Medicine in the media

This starts in the Royal Courts of Justice today. There are restrictions on what can be reported currently.  I am reliably informed that this legal blog  will have updates.

Best wishes, Simon.

Boots the chemist are making much of research just published in the British Journal of Dermatology. It involves their Protect and Perfect product, which is on sale in my local store, where there are signs saying that customers are allowed to buy only 6 bottles. Clearly they are anticipating great demand.

In 2007, the BBC program Horizon revealed results of a test of Protect and Perfect. They used it on 15 people over 12 days, applying the cream to the forearm and then assaying skin samples for fibrillin, which – say Boots may ”perhaps clinically improve photoaged skin”. 

Rightly, this experiment was criticised, and it was announced that proper trials were going to be done, and here, in the BJD, they are.

This is what Boots says about it:

“The trial was an independent study of 60 volunteers over an initial period of six months. Half the volunteers used No7 Protect & Perfect Intense Beauty Serum and the other half used a placebo product (the same formula, but without the anti-ageing ingredients). Neither group knew which product they had been given.

The results for No7 Protect & Perfect Intense Beauty Serum were astounding. After the initial six months were over, skin on the volunteers using the real No7 Protect & Perfect Intense Beauty Serum showed some repair of the damage caused by sun exposure. No changes were seen for the group using the placebo product.

Use of the No7 Protect & Perfect Intense Beauty Serum for an additional six months led to clinical reduction in the appearance of wrinkles, assessed by an independent dermatologist. Seventy per cent of people perceived a marked improvement in their skin, thus proving that the skin looks better the longer you use No7 Protect & Perfect Intense.”

I don’t think that’s quite how I’d put it. Certainly, it was an RCT, and that’s good. The 60 participants were blinded to either the placebo cream or the test cream for six months. After six months the groups were unblinded and they all used the test cream. However the study used linear regression analysis to “extrapolate the vehicle response to 12 months, thus allowing comparisons with the test product”. This seems like a bad idea to me: this technique is not as true to life as doing the comparative test in real life would be.  The assessments of skin changes were made by two dermatologists, and I am not convinced that we know this is a reliable and reproducible tool. But very interestingly, in the abstract summary it says “at six months, the test product produced statistically significant improvement in facial wrinkles as compared to baseline assessment (p=0.013) whereas vehicle-treated skin was not significantly improved (p=0.11).” A p value of less than 0.05 is usually treated as being statistically significant in medical papers. However, in the discussion section, please note (and my caps):

“Compared to the baseline, the test product did lead to a noticeable clinical improvement in facial wrinkles (P=0.013) in 43 per cent of treated individuals after six months, compared with only 22 per cent of those treated with the vehicle where there was no significant improvement in appearance (p=0.11). In a comparison between groups THIS IMPROVEMENT WAS NOT STATISTICALLY SIGNIFICANT but does indicate that larger clinical trials of cosmetic products might be expected to show useful clinical improvement after six months’ use.”

I interpret that as bit of a wish-list. I’m not astounded either.

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.

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.

The FAST campaign wants you to call 999 if you can answer, about someone you’re with, “yes” to the question “Has their Face fallen on one side?”, “no” to “Can they raise both Arms and keep them there?”, or “yes” to “Is their Speech slurred?” The idea is to get people with strokes to hospital as quickly as possible.

Several readers have been in touch to say that they found the ads on TV frightening and guilt-inducing – had they done enough for a friend or relative who had an evolving stroke? Was it their fault that a stroke progressed as far as it did?

I hope that the effects of these adverts will be investigated, in particular to see if they have any lasting benefit to public health but also to see what the adverse effects are – like what the readers writing to me have experienced.

The investigation into the Mid Staffordshire NHS Trust makes for harrowing reading. The mortality rate at the hospital was found to be high in patients admitted as an emergency. The first data that showed an increase in the standardised mortality ratio was in 2005. The Healthcare Commission investigation was done during last year, 2008, and is reporting now, 2009. It can be difficult and labour-intensive to interpret statistics correctly. But it is not helped if the length of time it takes to analyse the numbers approaches the life of some health policies.

The report highlights what can happen when fulfilling targets becomes the chosen marker of quality. The target of no more than a “four-hour wait” in A+E led to unsafe practices, such as triage in A+E being done by a receptionist. Similarly, money was saved by getting rid of the hospitals’ clinical staff, as highlighted in the report. The irony is that it’s not difficult to envisage situations where receptionists could be given some training, welcomed as “clinical partners” in “skill mix”, and the system declared innovative and cutting-edge. But these kinds of terms are used to make cost-savings sound palatable: the training for being able to triage is better given via nursing or medical school. Meanwhile, Mid Staffordshire was given Foundation Trust status, and “focused on promoting itself as an organisation, with considerable attention given to marketing and public relations”.

