Monthly Archives: September 2008

I had intended to use this evening to read the paper published by the British Journal of Cancer about survival rates from cancer over the past 20 years. This paper has had a lot of media attention. The upshot seems to be that people are living longer after a diagnosis of cancer, but those living in affluent areas (still) do better in terms of survival compared with those living in deprived areas.  I wonder if some of the reported improved mortality in some social groups relates to an increase in over diagnosis resulting from screening for some types of cancers – but cancers which were never going to affect lifespan anyway. For example, this can be true of some prostate or breast cancers (a subject touched on in a feature for this week’s FT Magazine about breast cancer here.)

Meantime, some media commentators have ascribed the differences in survival rates to all kinds of things including the quality of nutrition, smoking, exercise, alcohol, stress, and even the supposed greater ability of the middle classes to ‘nag’ one’s doctor for a diagnosis.

I would have liked to go and read the academic paper in full. However the journal is not part of my Athens subscription (the package offered to GPs in Scotland) until the paper is a year old. The individual parts of this paper cost $32  each. That adds up to quite a lot.

The British Journal of Cancer says that it is planning to allow free access to the journal –  but only for papers published over a year ago. This is good but it is not good enough. On the BJC website it says that “BJC is owned by Cancer Research UK, the world’s leading independent charity dedicated to cancer research”. It also says that “its far-sighted mission was to encourage communication of the very best cancer research from laboratories and clinics in all countries”. I imagine that if the standard subscription package offered by my institution doesn’t cover access then this would also be the case in many other countries too.

I would also have hoped that Cancer Research UK would consider that allowing journalists and other interested people rapid and full access to the complete studies to be an essential part of dissemination of the published research. This would allow for properly informed discussion and debate. Otherwise the information we get about cancer will continue to be as erratic and unhelpful as it currently is.

There are few things quite so embarrassing as being phoned by the school to be informed that your child, whom you saw just a few minutes earlier, is too ill to be at school.

Then there is also the issue of the semi-miraculous recovery whereby a child claims severe symptoms in the morning, requiring room service, extra pillows, continuous supply of warm drinks, etc, but then ends up feeling well enough to rollerskate to the school gate later in the day to collect siblings.

I can only be certain that here my medical degree does not help.

The first time I heard about neuro-linguistic programming, I was intrigued. By scrutinising and changing a person’s speech and body language, NLP promises to improve social and professional interactions.

It has, we’re told, the power to “unlock your capabilities”. Negative psychological patterns are identified, and can be “reprogrammed”. Sensitivity to others’ behaviour is also heightened. Indeed, by showing me how to “read” unconscious behavioural signs, it could allegedly help me be a better doctor.

The technique has been around since the 1970s. Its methods have been described enthusiastically in publications as respectable as the British Medical Journal, while the Royal College of General Practitioners is running NLP “master classes”. The course blurb says: “Neuro-linguistic Programming is the study of human excellence, in terms of how we can learn to take control of our consciousness … We know that an optimistic outlook and good emotional management improve health so it is important to teach others (and ourselves) how to change limiting beliefs and attitudes to restore health and maintain happiness.”

The remainder of this column can be read here. Please post comments below.

What happens when NICE says no? If NICE refuses to fund an expensive intervention to treat cancer, but the patient wishes it anyway, the patient must forgo all ‘free’ NHS care and pay for the intervention, plus all the rest of their care – ie be subsequently treated entirely as a private patient. Care then becomes very expensive.

There has been a lot of debate about this recently, with many arguing that this is wrong, and that patients should be allowed to pay for ‘top-up’ care for whatever additional treatments they may wish to have.

Freedom of choice is obviously desirable, but, as I’ve argued before, it has to be a meaningful choice. It is incredibly hard to look at newly generated evidence and to try and decide what it means for one as an individual. This becomes even harder when the data is 1) not free to access in its entirety 2) not yet peer reviewed (eg selected data being presented at a conference) 3) presented in ways where the best possible interpretation of the treatment is used (e.g. outcomes described as a reduction in relative risk rather than in absolute risk)  4) when the trial has been small scale and/or short term, which, among other things, may not be long enough or large enough for significant outcomes or adverse effects to be made apparent.

Hospital acquired MRSA infections in the UK have apparently fallen by a third in the last year according to the Health Protection Agenc y. Gordon Brown is writing to all NHS staff to say well done.

