Medical professionalism

As an unschooled observer of the money markets, I have been struggling in recent months to understand what anything is actually worth. In healthcare, there is a similar problem, though it makes for rather less exciting headlines. All NHS procedures have to be costed to the last penny, and reported on in “completed care episodes”. But just like financiers, healthcare professionals can’t put an exact price on everything.

Blood, for example, is a commodity given free of charge by people willing to sacrifice time and comfort in order to make a significant difference to someone else. Bone marrow is another “gift”, donated by those who know they will not be repaid financially for being inconvenienced. And then there are the gifts given in the aftermath of death: corneas, kidneys, livers, skin, hearts… all capable of transforming a stranger’s life.

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The British Association of Plastic Reconstructive and Aesthetic Surgeons have issued the results of a questionnaire asking surgeons if they have had to give emergency treatment to people who have had cosmetic surgery abroad. Unsurprisingly, the answer was yes. This is only the tip of an iceberg – there have been reports of patients returning after “transplant tourism” abroad, where people have paid for kidney transplant operations. What are doctors to do when patients present needing drugs to prevent rejection of the organ, or if a cosmetic surgery wound is badly infected?

BAPRAS says that there is a need for clear guidance as to what doctors should do. Should patients in this situation be made to pay private fees for medical intervention – after all, these are not things that the NHS has instigated, and normally, the team responsible for follow up care are those who did the procedure in the first place. It hardly seems fair that the NHS should be made responsible instead – costing time and money that should have been available to NHS patients. The uncomfortable bit is that doctors should be treating on the basis of need, and by the time there is a complication of surgery abroad, there is usually a need for urgent care. Where is the solution? Can doctors ethically ignore patients with such complications? Or should they simply be billed for their cost to the NHS?

When it was announced that both the presidential candidates were allowing sight of medical information about them to be read and reported on by journalists, I was slightly perturbed. Sure, I could see that perhaps the knowledge that one had no outstanding concerns with their health might – might – have some kind of relevance to an election.

But not really. First of all, while we can say that we are fine “at the moment” who knows what may be around the corner? Not everyone has risk factors for the illnesses that they will later die of. Medical “check-ups” are seriously limited in their abilities to offer a prognosis of any value. And in the case of a declaration of illness, disease or even risk factors for disease, how then can an electorate fairly decide if this will affect the ability to hold office? Many illnesses or disabilities need nothing more than the correct type of support or treatment. The real problem with the declaration of some health issues is not so much the disability that this may or may not reveal, but the disability that the public may imagine.

Lord Owen thinks we should be borrowing pages from the US book. He writes in the British Medical Journal this week: “Everyone who wishes to put themselves forward to the electorate as a potential national leader ought to be compelled by party rules to submit to an independent health examination that doesn’t involve their personal doctors and that is assessed by people of proven independence. This would not run into conflict with any existing legislation protecting the rights of the individual. If potential candidates knew they faced independent assessment and that they had a health problem then either they would not stand or they would make it public of their own volition. For example, John Kennedy, in 1960, believed that he would never be elected president if he admitted he had severe Addison’s disease. Yet there is no reason why someone who has Addison’s disease should not be US president if it is well controlled with replacement therapy.”

This is contradictory, unfair, and oppositional to the tenet that doctors should be first an advocate for the patient, and capable of a confidential professional relationship with them. Why on earth should JFK have “admitted” (in itself a pejorative term) to a condition which Owen rightly says need have had no impact on his abilities in office?

Owen also brings up the issue of Tony Blair and his heart irregularity which he says was not, as was contemporaneously reported, a new issue, but an old one.  “I do not believe it is in the public interest that this situation be allowed to continue,” Owen writes, wishing all this information to be placed in the public domain. But these type of heart rhythms are common, and readily treatable, and I can think of no reason why this should stop someone from being PM. What is the point of the public knowing about it? None. It is personal information, and even world leaders are entitled to have privacy.

So what kind of health problem should stop people declaring themselves a potential leader? I know people with metastatic cancer who have stable health, and who are also insightful and thoughtful. I know people who have major mental illness who are not only capable but who work in partnership with health professionals such that they can remain insightful and well. I know people with heart disease who have not stopped from being the same impressive businesspeople that they always were. Nor would I wish to restrict the groups of people who would hope to lead the country to those who are happy for their medical records to be laid bare. This introduces a dangerous bias. Egotism, overconfidence and irrationality are the qualities I most fear in politicians, and none of these are medical conditions.

I am taking a break from the blog for a week or two and will catch up then. 

“GlaxoSmithKline is to make public the level of advisory fees it offers to doctors and medical academics, and will strictly cap the payments they can receive in the US to $150,000 (£88,000) a year each. Andrew Witty, chief executive of the UK-based pharmaceutical company, said he was introducing tougher new rules to impose a cap “without exception” on such payments and promised to publish the amounts.”

I’m catching up with my reading. Andrew Jack interviewed Andrew Witty, the chief exec of GSK, in the FT a week or two ago. That’s the first paragraph of a very interesting piece. 

