Monthly Archives: April 2009

In the event of a pandemic flu, word was that medical students and all kinds of healthcare professionals (who don’t normally do diagnosis and prescribing) would be mobilised to take care of the ill populace.

Lots of doctors now work part time because of their children and family life. If a pandemic arises such that schools and nurseries are all closed, there will be a large number of people without childcare. But there will be lots of teachers who are not working because their school is closed. And I’d guess that there would be fair numbers of doctors who normally work part time who would be prepared to work more hours in an emergency – as long as their children were safe and being looked after.

I suspect that organising childcare might be a very important part of planning.

I’m glad to see that this public consultation by the Nuffield Council has been launched today, asking questions about the ethical issues involved in whole-body CT scanning and genetic screening done in private clinics for people with no current health problems. It’s very good that these issues are being raised and debated. But I’m a bit concerned that some of the questions they ask of potential contributors are not quite pointed enough. I’m concerned about both evidence-based medicine and screening tests, mainly because of the potential for harm these have and the lack of balanced information the latter may come with.

By going outside the NHS, these tests certainly have potential for fragmenting care, duplicating results and creating communication problems, all things the Nuffield Council are rightly concerned about. But it isn’t really these that worry me.  It might be worthwhile risking all these things if the potential for benefit from testing could outweigh the problems. But the tests the consultation is concerned about come with no evidence to justify them. There are enormous misunderstandings about the limitations of these tests - for example, the document says that CT scans for the well “provide a person-specific disease risk profile”. I’d disagree: for a cardiovascular risk profile, a discussion, a set of weighing scales, a blood pressure and possibly a blood test or two will sort that out – and all that can be got for free on the NHS. A CT scan will not tell you an awful lot of important things. Isn’t it regulation of these “services” that is primarily needed? But these thoughts are contained in the last pages of the Nuffield’s document: I’d prefer that that was the first question in a very necessary debate.

Guidelines, guidelines. My desktop, bookshelves and floor are covered with them. Advising on everything from diabetes to incontinence, they come from multiple agencies in increasing sizes and scope.

Some guidelines are excellent; they save doctors from a long trawl through the evidence and give directions in shorthand that everyone can understand. But Baroness Young, chair of England’s new health regulator, the Care Quality Commission, seems to have an unnerving faith in guidelines. Under her aegis, the CQC seems to have general practices in its firing line, and sees adherence to guidelines as a proxy for GP quality. This is alarming.

There are several issues the baroness might not be aware of – she does not have a healthcare background, after all. First, guidelines are a guide, not a formula. If guidelines for a generic population could be applied to everyone, why bother with anything but a computer and automated prescriptions? Individuals have different preferences, concerns, histories and views. The day I start ignoring the variability of people to enforce homogenous guidelines will be, I hope, the day that I lay my stethoscope down and do something else instead.

The remainder of the article can be read here. Please post comments below.

Update: 27th April

I am feeling a bit reassured. Here is an excerpt from Baroness Young’s emailed letter of today:

“I, and the Care Quality Commission agree with NICE and don’t advocate slavish obedience to guidelines but want to assess whether clinicians have considered good, evidence based guidance when making appropriate decisions in the circumstances of the individual, in consultation with patient and/or carer.”

I think I can live with that. Baroness Young  also points out that she has worked in health services management for more than 20 years: but then again, clinical work and decision making is something rather different.

Margaret Haywood was struck off by the Nursing and Midwifery Council last week. She had secretly filmed patients in the hospital where she worked to document the conditions, which she claimed to have previously reported. These images were subsequently broadcast on the BBC programme Panorama. There has been an outcry from nurses, as well as from some families of patients on the ward, objecting to the penalty. One has described the conditions there as appalling.

Was this fair? Yes. Patient confidentiality is sacrosanct. If you have to break it – and there are few reasons for doing so – it has to be after other avenues have been exhausted.

Thanks to Quackwatch for this link: the US Conference of Catholic Bishops have said that “For a Catholic to believe in Reiki therapy presents insoluble problems. In terms of caring for one’s physical health or the physical health of others, to employ a technique that has no scientific support (or even plausibility) is generally not prudent.”

So, will the NHS take the hint, follow suit, and suggest that this alternative therapy is dropped from being funded?






I am reporting good news, for a change. The UK Breast Screening Service has said it intends to rip up the leaflet which is currently sent to women with breast screening appointments. A recent paper in the British Medical Journal outlined the kinds of uncertainties and likelihoods the authors thought would have counted as “fair information” to give to women. This seems to have prompted UK Breast Screening to review the content of its leaflet and try to give better information.

I am a GP, and so my perspective on what is “better” will likely take account of the difficulties which I observe breast screening leading to. My wish list starts with wanting the new leaflet to describe screening explicitly as an intervention which one can accept or decline. Breast screening should not be something which is sold, or which one is persuaded or coerced into. Women should be treated as competent adults who have the pros and cons explained to them: it is simply not ethical for breast screening to proceed without proper counsel.