I foresee problems. There have been a couple of political drives on MRSA recently which have been non-evidence based; the ‘deep clean’ of all hospitals and a ban on long sleeves for staff (even though the Department of Health itself said this was non evidence based.) In fact, the nonsense spoken by the DoH demonstrates the absurdity of how MRSA is being dealt with. On one hand the Uniforms and Workwear policy they have produced keeps saying how important it is to look professional (no untied long hair, not ‘too many’ badges) because this could ‘send the wrong messages’ to patients about ‘professional pride’. At the same time, while acknowledging there is no evidence for it, the policy bans neck ties.  I know of hospitals expending considerable energy into banning cufflinks while doing precious little about their commodes being shared. There is no evidence that any of the government’s ideas have had anything to do with a decreased rate of MRSA infections. The danger is that the government believes its own hype and that its policies have made the difference.

I wrote about microbiological concern about MRSA transmission last year here. The things that do seem to make a difference to MRSA infections are antibiotic prescribing, the cleaning of all surfaces, especially the less obvious ones, and decreased bed occupancy rates. Banning neck ties is not only non evidence based but it is not the surface most able to come into contact with most patients either. What about blood pressure cuffs, stethoscopes, curtains around beds, and visitors?

Dr Rajendra Pachauri, who chairs the UN Intergovernmental Panel on Climate Change, wants us to eat less meat.

Pachauri is an economist (and a vegetarian) who believes that reducing meat consumption could also cut greenhouse gas emissions. The idea seems to make sense, since about one-fifth of global emissions are produced by the meat industry. I am already a semi-vegetarian: I avoid meat and only occasionally eat fish. This may be good for the environment, but is it any good for my health?

The question has always been hard to answer scientifically, for a number of reasons. Studies on the relationship between diet and health are often conducted retrospectively, which can cause problems. When, for example, a victim of a heart attack is asked about his or her dietary history, the response will be affected by “recall bias”. This means that present habits and events may influence perception of the past. In addition, it can be hard to ensure that individuals’ vegetarian diets are similar enough to act as a uniform comparison to carnivorous ones.

The remainder of this column can be read here. Please post comments below.

Lots of media coverage on a new study today, which is apparently going to compare the reported offences of prisoners while taking either placebo or a fish oil+multivitamin+mineral supplement. Some headlines  have interpreted this as ’Prison study to investigate link between junk food and violence’. I think that’s an extrapolation too far; the quality of the food the people eat isn’t going to vary during the study (although nourishing food, and the social interactions of eating should perhaps be an area of further interest in this group of people.)

The apparent health improving qualities of fish oils have been much overhyped in recent years. However there have been previous studies done looking at the effects of fish oils in prisoners and good quality evidence on a larger scale is to be welcomed. I haven’t seen the trial protocol on the register yet, but will keep an eye on this story.

Just as I was working out how to play a Harry Potter DVD an amazing television advert came on. It’s only broadcasting in Scotland but you can see clips at Get randomised. The website doesn’t say who is funding the ads, but I am impressed at the way that fair clinical trials are being promoted as a good thing and not, as per usual,  mad scientists coercing gullible victim human guinea pigs into crazed experiments.

What would be very nice would be a study to assess the impact (or not) of these adverts – fair tests for all interventions, indeed…

I don’t think that Peter Higgs has a fan club – yet. An interview with him in New Scientist this week reveals why he should have one. He is the theoretical physicist who has predicted the existence of a particle now known as the ‘Higgs boson’ which explains the origin of mass and which the CERN project in Switzerland, turned on this week, is going to investigate.

I very much like Professor Higgs for these reasons. 1) He is modest. He heard from a colleague that the name ‘Higgs’ had been attached to almost everything to do with the theories of mass generation (“I think I was first to draw attention to the particle associated with it…..I go around pointing out that nothing else in this kind of theory was mine or mine alone”). 2) He considers other people: he was concerned about the vogue for calling the Higgs particle the ‘God particle’ (“it might offend people who are religious”). But most importantly (3) he is very wary of the overselling of theories when they are still at the experimental stage and that overenthusisatic researchers can do real damage to the public at large (“He urges scientists not to repeat the mistakes of the past by overselling [the CERN experiments] as a machine destined to find the definite answers to the remaining mysteries of the universe.”)

 On number 3, I suspect that there are medical researchers and press officers who could learn rather a lot.

Exercise is good for you. This is the gospel that we doctors are enjoined to preach to patients – we even have prescription pads to refer people to the gym.

But there is a snag: the more you exercise, the more likely you are to pick up a sports-related injury. We are taught from an early age that warm-ups and cool-downs are the best way to prevent this, but it is not entirely clear whether either routine does us any good.

The science supporting the notion is far from robust. A review of the evidence published last year by the international, not-for-profit Cochrane Collaboration suggested that warm-ups did not prevent injury or muscle soreness after exercise, while cool-downs did not prevent post-exercise pain either. 

The remainder of this column can be read here. Please post comments below.

Margaret McCartney’s Blog

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