Monthly Archives: October 2008

Help the Aged have released details of a survey today. They conclude that 1.4m older people in the UK feel socially isolated and that 1.25m are often or always lonely.

I am often dubious about the way in which surveys are interpreted. However, the findings of this survey do bear out many of the sadder observations made in general practice. 

I have long thought that social cohesion is one of the best things for both quality and quantity of life. The current approach to improving health in older people seems to be focused on prescribing more drugs to treat blood pressure, cholesterol and depression. I would much rather see one’s cardiovascular risk factors and mood addressed through meaningful activity, pleasurable and varied diet, and companionship.

Here is Sir Michael Marmot (author of The Status Syndrome, among others) on neighbourhood effects on health: “Rates of mortality and illness differ markedly between areas…Cities all over the world have variations in health by area according to socio-economic level to a greater or lesser extent…Evidence suggests that neighbourhood characteristics such as social cohesion are crucial.”

A systematic meta-analysis published earlier this year  exploring how psychosocial factors relate to health found evidence that favorable psychosocial environments “go hand in hand with better health”.

A couple of years ago in Iceland, I was deeply impressed at the convivial atmosphere after work when whole neighbourhoods seemed to gather every evening – regardless of age or sex – in cheap, local hot spas. The conversation and welcome was fabulous, old people and young people all welcome alike. There was not much exercise going on: mainly people just sat around and chatted. Icelanders have a famously long lifespan. I suspect social cohesion has something to do with it.

One of my favourite things in life is music. There is nothing quite like making music en masse, and Glasgow City Chorus is performing the Missa Solemis on Sunday 3oth November in the City Halls. The second soprano section in particular is quite marvellous (not that I’m biased).

There have been various studies reporting the effect of singing on stress, and for improving mental health. I especially like a piece in the British Medical Journal from 1911 suggesting that choral singing prevents TB, and that sight singing could prevent “oral, throat, tracheal, and lung affections”. There is also a great letter just below it commenting on the “quackery” in the “great bulk” of the mainstream press as one of the “great scandals of the present day” – nothing much seems to have changed. More to the point, singing in a choir is a good excuse to get out of the house once a week and leave the ironing/general squalour behind.

Even if one claims no trainable voice, being in the audience seems associated with health. A study from the BMC Public Health from 2007 suggests that attending “cultural activities” is associated with health even when adjusted for socio-economic factors.

If any readers are in the area then and would like to come, I have a couple of spare tickets; drop me a line at margaret.mccartney@ft.com.

There is an interesting study this week in the BMJ. The study was a mailed survey to US internists and rheumatologists about their use of placebo treatments. The response rate wasn’t great (57%) but about half said they regularly prescribed placebo treatments. Most also said they thought it was ethically permissible.

Placebos do work and the placebo response is usually a clinically useful one. The question is how to use it practically without deceiving the patient. (I am not aware of any research that explores how the placebo effect varies according to what the patient is told about what the treatment contains; do let me know if you do know of any.)

Ethically, doctors should not deceive by lying or exaggerating what is being given. Some ethicists have postulated that by giving a placebo treatment and saying something like ‘we don’t really know how the treatment we are going to give you will work, but I believe it will, and it will not cause any side effects’ is okay. My  problem is that I am not quite sure this is a good enough explanation; I find the explicit omission uncomfortable.

However, the ‘placebo effect’ can be very usefully and ethically harnessed by way of ‘placebo-like’ effects,  the effect more generally of an ongoing relationship between patient and doctor. For example, continuous care from the same doctor, longer appointment times and empathy, all result in better outcomes for patients . The political direction that primary care has been sent in, though, hardly allows for the importance of these things to flourish.

Hail the designer vagina. While I was busy thinking that cosmetic surgeons were still sucking fat from hips and erasing bags from under eyes, I have missed the latest money-making trend. Two professors of uro-gynaecology at King’s College London recently observed that women are seeking surgical procedures to improve their intimate aesthetic appearances. Writing in Obstetrics, Gynaecology and Reproductive Medicine, the professors attributed this trend to “aggressive marketing” in the US and UK, combined with media coverage.

Some types of vaginal surgery are reasonable. For example, it may be necessary to treat the symptoms or side effects of cancer. Such procedures have been developed over the years, and are backed by research. Vaginal aesthetic procedures, meanwhile, have been created to meet a demand, although the source of this enthusiasm is not exactly clear.

The hymenorraphy procedure recreates a hymen, which supposedly reconstitutes the appearance of virginity. Has the demand for this been created out of a desire to appear “virginal”, or has momentum been ensured by surgeons willing to perform it? Many women have had their hymen broken during sporting activities. Performing surgery only keeps the myth of the “intact hymen” alive. Then there is the offer of G-spot amplification, in which collagen is injected into the vaginal wall. This US invention comes with the proviso that it cannot “represent a promise, guarantee or warranty that any patient who undergoes the G-Spot Amplification/G-Shot will achieve a particular result. Individual results do vary, and no responsibility is assumed for failure to achieve a desired result.”

