Effectiveness

 

 

 

 

 

 

 

 

 

 

 

Indoor swimming pools have many attractions. Heated and disinfected water, private changing space, and even the occasional Jacuzzi on the side. So why would anyone want to swim outdoors? Britain’s seas and rivers are often shockingly cold, and they are also inhabited by all manner of incontinent marine life. Add in the constant threat of exposure to chill winds and rain, and you do not have the ideal ingredients for a pleasant swim. Yet I must confess that I share the enthusiasm of the swimmers of Sandycove near Dublin, who are pictured here.

Even in the northern hemisphere, swimming outdoors has to be one of life’s most satisfying pleasures. It gives you the chance literally to submerge yourself in the beauty of the environment. One of my own favourite places is a bay on the western shore of a small island on the west coast of Scotland, where at sunset the colours of the sky appear to melt into the water.

Outdoor swimming is also brisk, invigorating and fun – and there is no doubt that regular exercise is good for you. The problem is that the medical literature seems filled with terrifying reasons to avoid it. But there is risk everywhere in life, and there are certainly multiple ones in doing no exercise or locking oneself indoors.

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The concept of doctor-rating websites seems to be gathering political momentum; in fact, it’s already a reality. The NHS is being offered this data, apparently to ensure that “patient choice” is offered and “patient experience” is good. I think it’s an unproven and potentially hazardous waste of money. There’s a piece that I wrote for the BMJ here; and you can also read Neil Bacon’s opposite point of view.

The weight-loss industry never seems to slim down. Now it is no longer just liposuction that surgery offers. Bariatic surgery, which deals with the treatment of obesity, is another option, but isn’t a quick fix. Like any operation, it has its risks – and people carrying extra weight often face problems with anaesthesia.

The National Institute for Health and Clinical Excellence (Nice) recommends weight-loss surgery, but only in specific circumstances: it is considered suitable for adults with a body mass index of greater than 40kg/m2, or for those with a BMI above 35kg/m2 who have another condition such as high blood pressure or type 2 diabetes and who have been unable to lose weight through diet, exercise or medication. The patient must receive intensive care via a specialist obesity service, and is encouraged to submit to long-term follow-up. Nice also recommends that surgery is used in the first line where the BMI is above 50kg/m2.

This kind of surgery usually consists of reducing the size of the stomach or bypassing it. It is often successful: one study found that there was a mean reduction in body weight of 23.4 per cent after surgery. However, this study didn’t compare surgery with medication used for weight loss – and indeed a lack of comparative evidence is one criticism levelled at the surgery.

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I was talking to a composer a few weeks ago. “This stuff doesn’t really exist except when it’s played,” he said, pointing to his score with heavy despair. “Whereas you’ve got a job where you can actually see that you are doing something good.” He couldn’t understand that my protests to the contrary were genuine: doctors cannot always be sure that they are making a positive difference.

Medical history is stuffed with examples of bad practice – lobotomy for just about anyone with a mental health problem, tonsillectomy for most people with a sore throat, bed rest for everyone with low back pain. I may exaggerate, but only a little. Even now, we don’t seem to appreciate the value of analysing what we are doing.

The US Senate has just passed a bill putting $1.1bn into research aimed at identifying which medical treatments work and which don’t. This sounds like a good idea, but of course not all research is created equal. Regular readers will be aware, for example, of the conflicts surrounding the Department of Health recommendation that all over-65s receive a flu vaccination. Some evidence supports vaccination, some indicates that it does not improve mortality rates. What to believe?

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The BMJ have got a good personal view written by Emeritus Professor Michael Oliver. It’s entitled “Let’s not turn elderly people into patients” and is based on the Prof’s own experience of healthcare.

