly, and some things definitely need to improve. But we hear a lot more within the media about NHS failings rather than successes. This doesn’t just affect morale within the NHS. It can also give a skewed view to people who are trying to decide whether or not to accept NHS care.

I am handing over to Emeritus Professor Joe Lamb who has emailed and who is keen for his experience of the NHS to be heard.

A total knee replacement in a Scottish NHS hospital On Monday 23/06/08 at lunch time I entered the Golden Jubilee National Hospital in Clydebank and, like all other patients, was allocated a single room with en-suite facilities, TV, phone etc and then was seen by the surgeon and registrar, the anaesthetist and various other staff. Next day at 8am I was given a spinal anaesthetic & sedative (my choice) into my arm. I woke at 11am, had a normal lunch at 12-30pm and was up on a zimmer by 4pm.

One of the medical newspapers, Pulse, has a news article saying that there has been a drop in the number of  homeopathic prescriptions by GPs in the UK. In 2005, there were 83,000 written, and in 2007, it had fallen to 49,300.

This is good news. It could be that GPs are becoming more critical about the evidence for their prescriptions, or patients are being more critical of the evidence for what works. One UK NHS homeopathic hospital has had funding withdrawn. The National Institute for Clinical Excellence evaluates interventions and recommends that treatments of marginal or no cost effective benefit are not funded. However it is most unfair that homeopathy, which the evidence says doesn’t work beyond that of placebo, has yet to undergo a similar evaluation.

Having said that, homeopathy does have a placebo effect,  a valuable thing. The placebo effect could be regarded more broadly as the beneficial effects of medicine which are not mediated by a biologically active ‘medical’ intervention itself – placebo pills and even placebo surgery have been found to have beneficial effects for patients. So have, for example, continuity of care, and longer appointment times. The ethics of using placebos are fraught. However, there is no such ethical problem with providing longer appointments and continuous care. It seems most unfair that the  people currently allowed to benefit most from the placebo effect are those who are prepared to use homeopathy. There are other, better things that could be used for more people to benefit from such ‘caring effects’.

Ever more medical tests are becoming must-haves. Now the glomeruli, the hardworking but scarcely acknowledged filters of the kidney, are at last to have their 15 minutes of fame.

Taiwanese researchers, reporting recently in the Lancet, say we should all know how well ours are performing. However, the blood test to establish the “glomerular filtration rate” (GFR) is not as straightforward as we might like to think. By looking at glomerular filtration rates over 12 years, the researchers in Taiwan found a link between a low GFR and an increased mortality rate. Because of this, they suggested that the GFR test should be promoted to the public

/…full column here

What do Health Boards do when something works very well? Change it, of course.

Health visitors are the senior and specialist nurses who work in general practice and take a special interest in new mothers and children. While a generation or two ago women might have had physically close relatives with whom to share information and concerns about children with, this is no longer commonplace.

Sir Liam Donaldson, the Chief Medical Officer, has published his report today on the ‘principles and next steps’ of medical revalidation. The bottom line seems to be that doctors will have to undergo relicensing every five years. We have annual appraisals already, but appraisals are meant to be supportive and reflective. The new system will have end points of pass or fail.

The problem with so many ‘wonder drugs’ is that one is prone to wonder drug fatigue. So is the new prostate cancer drug, abiraterone, lauded on so many front pages today the real thing? “Cancer drug could save the lives of 10,000  a year” says the Times, and it’s a big ‘could’. 

It’s a bit unusual for a study containing only 21 patients and which is in the initial stages (phase I) of testing as a treatment to receive such widespread and enthusiastic publicity. Apparently there was a briefing for journalists (not usually the case for releasing research) which probably contributed to just so many headlines. There are, after all, thousands of small studies published in thousands of medical journals across the world ever week. While some of the comments made by some people approached for views on the study are rightly cautious, I am still concerned that there appears to be an awful lot of enthusiasm about a drug that really is still in the initial stages of its assessment. 

The abstract for the paper is here.  And a conflict of interest: I found at least two more things declared as wonder-type-drugs in the papers today, and I don’t believe in wonder drugs.

I am always dubious about being interviewed (I prefer asking the questions.) I worry about how able I am to say what I mean to say, and often realise there was a better way of saying what I was trying to -  but half an hour after I’ve left the building.

A piece I wrote last year about the ‘cervical cancer vaccine’ attracted attention from both pro-vaccination and anti-vaccination lobbyists. 

The BBC are reporting that surgeons “could earn bonuses for successful operations”. Imperial College Healthcare Trust in London are said to be piloting such a scheme. The news has been greeted with general outrage on the BBC’s messageboard, and quite right too. The scheme presumes medical professionalism is dead. I don’t think it’s dead, but it is certainly in need of resuscitation and TLC – or at least a recognition and appreciation that the best doctors act out of the best interests of patients, not themselves.

Restaurants have toptable, teachers have ratemyteachers, and doctors are now to have views on them placed on the web at iwantgreatcare.org. This website has been designed to allow patients to rate their doctors for trust, listening and whether they would recommend them or not.

When I first heard about it, I reckoned it was a silly idea likely to die a quiet death were it ignored. Why do I think it’s silly? Well, feedback from patients can be very useful, but a website asking for only self selecting feedback (where extremes of views are most common) are hardly going to give a realistic view of how well a doctor is regarded by patients.

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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