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

I had been meaning to mention Dipex for ages, but I was recently told that it had just changed its name to Healthtalkonline , which seems a good opportunity to write about it. It’s a compilation of interviews with people describing their experiences with illness. I think it’s a fabulous resource for patients, and for also friends and relatives. No matter how much one reads about the impact or difficulties of a condition, the view of someone who has also been there can be very helpful. I recommend it.

The dirty semi-secret that GPs get paid per item of what they do – for example, immunisations, cervical smears, blood pressure checks – has been making me uncomfortable for years. I still do not know what the best way of paying GPs is. The Sunday papers this weekend are full of stories about GPs being paid not to send people to hospital. This is only the tip of an unpleasant iceberg. Professional medicine should be about doing the right thing for patients. And while doctors should have an eye on the cost effectiveness of potential interventions, and should not be wasting public money, there should be no personal financial gain involved.

What would be a better way? On one hand, the ‘independent contractor’ model (where GPs contract services to the NHS) at least has the chance to try and negotiate a decent professional contract. On the other hand, this hasn’t been achieved; would a standard contract actually allow professional values to flourish? Maybe a flat pounds-per-hour would be better; good practice could be audited by peer review and patient feedback. Not to mention a proper assessment of prescribing practices and referral rates.

Chronic obstructive pulmonary disease is a blight on British health, estimated to cause 20 per cent of medical hospital admissions. Primarily caused by cigarette smoking, it is a condition that damages the airways and obstructs the flow of air from the lungs, leading to breathlessness, a chronic cough and wheezing. The symptoms are distressing and, as one might imagine, they have a significant effect on quality of life.

So what treatments for COPD can improve a patient’s wellbeing, mood and sense of control over the condition? The answer may be surprising, in part because we have become accustomed to hearing almost daily about “breakthroughs” in genetic decoding and state-of-the-art biotechnology. New drugs are permanently “on the horizon”.

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

The Healthcare Commission have published a report today about the state of the NHS.

On Radio 4′s Today programme this morning, they had Dr Michael Dixon speaking. He is a GP and chair of the NHS Alliance, as well as being a Trustee of Prince’s Foundation for Integrated Health. Dr Dixon took issue with the charge that hospitals were not sending out discharge summaries quickly enough. He was asked why this was; he said the cause was “arrogance”.

There is no doubt that discharge summaries are important. But to accuse hospitals of “arrogance” as a cause of slow receipt of them by GPs? It is not uncommon for hospital doctors to phone GPs like me to discuss difficult cases or to flag up potential problems as a patient comes home. This is rather helpful. Not at all “arrogant”.

It is also common for patients to come to the surgery, or to deliver in, a hand written discharge summary with a note of the most important problems or changes to treatment. This isn’t “arrogant” either.

I know for a fact that many hospital doctors stay late or go back in when they are not supposedly working to get through the paperwork; I also know that hospital secretaries, who are paid appallingly, work long and hard to get discharge letters typed quickly. I also know that most secretaries could earn more money for an easier job elsewhere. Most secretaries do not just type letters but act as PAs and organisers for patients, smoothing paths and sorting problems. I have not met an “arrogant” secretary yet.

This kind of comment damages morale and does not recognise the real resources that the NHS relies on. Goodwill and vocation is what keeps the NHS afloat.

There is pressure being placed on employers to make their workplaces “healthier”. NICE released documents on this earlier this year, and this week the Scottish Executive have published their take on matters.

What is the good employer to do? The recommendations focus on employers increasing the amount of exercise that employees take in the course of their work. Move the photocopier further away to make people walk more! Increase the distance between the water fountain and the desk! Put up signs beside the lifts to encourage people to take the stairs instead! Encourage short walks at break times! Move meetings further away!

NICE say these guidelines are evidence based, but there is nothing about how much time employees lose for the company while they are walking an extra mile or two a week. Or are people to work longer hours to get the same amount of work done? That doesn’t sound too “healthy” to me. Nor is there much in the way of long term evidence for these changes. There are many behavioural studies successfully examining how to encourage exercise that can demonstrate short term gain – but it is long term increases in movement which generate most health benefits.  

I am dubious. My email correspondent in Virginia alerted me to this article  in which he is
featured. It is a different and rather more vigorous idea: constant walking at the desk, via a treadmill underneath it.

The more one learns, the less one is certain of. This is as true in medicine as in life. Thousands of clinical studies have investigated the effects of hypertension treatments, yet there is still considerable uncertainty about which drugs are most effective.

Meanwhile, many people with no history of cardiovascular disease are being diagnosed with hypertension, and encouraged to take medication for it. But what works best?

The Drugs and Therapeutics Bulletin, a slender but valuable journal, recently published a review of the current evidence on hypertension. There are four main groups of drugs to treat high blood pressure. The first, bendrofluazide, is a diuretic, meaning that urine production is increased, which makes it unpopular with some. Beta-blockers, such as atenolol, are another choice; but these are unsuitable for people with asthma and often trigger side effects, including impotence. Calcium channel blockers such as amlodipine are useful agents but can cause swollen ankles. And ACE inhibitors, such as enalapril, can cause renal problems and require monitoring.

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

Margaret McCartney’s Blog

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