Monday, 26 September 2011

My way or the highway

When I first looked after stroke patients as a registrar in 2007, it was common not to artificially feed patients for up to a week. If a patient could eat, then we would let them eat, but often patients who have had strokes are unable to swallow food safely, and risk aspirating it into their lungs. These patients need to be fed via a feeding tube that goes down the nose, and while we would eventually get round to it, there was never any particular rush to put one in, because at the time there was no evidence that early feeding improved patients’ survival. The result, therefore, was that we became comfortable with patients being starved for days at a time before we arbitrarily decided when the right time to start feeding was.

Thankfully, some new NICE guidelines came out, encouraging stroke teams to start feeding patients within the first twenty four hours, and now it has become standard practice to start feeding patients as soon as it is practicable.

When I look back at the way we provided stroke care only four years ago, and compare how we do it now, it feels as though the past is a foreign country: we let patients starve, and literally used to tuck up our new stroke patients in bed until we could get a CT scan done. Now patients should have their head scan almost as soon as they arrive in hospital, and many are offered clot-busting medication, put on pressure-relieving mattresses to stop sores developing, fed, kept well hydrated and start their rehabilitation on their first morning in the stroke unit. Care has improved almost beyond measure, because a compelling case was made to offer stroke patients thrombolysis, and as part of the service re-organisation that providing this kind of care involves, it has been possible to improve every other aspect of stroke care.

There is a dangerous phrase that we throw around in medicine: ‘There is no evidence for that.’ Sometimes we are at risk of becoming hostages to the evidence base, and the example of stroke care that I give is a salutary lesson in just that. Empiricism is a powerful concept, and the idea that we should only use treatments that we are confident do more good than harm is one  I will defend resolutely, as it asks that we do not countenance treatments that are dangerous, and do not waste our money on treatments that do nothing. But the need for a good evidence base and randomised controlled trials have become cognitive short cuts, that interrupt original thought, and creative thinking. The shadow cast by empiricism over medicine is actually longer than it should be, and my argument today is that sometimes it can stifle creativity and stop us doing things we know are right.

For example, the absent of any positive statement that feeding someone in the first few days after a stroke stopped us doing so, and allowed us to become comfortable with starving patients. Common sense, I think, tells us, that in the absence of any other evidence, it is probably better to feed someone recovering from a serious illness than starve them.

Hand-washing is another good example - most hospitals now have a policy that clinical staff in clinical areas should roll up their sleeves and remove their watches, and all but their wedding rings. The fact that the latter is allowed is held up as an example of the lunacy of the ‘bare below the elbow policy’ as is the fact that there is ‘no evidence base for it’. But the more I think about it, the more I realise that it doesn’t matter if there is no evidence supporting this kind of behaviour - by rolling up one’s sleeves and removing most of our hand and wrist adornments, we make it easier to wash our hands properly. I agree that removing our wedding rings would make  it easier still, but the point is this: Bare Below the Elbow is common sense, and it also sends the message to our patients that our hand hygiene is something we take seriously.

I can’t remember what initially got me thinking about this subject, but I do know that I have found it really rather invigorating over the last couple of weeks to really challenge all the things I do without really thinking. Every day there are lots of examples doing things one particular way because that is the way we do them. Over the next week try asking yourself what it is you are doing and why. Is it because it is the right way or the best way, or is it because it is simply the way you have always done it?

We like to think that most of what we do in medicine is driven by good evidence and best practice, but having done this thought experiment for the last week, my experience is that my decisions and actions are often driven by my own personal experience, and what is practical.

I haven’t yet decided what to do with this realisation. Answers on a postcard please.

Sunday, 18 September 2011

Be as impartial as you mean to be.

On Thursday and Friday, I attended a course on mentoring. The audience consisted mainly of GPs, with some hospital doctors, and interestingly, a couple of psychiatrists, who wanted to see whether mentoring approaches could be useful to them in their work with their patients.

As a self-selecting crowd, our attitudes to mentoring are probably not typical of the medical profession at large, and I assume that in general, we were more positive about the uses of mentoring than many. However, a few of the comments caught my attention; in particular, one GP who ambled in late commented that she had been mentoring for years, so thought she should see what it was all about. Hmmmm.

