Monthly Archives: January 2009

When is it time to say “enough”? As Barack Obama settles into the White House, I am hoping that his new surgeon general, widely expected to be CNN’s chief medical correspondent Dr Sanjay Gupta, will decide that with one particular issue, the time has come.

The MMR – measles, mumps and rubella – vaccine is safe. There have been several large-scale studies making this clear. None showed an increased association with autism, which became a big fear among parents in much of the western world, in the wake of the publication of a tiny, flawed research study in The Lancet in 1998.

Measles deaths fell worldwide from an estimated 750,000 in 2000 to 197,000 in 2007. This is thanks to a concerted campaign, run by the Measles Initiative (founded by Unicef, the UN Foundation, the American Red Cross and the Centers for Disease Control and Prevention in the US), which included mass immunisation of children.

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For several years I have been trying – and, evidently, failing – to suggest that the information that women get about breast screening isn’t very balanced. The problem- as I see it anyway – is that services are geared to get women to turn up for screening. Whereas, I would like services judged not on how many women turn up, but on how many women make good informed decisions about whether or not they want to have screening at all. As we have had more and better research evidence about breast screening it has become apparent that there are, as well as measurable potential benefits, also measurable potential harms. Just like operations or tablets, doctors should be explaining the pros and the cons, and trying to help people reach a decision about them. (And Gerd Gigerenzer is the master on explaining risk – his book Reckoning with Risk is brilliant.)

So, in the BMJ this week is a vastly improved information leaflet about breast screening, written by the Director of the Nordic Cochrane Centre and his colleagues; it’s available here.

I forgot to include a link to the paper – the start of it is here.

The EU Medicines Directive has decided that Orlistat, a weight-loss drug, can go on sale over the counter. You’ll be able to buy it without a prescription from pharmacies, and online. The difference between the over-the-counter version and the prescription variety will be the dose: the usual prescription strength is 120mg three times a day – the OTC product will be 60mg.

Is patient choice and increased availability a good thing? All drugs have side effects, and Orlistat – or Alli as the OTC version is to be called – is no exception. The side effects are mainly to do with bowels and incontinence – I will spare you any more detail. Still, it seems to suit some people, and there is evidence of benefit. How much benefit? The majority of studies on Orlistat have used the 120mg dose. Most trials also involved people being given stringent dietary and exercise advice. In trials, people taking Orlistat – with these provisos in place – have lost about 2kg-5kg more than people taking a placebo.

The problem is that we won’t know if this OTC development will work or not. As far as I can see, no one is looking into whether it will make a measurable and effective difference to people’s weight under these lower-dose and real-world conditions.

The other problem is fragmentation of care. The fact that more people are becoming involved with a patient’s healthcare without shared notes makes me concerned that we are creating problems-in-waiting. Shouldn’t we get this sorted out before even more drugs obtain an OTC licence?

We have come a long way since the humble bowl of Corn Flakes. Kellogg’s signature cereal was famous for being best enjoyed with “ice cold” milk. Its latest cereal product, Optivita, is being sold along far more complicated lines. Current television advertisements for Optivita proudly proclaim that the cereal has been approved by Heart UK, “the cholesterol charity”. The idea is that by choosing Optivita (an amalgamation of “optimal” and “vitality”) you are going to do good things to your cholesterol, so eat on.

Let us remind ourselves what high cholesterol levels mean in practice. High cholesterol is a risk factor for cardiovascular disease, as are smoking, obesity, diabetes, high blood pressure and a sedentary lifestyle. People can also inherit high cholesterol levels – a condition called familial hypercholesterolemia, which usually requires medication.

Cholesterol receives a lot of attention because it is easily measurable and, unlike one’s family medical history or diabetes, modifiable. Statin medication helps, but many people would, very reasonably, prefer to improve their diet than take a pill. This is where breakfast comes in.

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I am dismayed to note that complementary therapists are now able to register with the CHNC. Ben Bradshaw, the health minister who is also so keen on the non-evidence based ‘iwantgreatcare.org’ doctor-rating website, is reported as saying:  ”I welcome the opening of the Complementary and Natural Healthcare Council (CNHC) register…which the public can turn to for help. Members of the public who use these therapies will be able to check whether the practitioner they’re seeing is registered with the CNHC. If they are, they have the reassurance of knowing that they have had to meet minimum standards of qualification … Practitioners too will benefit by increased public confidence. Public safety is paramount. Registration, whether voluntary or statutory, is about protecting patients, and I am pleased to see this important milestone in voluntary registration.”

This is nonsense. What about protecting the public from ineffective interventions? Or false hope, wasted time and effort or indeed, potential harm? What is the point of improving “public confidence” in things that don’t work? (And “alternative” therapies which do work are taken up into orthodox medicine.)  Bradshaw would be serving the public far better by advising them to be cautious when engaging with healthcare interventions which have not been proven to work. Isn’t that the best way to “protect” patients? And, incidentally, Bradshaw’s signing off line — “People should always seek their GP’s advice to ensure that any other therapy they use does not conflict with orthodox treatment” – is the epitome of weasel words: how can a GP ethically end up taking responsiblity for things he or she doesn’t prescribe or suggest?

Thank you to a correspondent for the link to this promotional website offering workers suffering from colds all manner of unnecessary things. There are suggested out-of-office email messages (“I’m taking a BENYLIN® day or two and will reply to your email as soon as I’ve recovered!”) , recommendations for DVDs (all fairly rubbish, in my opinion) for frittering away your time until feeling better, and scripts of what to say to your boss when letting him or her know you won’t be in.

