Medicine in the media

This follows on from a post a couple of weeks ago about this paper in the BMJ and the duty of doctors to explain both pros and cons of breast screening to patients. Here is a letter and article on this subject today in the Times.

The number of computer programs that promise to sharpen, train and preserve brain function seem to be proliferating. There has been a lot of press coverage about a paper in the journal Alzheimer’s and Dementia . The authors reviewed all the evidence available on interventions aimed at preserving cognitive function in healthy elderly people. Just as I say in point number five of the 10 steps to health in ’09, the authors point out that there is no decent evidence that these kinds of programs work. Furthermore, they may even come with potential harms.

As Professor Peter Snyder, one of the co-authors, wrote in an e-mail to me yesterday: ”There are several lifestyle-related things that older persons can do that have much better clinical data supporting their effectiveness, for possibly delaying onset of dementia.  First, there is truly excellent physiological, neurological and clinical outcomes data supporting the role of regular exercise – even three times per week for 20 minutes per session of exercise (e.g., fast walking).  Second, we know that obesity, diabetes and heart-disease are all risk factors for Alzheimer’s disease.  Finally, I suspect that remaining cognitively active does indeed offer some protective benefit… the point of my paper is that there are no credible data to support the increased benefit of these marketed products and brief interventions, over maintaining a socially active lifestyle, remaining engaged and active with family and friends, learning new hobbies, music or a foreign language, playing Suduku or crossword puzzles, cooking, and reading good books on a regular basis.”

Personally, I find this advice very life-affirming.

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. 

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.

When I suggested, a while back, that walking was fabulous for health, I thought I was giving readers of this column sound advice.

All the evidence suggests that it’s good for mental, physical and environmental health, as well as being something many people find pleasurable. Who, I thought, could object?

Well, the man who wrote to tell me that he had tripped over his walking stick and fractured his ankle certainly did. (Sorry about that.) As did the lady who became so enthused by the prospect of reaping all those benefits I had mentioned that she decided to walk everywhere, only to have her bunion become infected – requiring antibiotics and surgical drainage. (I do apologise.) So too, the distinguished editor who, I understand, is still requiring treatment for foot pain. (Again, mea culpa.)

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

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?

A very interesting paper just published in the Archives of Internal Medicine. The study followed women before and after the introduction of a breast screening programme in Norway. They were compared to a control group of women who did not take part in the screening programme, but who would have been, had the programme been started in their area. This control group were invited for a one-off screening at the end of the observation time in order to work out how many had invasive breast cancers.

When the two groups were compared, the amount of invasive breast cancers was found to be significantly higher in the group of women who had regular screening. On first glance, this may appear to be a good thing – it seems that screening picked up more invasive breast cancers. But is it? The problem is that the natural history of these “invasive breast cancers” may not be as predictable as we would like to think, in that not all may cause a life-threatening situation. The authors concluded that “it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress”.

This is but one paper in a complex field, and I wouldn’t suggest that this research alone should make women decide what to do when the invitation to breast screening comes in. However, there are already uncertanties about how beneficial breast screening is. I think this paper does emphasise that there are still a lot of unknowns when it comes to breast cancer screening. The NHS Behind the Headlines service provides a useful analysis of the news coverage of this story but concludes that “women should continue to attend screening programmes”. I think this is a bit unfair; surely the best position is to invite women to weigh up the pros and cons for themselves, as they become known. But maybe this is also unfair; most people probably don’t have the time to devote to investigating this sort of thing and they should be able to expect disinterested, fair advice from their health professionals. 

Much ado with a new paper published by the New England Journal of Medicine . This study was placebo controlled and focused on treating people with ”normal” cholesterol but a high “c-reactive protein” (a marker of inflammation) with rosuvastatin (which is not a new statin as some media outlets have reported, but one already in use). Reports have been rather enthusiastic, eg from the Daily Telegraph: ” risk of a heart attack was reduced by 54%”. One doctor is reported as saying it’s “astonishing”. The trial was stopped early due to “remarkable” results.

The problem is that although the “54%” looks marvellous, and is true, this is the relative risk reduction, not the absolute risk reduction. It does not, by itself, give us a true picture of how meaningful this reduction in cardiovascular events is. We have to know what our risk of having such an event was to start with. From “table 3″ in the paper, the number of patients in the rosuvastatin group was 8901. The number of heart attacks in this group was 31. The placebo group was also made up of 8901 people. The number of heart attacks in the placebo group was 68.  The chance of this group of people having a heart attack on placebo treatment was 68/8901, or 0.76%. The chance of the other group of people, those on rosuvastatin, having a heart attack were 31/8901, or 0.35%. Thus, if you have a normal cholesterol but a high CRP, and if you take rosuvastatin, you can have a 0.35% chance of having a heart attack as opposed to a 0.76% chance.

I’m not very impressed. The other problem with this trial is that it was stopped early. Thus we don’t know what the long term benefits or problems of this approach were (article on this here) . And there did seem to be a small increased risk of developing diabetes in the rosuvastatin group.

However, there may be something else going on here. I mentioned the thought-provoking book The Cholesterol Con by Dr Malcolm Kendrick a while ago. He says, effectively, that cholesterol is nothing to do with heart disease. Statins seem to have some effect on outcomes, but probably have another way of working which has nothing to do with cholesterol, but something to do with inflammation.

The Advertising Standards Authority have announced that they are upholding my three complaints against a leaflet about Lifescan. You and Yours are doing a piece about it at noon today. More on this later.

Help the Aged have released details of a survey today. They conclude that 1.4m older people in the UK feel socially isolated and that 1.25m are often or always lonely.

I am often dubious about the way in which surveys are interpreted. However, the findings of this survey do bear out many of the sadder observations made in general practice. 

I have long thought that social cohesion is one of the best things for both quality and quantity of life. The current approach to improving health in older people seems to be focused on prescribing more drugs to treat blood pressure, cholesterol and depression. I would much rather see one’s cardiovascular risk factors and mood addressed through meaningful activity, pleasurable and varied diet, and companionship.

Here is Sir Michael Marmot (author of The Status Syndrome, among others) on neighbourhood effects on health: “Rates of mortality and illness differ markedly between areas…Cities all over the world have variations in health by area according to socio-economic level to a greater or lesser extent…Evidence suggests that neighbourhood characteristics such as social cohesion are crucial.”

A systematic meta-analysis published earlier this year  exploring how psychosocial factors relate to health found evidence that favorable psychosocial environments “go hand in hand with better health”.

A couple of years ago in Iceland, I was deeply impressed at the convivial atmosphere after work when whole neighbourhoods seemed to gather every evening – regardless of age or sex – in cheap, local hot spas. The conversation and welcome was fabulous, old people and young people all welcome alike. There was not much exercise going on: mainly people just sat around and chatted. Icelanders have a famously long lifespan. I suspect social cohesion has something to do with it.

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