Having been mentored myself, I thought I was entering the course with a clear idea of the skills needed to become a good mentor, and also the belief that I had many of them already; the assumption being, that as a doctor, my professional life consists of talking to patients, eliciting the information needed to make a diagnosis, and then help them deal with the information and choices relevant to their problem.

Of course, this assumption betrays my ignorance. Many of us in the room struggled to leave behind our preconceptions about what mentoring is, and how it should work; in fact, I think that there are some people who still don’t get it. A theme throughout the course was a fixation of comparing mentoring practices with the kinds of tips and tricks that we use in medical interviewing, and the idea that the framework that we already use for eliciting information and forming conclusions is one that serves us well already, so surely should form the basis of this slightly different way of assisting people.

And yet therein lies the rub: mentoring isn’t so much about diagnosing the problem, and identifying the solutions, but rather about enabling individuals to steer their way through issues and challenges. Mentoring often seems to involve dealing with people who are bashing against a concrete block in their path, and the challenge is to help them realise that there is a clear track on either side.

It can be achingly frustrating to deal with someone who’s problem, in your eyes, have an easy fix. As a doctor, I have become accustomed to having the authority to say to people what the problem is, and what I think the solution is. In fact, such an approach is encouraged by the societal expectations of doctors, and the way we are trained. However, telling someone what the solution to their ails is is not the same as them solving it themselves.

Mentoring aims to help people reach higher by using the skills and abilities already within them. It is very  much about enabling them to tackle issues in their own style. Applied to patients, this represents a markedly different approach to practice than I am used to. I wonder how affective it will be, as I know that some of my patients think that when I ask them what they would like to do, it is because I do not know what should be done. In such situations, I have to play the traditional role of the doctor, but the manifestation of such expectations from my patients should not dissuade me from honing my skills further.

I find the techniques that mentoring requires to be a useful way of examining how I interact with my patients: if I’m honest, with virtually every patient, there is a course of action that I think is the ‘right’ one. This will be based on many factors, including my genuine assessment of what is in the patient’s best interests, but even this kind of conclusion involves significant value judgements, and it doesn’t matter how open I am, my preconceptions and biases are bound to influence the language I use with the patient, to steer them towards the decision that I think is the best one. I often wonder whether the anguish and dismay I feel when I think a patient makes the ‘wrong’choice is driven as much by the dismay that I have not been able to persuade them to agree with me, as it is by the concern about what will happen to them.

I therefore have to acknowledge that the prospect of learning how to support someone’s decision-making in a non-directive way opens up the possibility that I will become a more accomplished communicator and doctor. This is a tantalising prospect, as I have yet to confirm what the vision might be. All I know now is that it seems like a powerful idea to be able to learn how to help someone without my own vested interest and innate biases playing too big a role. I’ll let you know how I get on.

Sunday, 11 September 2011

Obesity and the Dream Chaser

Yesterday afternoon, I visited one of the hospitals I used to work at. As I approached its imposing main entrance, I stood and watched 7 paramedics trying to load an enormous man on a stretcher on to an ambulance. They couldn’t do it - the driver had to get out of the cab lend a hand; with the combined muscle of an even 8, they just managed it. Now that is a big man.

Obesity is a problem - I remember when I was a house officer, we were told that if we wanted to scan someone too big for our CT scanner, we would have to send them to  London Zoo - imagine the humiliation for the patient: ‘I’m sorry, Sir, but you are too fat to have a CT scan, so we are going to have to send you to the zoo, where they are used to dealing with larger specimens.’ I never quite worked out whether the London zoo scanner had a table that such patients could lie on, or whether they had to use the slings that they put their sedated animals in.

I later heard that the zoo was no longer prepared to do scans for the NHS, because it was taking up too much of their scanning time. I suspect that this is aprocyphal, but it paints a picture. In any case, some bright spark decided that it would be a good idea to up rate the loading capacity of the tables we use in the CT scanners, so the problem of having patients that are too big to scan is not one we face all that often.

But we have had to adapt the way we do things - wheelchairs are wider, theatre operating tables are stronger, and we have access to re-enforced hospital beds when we need them.

Being overweight has become the norm. My Mum showed me a photo of her class at primary school, and the only chubby kid in the class was the son of the chap who ran the chip shop. I want to believe his name was Rollie, but I don’t think it was. I suspect the ratio of chubby to not chubby has changed dramatically over the last twenty years.