I suspect there are a fair amount of doctors both in hospitals and general practice who sometimes talk, over coffee, about whether or not their medication does any good at all and in fact just does harm – or maybe I just associate with medics who are as cynical as I am. The trouble is that this attitude may be cynical, but is often correct. All medicines have side effects. Medication used for preventing cardiovascular disease is increasingly commonly used in more people – especially, as the Prof says, in older people, 75+ - yet the margin of possible benefit may be small. Sure, if people want to take medicines and have been properly and fairly advised about them, fine. But all too often, standardised protocols are applied with such rigour that the person’s opinions about their options aren’t highly prioritised.

I doubt that there has ever been a golden age in medicine, but the current obsession with clinical guidelines, and the GP contract and hospital targets which prioritise political targets over clinical ones are dreadful. What is worse is that the medical “profession” seems to have given up objecting and has more or less accepted them.

I am pleased to see that PatientPak (“introducing the world’s first antisuperbug kit”) have been admonished by the Advertising Standards Authority . I wish I had been able to mention it in this piece for the BMJ before it went to press….

One could be forgiven for thinking, after reading certain recent media reports, that vitamin D can perform miracles. This humble supplement, it was claimed, had the power to prevent no less an evil than multiple sclerosis, prompting reports of a rush on health food shops and pharmacies.

MS is a chronic illness that affects the nervous system. An afflicted person can have a variety of symptoms, some minor, others with serious consequences for mobility and health. There are few treatments, and there is little agreement about cause.

One theory is that MS is an autoimmune disease, in which the body reacts aggressively to its own cells. Others think it’s a genetic disorder, since the relatives of MS sufferers are at increased risk. Another possibility is that there is an infectious agent responsible, perhaps a viral trigger. One compelling explanation relates to geography: the further one goes from the equator, the greater the number of MS cases, suggesting that a lack of exposure to sunlight could be an influencing factor.

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

More from the Prince’s Foundation for Integrated Health: we should look forward to May, when publication of guidelines with an “integrated approach… bringing together mainstream medical science with the best of other traditions… movement including exercise, yoga, tai chi/qi gong…” will apparently be published.

The PFIH is working with Mind and the Royal College of Psychiatrists, among others, to achieve this aim. I am horrified – the RCP has had (at least, up till now) a strong ethos for evidence-based treatments. I can’t imagine these reputable organisations working directly on guidelines with the pharmaceutical industry, for example, on how to use their products in hospitals. So why turn to the PFIH for “inspiration, understanding and practical tools” on “integrated health”?

Good facilities should be expected in psychiatric hospitals but are nothing to do with “integrated health”. Instead, they are everything to do with treating people well and with dignity. Integrated health is also nothing to do with the occupation which patients may benefit from - woodwork, gardening, crafts – but don’t often get the chance to thanks to the decimation of the numbers of occupational therapists in hospitals and the community.

Antibiotics don’t work on most colds, flu or sore throats. This is old news, but the Department of Health is re-launching their Antibiotic Awareness Campaign to remind us. Indeed, the more antibiotics are used, the bigger the problem resistance becomes. So I’d like to know what the sense is in making antibiotics prescribable by more healthcare workers, in reducing the amount of pharmacology taught in the medical undergraduate curriculum, and in plans to make certain antibiotics available over the counter.

Duchy Originals was established by the Prince of Wales in 1990 to raise the profile of organic food and farming. Lines from the company, which gives its profits to the Prince’s own charities, include Rose and Mandarin Shampoo, oaten biscuits, sherbet lemons and handmade Sandringham Strawberry Preserve.

With regal glee, the Duchy website recently announced a new product range. “Suffering from the sniffles? Try a Duchy Herbal Remedy!” Andrew Baker, Duchy’s chief executive officer, said: “Our decision to launch these products reflects The Prince of Wales’s passion for integrated healthcare.” Well, my own pleb’s passion is for evidence-based healthcare that doesn’t cost more than it needs to. So, let’s look at the evidence.

First, the “Detox Artichoke and Dandelion Tincture”. It allegedly can “help support the body’s natural elimination and detoxification processes”. There is no scientific evidence to support the need for “detox”. Detox is a concept which is designed to make us feel that there is a quick fix to long-term excess. There isn’t. The product costs £10. I think this represents particularly bad value.

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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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