Don't pass the buck Tony.

Beware the word "Crunch".
Think cornflakes for example. The old-fashioned variety which 6minutes grew up on had around 6% sugar. Today's Crunchy Nut cornflake on the other hand contains 31.7% sugar, or 400% more than its predecessor.
Now Kellogg's have given Sultana Bran the 'crunch' treatment too. Compared with Sultana Bran's 22.7% sugar content, Sultana Bran Crunch has 28.4%, or nearly 30% more. Rather than 14.2% fibre content, the new version has just 8.7%.
To a hurried shopper, the difference in content is undiscernable; only a conscious and deliberate examination (with a magnifying glass if you're over 40) shows up the former as a significantly less healthy product.
Not that I'm blaming Kellogg's for the obesity crisis. It's a no-brainer that in a free-market economy companies will try to boost sales in any way the law allows, and if that means high-sugar, low fibre cereals, so be it.
But as our girths grow and the number of healthy choices on the supermarket shelves shrink, labelling is just one option we should consider.
If cigarette packets alert smokers their contents may cause mouth cancer, why shouldn't cereal packets warn of an increased risk of heart attack, diabetes or premature death?
Instead, last week saw the introduction of a voluntary food-labelling system that is more likely to mislead than inform, and has health experts up in arms. According to nutritionist Rosemary Stanton, the new labels showing the percentage of daily intake a serve of a food provides to an average adult, 'fails to give people any understanding about what is an acceptable daily intake".
If it's true, as reported in the SMH that the new system has the approval of parliamentary secretary to the Minister for Health and Ageing, Christopher Pyne, I wish he'd listen to the most compelling argument I've heard on government regulation in a recent ABC program.
At a forum called, "Yes I'm fat, but it's not my fault", Professor Richard Ingelby from Deacon University compared keeping people healthy with keeping the peace. Not only does government have a responsibility to ensure its citizens live peacefully together, but individuals shoulder this same responsibility, says Professor Ingleby. Surely, the existence of the police force doesn't reduce the personal responsibility we all have, he says. Indeed, says the good professor, it's easier for individuals and governments to be responsible if they have a shared responsibility.
It's not an either/or situation.

When I hear the words 'going overseas for surgery', it's would-be buxom wenches heading to Bangkok for a cheap boob job, or forty-somethings trying to turn back the clock, that come to mind.
But a recent NEJM article entitled 'America's new refugees - Seeking affordable surgery offshore' has little in common with what's come to be known as 'medical tourism'.
Instead, this latest and growing phenomenon concerns middle-income Americans who simply can't afford necessary surgery in their own country. A case described in the journal tells the story best.
Howard Staab, a self-employed, uninsured, middle-aged carpenter from urban North Carolina, needed surgery for an acute mitral valve prolapse. The problem was he didn't have US$200,000, the figure quoted by his nearest regional hospital for the repair, nor the 50% up-front deposit required.
And little wonder he didn't have health insurance.
For the first time, 2006 has seen the average health care costs for a family of four, including insurance and out-of-pocket expenses, exceed the entire annual wage of a low-income worker in the US, according to the NEJM, which also noted, seemingly without irony that: 'A sympathetic hospital employee suggested that if the patient allowed his condition to deteriorate to a life-threatening emergency, the hospital would be compelled to provide the surgery and would afterward pursue debt collection".
Shopping around got the price down to $40, 000 at a Texan hospital, but this still meant Staab selling his home, so his medical student son investigated the overseas option. He found a cardiovascular surgeon and New York University graduate, Naresh Trehan, who was practicing at a new, private hospital in New Delhi.
No prizes for guessing the procedure went ahead at a fraction of the cost. Staab paid just US$6,700 in medical costs and his wife describes her family's care at US hospitals as far worse than that her husband received in New Delhi.
In the words of the NEJM authors, "offshore surgery .... is a symptom of, not a solution to, our affordability problem".
And we reckon our health system's bad.

I'm your doctor, not your mother

Earlier this week, 6minutes wrote some sympathetic pieces on men's health prompted by the MJA issue on the topic, and is totally in favour of encouraging people with Y chromosomes to come to the surgery.
However, one of the oft-mentioned suggestions to overcome men's avoidance of things medical always gets my goat - to "arrange special after-hours clinic times that are more accessible to men".

Of course, I haven't heard similar recommendations for specialists, but reading this again in the MJA had me wondering what century I'd been transported to.

Most women these days work, many have primary care of children, and the figures still show we do the majority of housework (although 6minutes household doesn't conform to this latter trend).
As a female GP with kids, the last thing I want to do is stay back working nights away from my own family, or paying a babysitter, so I can check the blood pressure of some guy who can't get it together to get off work an hour early for the sake of his own health. Without wanting to make it a competition, I've seen women struggle in for a pap smear with three squirming kids under four.
At some point, we all have to take responsibility for our own behaviour, health-related or otherwise. Sometimes, life just isn't convenient for men or women.