A recent family debate centred around whether overweight people should pay extra for health care, because obesity is a self-inflicted condition, borne out of eating too much, or rather, by not being able to control oneself enough to stop eating eating and associated with higher health costs.

I argued against this view point with the idea that obesity should be considered a problem of poverty and poor education - it is the new malnourishment- everyone has enough to eat, but cheaper and easy-to-prepare food tends to be less healthy.

But I wondered if I was being over simplistic about this: obesity is a problem affecting the whole of society, not just the poorest parts of it. The Independent ran an article recently stating an estimate that by 2030, half the population will be overweight.

Will we end up like the people in Wall-E, too fat to walk, and living our lives in floating chairs, consuming entertainment and ingestibles?

This modern epidemic is more than just an imbalance between calorie intake and energy expenditure - the balance of our entire lives has shifted. For example, we used to forge our leaders on the sports pitch - ‘play up, play up and play the game!’ and all that ( )  and while this was not an entirely good thing, serving as it did to stifle social mobility, it did at least mean that lots of people grew up doing lots of exercise, and that in itself is not a bad thing.

School seems to be overly focused on exam results, and these kids really do work hard.  The price for failure, defined these days by a B grade or below, is so great, that other important factors get neglected - sport, responsibility, independence, critical analytical skills and so on. Education seems to bow to the Exam God, and we enter adulthood without the exercise habit.

But there’s more to it than that: I have no doubt that I did a lot of growing up on the sports field - the joy of winning, the pain of losing, the camaraderie, and the ecstasy of performing way beyond what you ever thought possible. There is something incredibly powerful about playing a part in the hopes and expectations of other people that mirrors closely a lot of what is important both in life and in the work place. Sport can teach us about personal responsibility, team work and the value of hard graft.

When I was twelve, we had a new rugby coach from New Zealand - he was young, charismatic, and a junior All-Black. To us he was a seasoned international, and our hero. He taught us the Maori Haka, and showed us that you didn’t have to be naturally brilliant at something for it to be worth trying hard at it. We worked our little prep school socks off for him, and had one of our most successful seasons ever. In the final, crunch match of the year, we played our nearby rivals, and despite camping out on their try line, and giving it everything, we lost 4-3 - not the highest scoring rugby match in history, but keenly contested all the same. At the full time whistle, most of us just burst out crying - the frustration at working so hard, coming so close, and yet still losing was too much for us at the time. But on the bus home, our coach congratulated us for being men enough to care, and for showing it. He told us that that was not a sign of weakness, but rather of strength.

That was one of the most important lessons I ever learned: it is ok to try and fail. Success is not the only outcome that justifies the effort. In fact, we often learn more from our failures than we do from our successes. It is the opposite of this attitude that causes people to stop chasing their dreams, and to settle for something less.

I have seen a lot of ‘settling’ by young doctors, who confused and scared by the challenge of chasing their dreams (eg becoming a surgeon or a neonatologist) settle for an easier, more predictable option.

So what is my point - that we are becoming fat and risk averse? Possibly. But really, what I wanted to say was that the problems we face in society are usually much more complicated than they appear, and we should be wary of simple solutions that do not tackle the actual cause. Obesity is not simple a problem of people eating too much, and not doing any exercise - these are simply the manifestations of much deeper changes in the way we live, and solutions need to tackle all the different facets involved, from education, to work, to leisure time, so that living healthy, fulfilling lives stops being something we have to learn to do, to becoming simply the way we live.

Monday, 5 September 2011

The 3-step cost-saving plan.

This morning, I wrote to my MP to highlight my concerns about the Health Bill. Today, at work, at the prompting of Clare Gerada via Twitter, I encouraged some of my colleagues at work to do the same. A few of them told me that they didn’t like the sound of the Health Bill, but they were really confused about how it would change the delivery of health care.

Today’s blog, therefore, is my cheat sheet on what I think the main causes for concern are:
  1. The Health Bill removes the responsibility and accountability of the Health Secretary to provide a comprehensive health service. Andrew Lansley argues that this is a conscious decision to put patients and doctors in the driving seat, but it is much more than that, as we will see shortly.
  2. Commissioning consortia will be responsible for the patients enrolled at the GP practices that make up the consortia, rather than the population of people within the geographic area covered by the consortia.
  3. The limits on the amount of private work that hospitals can take on will be lifted.