The ingredients of Benylin Max Strength Capsules are:

Paracetamol (available on its own, at a much cheaper price)

Caffeine (available from your teapot/cafetiere, where it is supplied along with warm, tasty hydration)

Phenylephrine (a decongestant; but you might be interested to read this abstract from a 2007 US systematic review of its effects; it concludes: “There is insufficient evidence that oral phenylephrine is effective for nonprescription use as a decongestant.” )

In other words, I think we should still call them “sick days”.

Why do men’s ears get bigger as they age? I don’t know, I told my editor, but I shall try to find out. Medical school teaches you a lot of things but this wasn’t one of them. The resource most likely to help answer such ponderables is PubMed, an online resource that replaced the book-bound Index Medicus, which was enormously large and hideously time-consuming.

PubMed tells us quite a bit about ears and age. In 1995 a general practitioner called James Heathcote wrote an entire paper in the British Medical Journal on this very subject. Four doctors measured the ears of patients aged 30 and over who were attending the surgery on unrelated matters. Among the 206 patients studied, the mean ear length was 67.5mm and, on average, ear size seemed to increase by 0.22mm per year. This proved, said the authors, that older people have bigger ears. Now, a number of criticisms could be made of the study – for example, the selection criteria might not have been random enough to reflect the general population – but the results are still fascinating, and prompted a number of responses.

A professor of clinical gerontology wrote to the journal to say that his Chinese grandmother had told him he should stretch his ears daily in order to ensure a long life. He also cited a paper from the American Journal of Medicine in which 108 patients were studied to see whether having a diagonal crease in the earlobe was a predictor of lifespan. They followed the patients for eight years, and found that those with a diagonal crease did die earlier from all causes. But, worrying though this is for those with creased skinflaps, it still doesn’t explain why ears get longer as we age.

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There have been stories recently about how much the NHS are paying agency staff to work shifts. These kind of locum shifts are usually contracted at short notice or include unsocial hours. But it’s madness – £188 for an hour’s work? I have heard worse recently: a GP paid £200 an hour for working at New Year, and an anaesthetist paid almost the same for working at Christmas.

This is one outcome of allowing market forces to dictate NHS spending. There was a time when the NHS made people work “emergency”, unfeasible or dangerous hours for pennies in order to save money, but the pendulum has now swung too far. The problems started when out-of-hours work began to be counted up by a government who had decided to start contracting for it, hoping to save money. They did not believe the hours that they were told were being worked and then they badly underestimated them. It ended up being far more expensive than had been planned for. “Medical professionalism” started to erode: every little thing  is expected to be costed and accounted for. In turn, it is easy for healthcare workers to refuse to do things – even important things – that have not been contracted for, and then blame the contract as the reason why. Professionalism in healthcare is desperately needed, but I am not convinced we will realise this until the NHS is on its knees and the doctors have all clocked out. 

Getting out of bed on a January morning can be tough. It’s cold outside, it’s warm under the duvet and you’re tired after another late night. The very last thing you feel ready for is work. But we should ignore any negative messages our mind and body mischievously send us about having a lie-in – because work is good for us. Indeed, it matters to us far more than we might think.

I was convinced of this a few years ago by a superb occupational therapist who pointed out that if somebody has precisely nothing to do, day after day, they will not thrive. Work gives us meaning, structure, social inclusion, relationships and, usually, a visible outcome or product we can be proud of. It also gives us the money needed to buy the heat, light and food that we need to live.

Of course, it is entirely possible for a resourceful individual to find purpose in life without ever resorting to gainful employment. But there is no denying that for most people, work is the best way of avoiding a life of thumb-twiddling.

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Sir Richard recently gave an interview to the BBC  when he said, amongst other things, that the healthcare industry could learn from the airline industry; and that all healthcare workers should be screened for MRSA and treated for it because it “is far better than having people dying from unnecessary diseases, and all the misery and pain that that causes, and the cost to the NHS which is enormous.”

Sir Richard is now vice-chair of the Patients Association. If he wanted to go and talk to the scientists who actually do know about MRSA then he would find out all kinds of things; for example, in many outbreaks of MRSA, staff strains are different from those that patients are colonised by. And that MRSA is on places that may not routinely get cleaned; and that it is a bit daft to be so concerned about cleaning bedposts if there is only one commode being shared by a whole ward. Now, if Sir Richard was proposing research to find out what the most cost-effective ways are of reducing MRSA (and other hospital aquired pathogens) transmission and disease resulting from it are, I would be entirely supportive. But presuming that one knows the answers when it is clear that this is a complex area where randomised controlled trials are few – is dangerous.

As for the airline/healthcare analogy, well…

If a pilot thinks it’s unsafe to fly due to risk factors, for example poor weather, then they don’t. They stay, rightly, grounded. If a doctor thinks that surgery will be high risk, they don’t always have the choice of staying ‘grounded’ and not operating: the illness may well be the reason why the operation needs to be done. In other words, the airline industry has much more choice about the risks it is prepared to take on.

And. Airlines fly routes that are profitable and readily possible. Healthcare has to deal with things that may be neither. Neither can the identification of ‘near misses’ in air travel be used as a reason to compare it with safety in healthcare – in any case there seems to be justified concern that pilots don’t always ‘fess up.

This isn’t to diminish the huge responsibility which airline pilots take on and have. Aviaton and healthcare systems may have some similarities but they are limited. Here is one comparision it might be worth making. A pilot has a co-pilot and a standard number of crew without whom he cannot fly. The healthcare vogue is for promoting less qualified team members to diagnose and treat conditions. This is analogous to the pilot remaining at the airport but taking responsibility for the cabin crew flying the aircraft and dealing with any problems. It may be cheaper to do so but it isn’t necessarily desirable or effective. This is something which competitors to NHS primary healthcare may wish to note.

Margaret McCartney’s Blog

This blog is no longer updated but it remains open as an archive.

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

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