People have written entire books about the problems of screening. I will stick to just two things: “overdiagnosis” of what is sometimes called “pseudodisease”, and limited gain. “Overdiagnosis” relates to the fact that it’s not just full-blown cancers that are detected. Some of the abnormalities seen and biopsies examined can represent situations where the prognosis is uncertain. Some of these are a condition called “ductal carcinoma in situ”. This makes up about 20 per cent of “breast cancer” diagnosed at screening in the UK. While these are commonly treated with surgery and possibly chemotherapy and radiotherapy, only a minority may end up progressing to a life-threatening cancer. Studies done at autopsy imply that 15 to 39 per cent of women die with, rather than from, this type of cancer.

The remainder of the article can be read here. Please post comments below.

Of particular concern to me about the latest political scandal is the idea that the leader of the Conservative party was to be invited to publish his “full financial and medical records” apparently as a way to reassure the public that he had not had a sexually transmitted disease.

It is difficult to see how a political class offering sympathy to a recently bereaved father a few weeks ago can turn nasty so quickly. It is also rather disappointing to see that STIs are still as wearily ”embarrassing” as ever. But one thing is clear to me - no politician should ever be allowed to make his medical records public. It would only make political stupidity seem reasonable, and in any case, it is no one’s business but the person who the record is about.

And lo, the government said, we must woo voters. And they had a great idea: check ups. Let’s not leave them to the private providers. Let’s put them on the NHS. Everybody loves a check up.

The Department of Health sets out its new idea in a policy paper “Putting prevention first – vascular checks: risk assessment and management”. This includes the laudable aim to prevent ‘at least’ 9,500 heart attacks and strokes in a year. It is also estimated that the program could prevent 4,000 people from developing diabetes and ‘detect at least’ 25,000 people ‘earlier’ with diabetes or kidney diseases.

I’m beginning to think that this sounds suspiciously like a screening programme. The publication goes on: the vascular risk assessment programme will enable ‘everyone between 40-74 in the population to have their vascular risk managed appropriately’. Sounds daunting. Millions of people will be need to be assessed, and an enormous amount of healthcare staff time will be diverted. In light of this, one should expect this scheme to have been tested in real world situations with real world benefits in the UK population it is targeted at. One would be interested especially in medium and long term effects. One would also hope that adverse effects and cost efficiency have been examined. Instead, most of the work examining the effects of this scheme has been done through assumptions and modelling scenarios.

Further, because most of the work is intended to be done outside of GP surgeries, medical advice is not always going to be readily available. I cannot be the first doctor to have been faced with an anxious patient concerned that a cholesterol reading performed beyond the surgery has been found to have been marginally, and inconsequentially, higher at a private providers. I would not have wasted resources in needlessly repeating a test, but this is only going to be a small part of the difficulties of this new scheme. Screening tests should be done as part of an evidence-based policy which acknowledges the possibilities of false positives, negatives, and impact of tests on peoples’ lives.

Screening tests are complicated, messy and confusing. Throwing inadequately tested tests at the problem is rarely the solution.

We all know that radiation from X-rays, along with other ionising radiations, is potentially harmful. Indeed, it’s quite easy to start worrying about the “risk” involved in having an X-ray – even though most of the radiation we’re exposed to comes from naturally occurring environmental sources.

Still, the sensible use of X-rays is rightly drummed into medical students, the message being that there must be a good reason to take one. Chest X-rays used to be taken routinely before an operation – a kind of “just in case”. The practice was abandoned when doctors realised that if there were no symptoms or examination findings to suggest an X-ray was needed, it could not be justified. Similarly, X-rays used to be standard for people with low back pain, until it was shown that they did not pinpoint the source of the trouble. These days, for low back pain, they are used only in specific circumstances.

Of course, being overly concerned about the health risks of X-rays can also be dangerous. For example, an unwell woman who is also pregnant will probably not be given one for fear of harming the foetus, even though this reluctance has been cited as a potentially avoidable contribution towards maternal – and foetal – death.

The remainder of the article can be read here. Please post comments below.

The New England Journal of Medicine recently published research findings on prostate cancer screening. The results, from my reading at least, showed that screening was not terribly useful. So I was bewildered by subsequent media coverage that urged men to exercise “their right” to a prostate specific antigen blood test or PSA. A number of people called for the UK urgently to review its PSA screening policy.

The problem is that many prostate cancers are “benign” in their behaviour – men die with, rather than from, them – and the treatment is worse than the disease. The difficulty is in distinguishing these more placid tumours from aggressive ones.

The NEJM reported on two randomised controlled trials, one from Europe and the other from the US, where the PSA test is already widely used. The US study, involving almost 77,000 men, assigned half to PSA screening for six years and rectal examination for four years. The other group had “usual care”. After seven to 10 years’ follow-up, there was no significant difference in the mortality rate between the two groups.

The remainder of the article can be read here. Please post comments below.

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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