Public health

Over the past few weeks, I have been offered massages, gym visits, vitamin supplements, make-up tips and consultations with cosmetic surgeons. All these generous invitations came from PR companies keen to create a media glow for their clients’ products. Since an awful lot of column inches seem to be devoted to genome testing at the moment, I began to wonder if this was the latest thing being dangled under journalists’ noses.

There are numerous reports in the British media of how marvellous and easy it is to undergo genetic screening. You simply give a sample of your DNA (a swipe of your cheek on a swab will do) and hand over your cash (anything from hundreds to thousands of pounds, depending on the company). Voilà, by return of post, you are told your “genetic risk profile”.

Two themes emerge from the articles written by these journalists staring, rapt in wonder, at their own genetic code. First, they see this as a part of the information revolution: at last we are in charge of our destiny; no longer are paternalistic doctors preventing us from discovering what we have the right to know. Second, doctors better get themselves trained up on how to use this information; if they don’t, the service the consumer pays for won’t represent value for money. It’s doctors’ responsibility to help us use this information appropriately.

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Squeamishness is relative. I am unfazed by childbirth, urinary catheters and vomit. I am less good with injuries to the ends of fingers or toes, which always make me want to look away. My biggest fear, however, is of eyes.

Operative ophthalmology, in particular, sets me on edge – the eyelid clamped back, the surrounds of the eye draped to keep the area clean and, all the while, the conscious eye watching the approach of the surgeon’s hand. But not everyone is troubled by this prospect. Indeed, a number of FT readers have asked me about laser eye surgery – whether it really works, and what, if any, are the complications?

The information about laser eye surgery on the Royal College of Ophthalmologists’ website gives a useful overview. Laser eye surgery is not suitable for all spectacle-wearers, and some may still have to wear glasses either post-op or at a later stage. Surgery is also expensive – the bill can run to many thousands of pounds.

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The ritual of weekly baby weighing clinics is unlikely to end anytime soon, and so I am delighted to learn that – at last- the old World Health Organisation baby weight charts are being ditched in favour of more evidence-based ones.  Previously, the charts “smoothed over” the differences in normal childrens’ weight gain in the first two weeks of life: now, the fact that “all infants show different patterns of weight gain” in these two weeks is accepted and instead the weight gain relative to birth weight is more important. Additionally, there are now charts specifically for pre-term infants.

I am sorry to say that I never knew the old infant weight charts to be contentious until I (or my child) was on the wrong side of them. The old charts were based on forumula-fed babies. Breast-fed babies, having a different pattern of weight gain, tended to look malnourished on the old charts rather than thriving.

The charts are free to download from the Royal College of Paediatrics website.

We are living in uncertain times. Circumstances will probably have changed by the time this column appears, but whatever happens, swine flu will probably still be making headlines.

People don’t like uncertainty, either as patients or doctors. It would be easier if we could predict the spread of disease reliably, or the effect of medications accurately. The prospect of a swine flu pandemic has triggered a million questions and concerns – and the answers to a substantial proportion of them remain unclear.

This is not stopping many people from trying to make a fast buck. Companies are selling alternative and complementary medicines – which will, so they say, reduce the chances of flu – and expensive hand washes, insisting they are essential in pandemics. These products parade all manner of claims, yet few admit they are untested. Conversely, people who are honest about the uncertainty of the evolving flu situation have been misquoted or have had their estimates pushed to the edges of reason by an anxious media.

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I live with an Irishman, which means that at home we drink Barry’s Tea. In my early married life I was “not allowed” this Irish brand, as apparently I did not appreciate it enough. Now, there is a supplier in Glasgow and we no longer have to import boxes of the elusive blend from Dublin. I am still not allowed to make it, however, as there is a very specific brewing time – at least five minutes, so I’m told.

This method of preparation may be a good thing, for in the process of brewing, then adding milk, the tea is never piping hot. According to a recent study in the British Medical Journal, the temperature of tea could be a risk factor for cancer. The habit of drinking of hot tea in Iran, where the study was conducted, seemed to increase the likelihood of developing oesophageal cancer.

More than 80 per cent of oesophageal cancers are diagnosed in the developing world; men, too, are at increased risk, accounting for almost two-thirds of sufferers. In Iran, there are 17.6 cases per 100,000 of the male population; in China, the rate is 24; and in England, it is 14.

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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.

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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.

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.

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Pleased to see that ripples from the UK have now reached the US.

I have been inspired by Harry Eyres’s piece on Slow London in the FT over the weekend. So much of working in medicine feels like a sprint. Short and overbooked appointments, busy clinics, multiple bits of administrative work to be ticked, crossed, signed and dated; e-mails and correspondence to deal with, questions from patients and carers and family members; equipment to be checked, replaced… it can feel frenzied.

Yet in medicine, seriously valuable things go missing in the fast pace. A detailed case history can be time-consuming to obtain but can save so much more on the wrong or unnecessary tests or investigations. Waiting to see if a symptom or test result improves may feel like a waste of time or even laziness, but can, in certain cases, be the most diagnositically useful thing to “do”. Allowing recovery from serious illness can sometimes feel frustrating: can nothing else be done? Yet it may be that “building in time” is the purest and most effective way back to a usual lifestyle.

Imagine if we could get rid of all the time-sapping, cash-depleting vogues in the NHS – Choose and Book and the tick boxes of the GP contract, for example – and invest instead in giving doctors and patients a bit more time to have adequate consultations?

“And so,” said my extremely pregnant friend while ordering lunch, “we’ve talked about it, and we’re going for nipple stimulation.” Nipples do not normally come up over coffee. I must have looked alarmed. No, no, my friend insisted, this was an evidence-based endeavour to bring on labour. She thought that I would approve. And what’s more, she said, lowering her voice conspiratorially, this method was free, easy and – quite possibly – fun. Gleefully, she ordered a large helping of curry to be washed down with raspberry tea.

So I had to go and look it up. And indeed, there is a reasonable amount of research showing that gentle breast stimulation, while not guaranteed to induce labour, does seem to have a better chance of beckoning baby out than no stimulation at all. The woman has to be at the right point in pregnancy for it to work. Also, more research on safety has been recommended – and no one, of course, should be trying to induce birth unless their midwife or doctor agrees. In any case, this method is not for the easily bored. Some studies suggest that between one-and-a-half and three hours of such stimulation a day are required to produce the desired effect.

But when it comes to the supposed methods women can use to induce labour, old wives tell many tall tales. Having sex is the most mentioned and near-mythical birth inducer. But there is not a lot of evidence to tell us whether the theory, which hinges on the labour-inducing effects of the prostaglandins in semen, is sound.

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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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