Now, publishing the amounts GSK pay doctors is very good, but, er, 88K a year? For a couple of lectures and lending one’s name to a bit of ghost-writing? GSK, please save your cash and don’t pay any doctors not wholly employed by you for any advisory anythings. Last year the kickbacks received by orthopaedic surgeons – some up to $1m worth – in the US were revealed after a federal investigation showed just how closely doctors and the orthopaedic industry were “working”.  There is still cash being thrown at doctors in the UK. I am tired of throwing out all the invitations I get to hearing the latest on cardiac risk factors/obesity management/urinary incontience over dinner at very nice restaurants courtesy of pharmaceutical reps.

Would you want the advice of a doctor who has just been eating canapes courtesy of the latest anti-inflammatory rep? Would you take the recommendation for your type of hip replacements from someone who has just spent a few five star days giving “consultancy” to the manufacturers?

I hope not. Medicine is difficult enough without having one’s judgment impaired by biased interpretations of the evidence. There is lots of dialogue to be had between doctors and both the pharmaceutical and medical device industries. But this should be done without personal gain. 

That should be obvious. Professionals should not be technicians who can be puppeteered at the whim of the sponsor; they should be acting for the best interests of those they serve with 20/20 clarity. That’s surely the bare minimum we should expect as patients, from doctors?

Every time I have written about this I have had emails from doctors who tell me that I am a fool. You can have nice dinners and lux conference stays and still be a pro, they say, I can’t be bought! But of course you can. Anyone can. The point of being a professional is surely that you choose not to be.

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.

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.

It is reported that Peter Mandelson recently ended up in hospital to be treated for a kidney stone. It is also reported that Lord Darzi, the health minister who believes polyclinics are the future, dined with Mr Mandelson, and was later called upon to see him professionally. 

Who knows what actually happened, but ‘dinner party’ consultations are an overwhelmingly bad idea.  Architects, policemen, lawyer and hairdresser friends tell me the same thing: informal, convivial advice has a tendency to end in tears and should be regarded as a bad idea for the following reasons: 

1) the consultee may not be willing, due to circumstances, to disclose full information

2) the consultee may too willing, due to cirucmstances, to disclose way too much information

3) the consultant may be very biased due to feelings/lack of feeling for the consultee and may be influenced into under or overinvestigation

4) dinner parties where the best treatment for piles and chlamydia are discussed do not make for the most fun evenings

There must be more reasons.

Regular readers will know that I have concerns about many tests used in the UK for screening. Screening tests are used when people are well, with no symptoms of disease. The aim of screening is to pick up a disease process at an early, pre-symptomatic stage such that an effective intervention can be used to prevent complications.

Real life is rarely that simple. A while ago I was asked (live on radio) for an example of a perfect screening test. Unfortunately, all I had to offer was a long silence as I tried (and failed) to think of one. Instead screening tests offer a balance of probabilities, and the risks and benefits of interventions which can then be offered are usually more complicated the more one examines them. (I’ve just finished reading Sir Muir Gray and Dr Angela Raffle’s excellent book Screening, Evidence and Practice. Raffle is a public health consultant, and Gray was the Programmes Director of the  UK National Screening Programme from 96-07. The first line of the preface is ‘All screening programmes do harm’.)

Excellent pieces in the New England Journal of Medicine on military medical ethics, and psychiatrists‘ position in interrogations. There are concerns that army psychiatrists are being trained in areas which could conflict with professional ethics. Doctors are not meant to either conduct or participate in interrogations. However obtained documents suggest that the Department of Defense  still wants doctors to be involved.

There is a piece in the Observer this week about the Jeremy Kyle show. The author says that people with serious mental health problems are prey to the exposure these kinds of shows bring. These shows - where aggressive confrontation and public goading are to used to provoke and taunt people about personal problems or issues – are nasty to watch. On the Jeremy Kyle show there is apparently a “qualified mental health nurse and psychotherapist” who “found no evidence of mental illness” and decided that a “contestant” was “fit to take part”.

Is there really a way to decide if someone is “fit to take part” in such an exercise? Doctors are often asked to fill in certificates claiming that one is “fit to take part” in all sorts of things from skydiving to marathon running. One can say perhaps that there is no obvious reason why one should not do certain things, but there are seldom criteria where it is possible to say that one will be capable of a task. There are a few things where there is clear demarcation of acceptable risk; for example, the criteria for fitness to drive is something the DVLA is very clear about. These kinds of shows, however, are a different thing.

The Channel 4 show Big Brother hires psychologists. These shows look for people who are going to be “good entertainment”. In this context, it usually means that the people are chosen with the belief that they will provide drama. Again, in this context, it usually means conflict with oneself or the group. Presumably the presence of psychologists provide the television company with something to arm themselves with against charges that they place people in potentially damaging situations, played out live and in the public arena. Freedom to do as one wishes is one thing.  But the presence of a psychologist does not guarantee happy endings.

I do know one thing, though. The less television I watch, the happier I am.

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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