Questions about healthcare

Why do men’s ears get bigger as they age? I don’t know, I told my editor, but I shall try to find out. Medical school teaches you a lot of things but this wasn’t one of them. The resource most likely to help answer such ponderables is PubMed, an online resource that replaced the book-bound Index Medicus, which was enormously large and hideously time-consuming.

PubMed tells us quite a bit about ears and age. In 1995 a general practitioner called James Heathcote wrote an entire paper in the British Medical Journal on this very subject. Four doctors measured the ears of patients aged 30 and over who were attending the surgery on unrelated matters. Among the 206 patients studied, the mean ear length was 67.5mm and, on average, ear size seemed to increase by 0.22mm per year. This proved, said the authors, that older people have bigger ears. Now, a number of criticisms could be made of the study – for example, the selection criteria might not have been random enough to reflect the general population – but the results are still fascinating, and prompted a number of responses.

A professor of clinical gerontology wrote to the journal to say that his Chinese grandmother had told him he should stretch his ears daily in order to ensure a long life. He also cited a paper from the American Journal of Medicine in which 108 patients were studied to see whether having a diagonal crease in the earlobe was a predictor of lifespan. They followed the patients for eight years, and found that those with a diagonal crease did die earlier from all causes. But, worrying though this is for those with creased skinflaps, it still doesn’t explain why ears get longer as we age.

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

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.

Medical lore has created something of a cult around the measurement of children’s temperatures.

A fever seems to be something which is suspected and then recorded, swiftly followed by the administration of medicine to “bring it down”.

Some confessions. My home medical kit isn’t up to much. At one point it did contain a thermometer, which came free with a purchase at a petrol station and subsequently broke. It was a complement to what I saw as the only vital medical accessory for a household with children: infant paracetamol.

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

The only thing separating reiki and reflexology from rational medicine and progress is evidence. And what evidence-based aficionados like me love best is the randomised controlled trial, the process by which most drugs and treatments aspire to be tested. But are we now hearing its death rattle?

In a recent lecture at the Royal College of Physicians, Professor Sir Michael Rawlins appeared to have stuck the knife in the randomised controlled trial. Sir Michael, chairman of the National Institute for Health and Clinical Excellence, effectively said that such trials weren’t the be-all and end-all. “Sir Michael Rawlins attacks traditional ways of assessing evidence”, the story went. But it is not the value of these trials that is the problem, but rather how we chose to think about their conclusions.

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

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.

Free newspapers, a takeaway menu, special offers from the supermarket and, in the pile of mail cascading on to the doormat, a glossy leaflet from a health clinic, advertising a special check-up service.

“Put your mind at ease with a health check from Lifescan, the UK’s leading provider of private CT assessments,” it said, alongside pictures of glowingly healthy people. “Wouldn’t it be reassuring to be given a clean bill of health,” the leaflet went on, before asking: “Would you benefit from a Lifescan health check? Certain things can put your health at risk – smoking, for example, or if your family has a history of heart disease, stroke or cancer. So, too, can diabetes, high blood pressure or high cholesterol, and a stressful or sedentary lifestyle.”

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

In the wake of the subprime crisis and the stock market slide, counselling and psychotherapy services have been quick with offers of help for those dealing with the fall-out.

A generation or two ago, discussion of one’s personal problems was more commonly done in the public house, with a priest or parson, or with friends and family. This does not necessarily mean that it was ideal or even helpful. But is acquiring a professional ear for life’s troubles any better?

It would be quite normal to be upset by the loss of a much-loved job, or a lifetime’s savings. The question is whether professionally dispensed “therapy” would provide any greater comfort than one’s usual coping methods. Stressful events can act, in some people, as a trigger for anxiety or depression. But for those who are not ill, and who do not have a psychiatric disorder, indiscriminate use of therapy may actually do harm.

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

There is pressure being placed on employers to make their workplaces “healthier”. NICE released documents on this earlier this year, and this week the Scottish Executive have published their take on matters.

What is the good employer to do? The recommendations focus on employers increasing the amount of exercise that employees take in the course of their work. Move the photocopier further away to make people walk more! Increase the distance between the water fountain and the desk! Put up signs beside the lifts to encourage people to take the stairs instead! Encourage short walks at break times! Move meetings further away!

NICE say these guidelines are evidence based, but there is nothing about how much time employees lose for the company while they are walking an extra mile or two a week. Or are people to work longer hours to get the same amount of work done? That doesn’t sound too “healthy” to me. Nor is there much in the way of long term evidence for these changes. There are many behavioural studies successfully examining how to encourage exercise that can demonstrate short term gain – but it is long term increases in movement which generate most health benefits.  

I am dubious. My email correspondent in Virginia alerted me to this article  in which he is
featured. It is a different and rather more vigorous idea: constant walking at the desk, via a treadmill underneath it.

There are lots of reports that “faith in God really can relieve pain” and such in the press at the moment. These reports are based on a study published in Pain (yep, medical journals have all the most exotic titles: Gut, Brain, Breast, Lung….) and the abstract is available here.

Unsurprisingly, the research does not prove anything about a faith in God relieving pain. What does it show, then? The researchers compared 12 practising and believing Catholics with 12 nonbelievers. The researchers administered electric shocks to the subjects’ hands while asking them to study either a religious picture of the Virgin Mary or a secular image. When the groups were compared, the Catholics studying the image of the Virgin percieved that they had less pain. This correlated with specific findings on functional MRI scans which the researchers thought could play a role in brain regulation of pain in this group. 

This is interesting, but it does not prove that faith in God has reduced pain. It shows that pictures of the Virgin Mary, presented to people likely to be familiar with that image, caused reductions in those people’s perceived pain. It may have been the case that any familiar image – religious or not -  would have been as capable of distracting people from pain.

That is worth exploring. While distraction is a well known technique for helping with pain, more work may help sort out what kinds of visual distraction work best for what people.

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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