My adverse reaction to prescribing software

6minutes loves computers and gadgets, but has long complained about her medical software – a minor player in the market – especially in regards to the lack of drug alert prioritisation. Most infuriating are alerts which tell me the two drugs in a compound preparation interact with each other.
My previous grumbles have attracted silence on the part of the software company, (admittedly not named in previous rants) and an “it’s our database but it’s up to the software companies how they use it”, reply from MIMS, the drug database used by my software, Plexus, owned by IBA.
A recent discussion with an insider in the medical software industry shed light on why the quality of clinical software tends to lag behind that of billing packages.
As is the case for most products, there are two main drivers for companies to produce high quality software – a healthy financial return and regulatory requirements.
On the financial side, software manufacturers want doctors to buy their brand, and therefore aim to produce a competitive product. Unfortunately, market forces are yet to push the calibre of clinical software to dizzying heights.
The other source of funds for software companies are government subsidies, but these are project based and serve the government’s purpose of collecting data, saving money, and winning votes through things like simpler billing – think HIC online, HealthConnect and MediConnect. As 6minutes understands it, there are no subsidies for global functionality, ie safe, user-friendly programs with quality decision-support.
Perversely, software company’s own insurance policies don’t encourage quality either. A program doesn’t need to have an easily accessible allergy field but does require every potential drug interaction to be included, regardless of how trivial and confusing for the prescriber.
On the regulatory front, industry standards and government requirements appear to have little impact despite ample data that electronic prescribing is causing harm as well as benefit.
Clinical software simply needs to improve.
Patients, doctors and taxpayers deserve software that facilitates safe and wise prescribing, including features such as prioritised drug alerts, better drug-disease information, and a compulsory dashboard of basic information, including allergies.
Government has little hesitation in forcing doctors to jump through hoops in the name of quality and safety.
It’s time it demanded the same of medical software companies.

What patients want

I’d wager not many practices include a patient on the employment panel when they interview new staff. Yet according to a speaker at the recent RACGP conference, it might be the best way to ensure we hire patient-, and therefore practice-friendly staff.
Associate Professor Michael Greco, a Franciscan monk in a previous life, is as patient-centred a GP as you’d expect from his history, and his motto, which from memory he borrowed from somewhere, extremely apt - “Nothing about us without us”. Although always putting patients first is inimical to much of our training, most general practitioners at least pay lip service to this philosophy, and sincerely want to provide a good service to our patients. But rather than assuming we know what patients want, we should ask them, says Professor Greco, Director of the Client Focused Evaluations Program. Not by popping a suggestion box in the waiting room, but with routine surveys on patient expectations or perhaps even a ‘critical friends group’ of patients whose specific aim is to give constructive feedback.
From his own experience, patients’ wishlists fell into five domains, and only one involved safe, high quality medical care. Access and waiting, a clean comfy, friendly atmosphere, information and choice and relationships were the other patient wants.
Complaints about UK practices listed on Professor Greco’s website lists include waiting times and continuity of care. More specific complaints, which may ring a bell with Australian doctors were too many leaflets on display in the waiting room, privacy problems and reception congestion, children’s toys causing a hazard to elderly patients and inadequate telephone systems. “The patient is everything”, says Professor Greco, whose patients have led practice workshops on topics such as diabetes, and designed a website for the practice.
To quote Professor Greco quoting the Bombay Hospital Motto, written by Mahatma Gandhi: “A patient is the most important person in our Hospital. He is not an interuption to our work, he is the purpose of it. He is not an outsider in our Hospital, he is part of it. We are not doing a favour by serving him, he is doing us a favour by giving us an opportunity to do so”.

Gen Y - self esteem on steroids

It’s hardly likely the 4.5 million Australians born between 1978 and 1994 and dubbed Generation Y all share a common personality, any more than the nearly 2 million born under the influence of a certain star sign will meet a tall handsome stranger next Wednesday night. (apologies to devout astrologers and Linda Goodman)
Even an avid proponent of the generational divide says there’s as much diversity within generations as between generations.
Addressing last week’s RACGP conference, author Peter Sheahan said however shared life influences of those between and 12 and 28 indelibly affected their mindset. They’re ambitious, need instant gratification, and separate effort from reward. Put simply, they have “self-esteem on steroids’, he says.
As a result, Gen Ys live all spheres of their lives differently to their predecessors. It’s not the expense of housing that sees this group living with their parents well into their twenties. Gen Ys see their parents as friends rather than authoritarian figures, says Sheahan, and between a third and a half of people aged 21 to 28 still live at home.
Whereas previous generations often wanted the freedom of their own place where they could drink alcohol and have sex. Now, says Sheahan, they’re doing that at our place.
When it comes to jobs, Gen Ys can be hard to please. As an employer, rather than interviewing a Gen Y for a job, they’ll interview you, says Sheahan, and employers must position themselves as ‘employers of choice’ to successfully recruit them. This seems code for paying them heaps.
Many of us in the audience weren’t so sure how relevant this advice was to our profession. But given that in 10 years, 42% of the workforce will be Gen Ys, we might just be surprised.

Try this quick quiz

Want to know your JASPA (Journal associated score of personal angst?
Try this quick quiz.
J - Are you ambivalent abut renewing your journal subscriptions?
A - Do you feel anger towards prolific authors?
S - Do you ever use journals to help you sleep?
P - Are you surrounded by piles of periodicals?
A - Do you feel anxious when journals arrive?
If you answered yes to none of these questions, chances are you're a liar.
If you answered yes to between one and three questions, you're probably pretty normal for a doctor.
Sorry, but if you answered yes to more than three, then you're really just one sick puppy.
I'm not giving my own score away, but did this quiz at the annual RACGP conference last week in a talk by Professor Paul Glasziou from Oxford. Originally outlined in a BMJ article, the JASPA score is a measure of information overload.
In fact, it's overload, not incompetence, that explains the majority of the gap etween evidence and practice, said Professor Glasziou. To update your medical knowledge by learning about just one condition per day, it would take 25 years to cover the territory, and of course well before then much of the information you'd learnt would be out of date.
Journal searches on the other hand have their own problems, and Medline now publishes about half a million articles per year. Ninety RCTs are published every day.
Simply put, the number of trials are just getting away from us.
Solutions to this problem are gradually evolving. One such solution for UK doctors is the Primary Care Question Answering Service, and although Aussie docs cant post questions, most of our questions arent unique and a quick search on the site will reveal one similar.
Apparently a similar service exists in Wales.
I'm going to bookmark these sites and given them a go.