Yet the Government is reluctant to admit that the target culture will not sort out all the NHS’s problems. Nor will shiny PR polish resolve understaffing and overstretching. Should we not just ditch ineffective policies, base healthcare policy on evidence, and move on?

Denmark is reported to be paying 40 women compensation after developing breast cancer. The women are being compensated because they were shift workers. It seems that women with a family history of breast cancer are not going to be compensated.

Is this going to be a precedent? How certain can we be that shift work is a carcinogen? There have been concerns for several years, but the problem is that prospective randomised trials to examine potential factors like this are difficult to do. One would need to be sure that it was the shift work, and not factors about the people doing shift work, or the unrelated habits that shift work might lead to, that were the cause. Retrospective studies can at best show an association, rather than causation. The International Agency for Research on Cancer – part of the World Health Organisation – says shift work is “probably” carcinogenic to humans, with “long-term nightworkers” having “a higher risk of breast cancer risk than women who do not work at night. These studies have involved mainly nurses and flight attendants…” 

There are plausible biological explanations – involving melatonin – and animal studies that would fit the thesis. But if we want more definite evidence, that means more research.

There has been much press coverage of The Lancet Oncology’s paper this week on screening for ovarian cancer. Screening – looking for disease before a person has symptoms that suggest the disease – is often harder than it seems, thanks to the myriad problems it can create. That’s not to say that screening shouldn’t be considered or investigated as a way to try to add quality and years to life. But it is important to consider all the negatives as well as the positives when the screening is being tested – as the Lancet research is doing.

I have three concerns. First, this paper is an interim one – the study hasn’t finished, and as such, it isn’t possible to say whether or not screening for ovarian cancer will prevent deaths. However, it is a large, randomised trial, which is a good thing.

Second, the authors acknowledge that there is a degree of “over-diagnosis” going on: “44 per cent (22 of 45) of the primary ovarian cancers detected in the USS group were borderline.” (USS is ultrasound – one of the methods which was being compared as a tool to use for studying the effects of screening.) “Borderline ovarian tumours have 10-year survival rates in excess of 95 per cent… It could be argued that these cases would be best classified as false positives… Once borderline cancers are detected during screening, it is difficult not to operate given that borderline and stage I invasive ovarian cancers share common morphological features on ultrasound imaging.”

Third, we do not yet know about the full impact on health of patients who had to undergo more than one round of screening. These were cases where the first screening test was abnormal and further tests were run either right away or several weeks later. This may have an adverse impact on psychological wellbeing – some people may be made sick with worry.

None of this means that it might not be a worthwhile test to do. We have to wait for the full results of the trial.

The MB ChB medical degree confers a Bachelor’s degree only. True doctorates are PhDs. However, I am guilty of having the title of “Dr” on my bank card. This was only because I thought it might help me get a (larger) overdraft when first out of medical school. But otherwise, at the hairdressers, school gates, and in the world at large, I am Mrs Married. At work, I generally introduce myself without title and then explain what my job is — ie, a GP. On aircraft, I am most definitely Mrs and will always offer to mind the children while my medical husband answers the call for “any doctor on board?”.

In other words, I can’t quite explain why some people seem to get joy out of calling themselves “Dr” at every opportunity – it’s unnecessary and rarely useful to oneself. But it may be useful for patients. I have pondered this as I have observed signs outside chiropractors premises with “Dr” in front of all the names, and dental surgeries too.

The background to this is one of increasing confusion and blurring of identities of many people who work in healthcare with potentially confusing titles (nurse practitioner, nurse consultant, specialist practitioner, house officer, Foundation Year 1, Foundation Year 2, specialist trainee, etc). Of course, other healthcare workers may have a PhD but not a medical degree and be correct in calling themselves Dr (certainly technically more correct than Bachelor medics using the title). But surely the crux is in making sure patients, who probably have more important things on their minds, have a clear idea about who is who?

The medical colleges and the General Medical Council have been rather quiet on this topic. But the Advertising Standards Authority recently reached a couple of interesting judgments. First, against Wigan Chiropractic Clinic. The advert the clinic placed was found to be misleading, in that it implied that the chiropractors were medically qualified by describing them as doctors. (“Who can a Chiropractor treat? Our Doctors are well experienced at treating everyone.”) There were more complaints also upheld about the clinic, but more on that later.

The other recent judgment made by the ASA was that against a dental surgery  where the dentist had advertised his practice using the title “Dr” before his name. The ASA said that “the title ‘Dr’ before a practitioner’s name should not be used in ads unless the practitioner held a general medical qualification, a relevant PhD or doctorate (of sufficient length and intensity) or unless the similarities and differences between the practitioner’s qualifications and medical qualifications were explained in detail in the ad”.

The use of medical titles shouldn’t be about prestige (and it’s debatable whether ‘Dr’ confers any) or snobbery, but accurate information for patients and colleagues.

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….

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.