These three issues add up to some significant changes in the way that we deliver health care.

The services that will be needed by Consortia’s registered populations will differ from the services required by unregistered patients - the latter tend to be poorer, more poorly educated and in poorer health than the former.  But Consortia have no obligation to provide services for these needy, unregistered patients. Unregistered patients will therefore experience worse access to primary care than they currently do, and will no doubt have to resort to emergency services more often than they do now.

However, the hospitals that these patients will present to, will be hospitals that will be increasingly geared towards providing private care for their more affluent, insured patients. Our unregistered patients will experience long waiting times, high cancellation rates, poor facilities, and perhaps even poorer quality care.

When they get fed up with a poor level of service, they may eventually complain to the Health Secretary, but he will plead powerlessness - after all, he will argue that he has given the power to organise and commission local services to local patients and doctors. He will say that the service you receive is the service that you and your fellow citizens have asked for, and what’s more, he is not responsible for it anymore.

We all know that health care will experience significant cost challenges over the next decade, but who knew that the government wanted to meet this challenge by ensuring that more and more people would effectively be excluded from health cover?

Sunday, 4 September 2011

A thought experiment on the future of health care

Baroness Williams is arguing that a major flaw of the health bill is that it removes the obligation of the health secretary to provide a comprehensive health service ( ). Coupled with the decision to lift the cap on the amount of private work hospitals are allowed to do, she feels that we will achieve a health system in which private patients will dominate the agenda, and free health care will be truncated and relegated. She argues that this follows the example of the American health service, which is notoriously inequitable, and represents a backwards step for the UK.

Predicting the behaviour of individuals in times of ill-health can be tricky - I have no specific data on this matter, but I can call upon a wealth of personal experience which tells me that there is no such thing as odd behaviour when it come to ill-health: I have met a man in his 40s who spent three months lying in bed, unable to get up, before he sought medical help, and I have met a young woman who insisted on doing her own rectal exam in A and E, so that I wouldn’t have to. There is nowt as queer as folk.

What however is clear is that health care is important to people. Wealthy countries around the world spend billions on their health care. Per person, the expenditure on health care in the USA is two and a half times the European average, and yet 50 million Americans still have no health care cover, and the cost of medical treatment is the biggest single cause of bankruptcy. Overall the level of expenditure means that a lot of wealthy Americans are probably spending a lot of money on health care cover that they do not need.

We live in a country where the concept of not being able to access medical care, and spending all of our money on medical bills is unthinkable. We live in a country which spends less money per capita that any other major Western country, but still achieves similar health outcomes. The NHS is one of the most efficient health care systems in world, because of its economies of scale, and because of its lower administration costs: in countries where there are competing health care providers and insurers, they must each duplicate the administrative set-up themselves, rather than having the one set-up we have.

The price we pay for the kind of access that we have is that the people who contribute the most money to the NHS pot, are the people who tend to use it the least: there is a clear correlation between health and affluence. The way we fund our health service is a value judgement that we as a country made in 1946, and one to which many still adhere. But not everyone agrees.

If you are having trouble imagining how the NHS will change after the Health Bill, think about how you access dental care today. The concept of NHS dental care is often illusory, and where it does exist the level of care can be two tiered. I think dentistry serves as a really useful microcosm of how the NHS could change.

Given wider availability of private services, and lengthening waiting times for NHS services, an increasing number of people will take out private health cover, and no doubt businesses will increasingly offer health cover as an employment perk. Hospitals will compete for the higher tariffs they can charge to private patients, enticing them with better hotel services, fast access, preferential scheduling and a more personalised service. The NHS patients will wait longer, in poorer accommodation, and experience cancellations more frequently. As the level of service and experience (if not necessarily quality) plummets, more people will find the money to go private, perhaps risking bankruptcy (remember how much we value good health care). There will be an increasing clammer from those with health cover for tax rebates to reimburse them for the contributions they make to the NHS, and so the spiral starts.

Of course, I may be wrong, and the Health Bill may transform the quality and level of medical care in the NHS, but my mind cannot reach such lofty imaginative heights at the moment.