Bite worse than bark

I read somewhere recently that the number of large dogs in Australia is decreasing, but at the same time there’s a rise in the prevalence of tiny dogs that look more like a fluffy slipper more than a canine companion.
Just back from a walk during which my companion and I were scared on two occasions by large, scary and unrestrained dogs, I can’t honestly say the news displeases me. In both cases, the situation could have easily turned ugly.
Further strengthening my irritation with dog-owners who allow their huge dogs to wander the streets or be off the lead is an article in this week’s BMJ on the burden of dog bite injuries.
Before a team of Rottweilers is dispatched in my general direction by the animal rights lobby, let me say I’m a long-time dog-lover; tonight we had a large Airedale and a schnauzer in tow. But as is the law, they were on leads, an appropriate rule in an area where every second house has small children or dogs, or both.
There’s still debate over which dogs attack humans most, but according to the BMJ the consensus is that the “higher risk animals include larger dogs, German shepherd dogs, pit bull terriers, Rottweilers, and chows, but all dogs should be considered dangerous; even smaller dogs such as Jack Russell terriers inflict severe bites”.
Personally, this rings true. I once cohabited with a placid chow called Daisy, whose name reflected her nature, while my cousin had a Jack Russell that attacked her poddy calf which subsequently died from the injuries. It’s hard to imagine a toddler would have fared much better.
And for some reason, the problem seems to be growing. I’m not sure of the Australian figures – readers are most welcome to fill me in here – but despite a fall in UK dog ownership, hospital admissions are growing, and I don’t think it’s because the NHS has gone soft on its admission policy.
An accompanying editorial in the BMJ discusses several proposed strategies to reduce dog attacks, now considered a child protection issue.
Sadly, many intuitively sensible schemes are likely to fail because they don’t take into account the high proportion of dog attacks that occur in the home. Initiatives such as compulsory muzzling in public places and dog-free parks won’t prevent Fido turning on his family if they get between him and his dinner.
I’m sensing an emerging zeitgeist here; a recognition that while we love our dogs we love our children more.
If we want to continue to enjoy the companionship of man’s best friend, as a community we need to do some serious limit-setting, and we need to do it now.

Guidelines, schmidelines

In Wednesday’s issue, 6minutes reported on the new whizzbang [American Heart Association guidelines on heart disease in women, in particular the bit about aspirin.
Maybe it’s just me, but the guidelines, which took years to compile and have over ten pages of references, left me with as many questions as answers.
For example, for women at high risk of CVD, the guidelines are clear they should take aspirin, but far less clear about the dose.
“Aspirin therapy (75 to 325mg/day) should be used in high-risk women unless contraindicated.” Well, which dose is it?
Similarly, the advice for low-risk and healthy women had me scratching my head:
“In women greater than or over 65 years of age, consider aspirin therapy (81mg daily or 100mg every other day) if blood pressure is controlled and benefit for ischemic stroke and MI prevention is likely to outweigh risk of gastrointestinal bleeding and hemorrhagic stroke”.
My first admittedly cheeky question is how someone takes 81mg of aspirin given tablets come in 100mg or 300mg doses, so presumably it’s some kind of average.
More seriously, it is precisely the weighing-up bit that busy clinicians need help with.
“Considering” aspirin isn’t going to save a life. In fact, I’m pretty sure that even before the guidelines I might have “considered” aspirin. What I’d like to know, especially from such a well-researched guideline, is how to quickly and easily “weigh” the evidence between bleeding risk and cardiovascular ischaemia.
Even more ambiguously, the evidence on aspirin for healthy or low-risk women <65 years appears twice - once in the “what might work” category and once in the list of “what doesnt work”.
While in one section, it’s advised to consider aspiring in “women <65 years of age when benefit for ischaemic stroke prevention is likely to outweigh adverse effects of therapy”. But in another, “Routine use of aspirin in healthy women <65 years of age is not recommended to prevent MI”.
A call to the University of Tasmania’s Professor Mark Nelson – a man who really has his head around this stuff - cleared things up a little for this younger group. His interpretation of the guidelines is that aspirin is NOT routinely recommended for primary prevention.
But, he told 6minutes, in the absence of other good evidence the authors have left it up to individual clinicians to calculate individual risk for other groups.
I’d thought that calculating individual risk had been the advice for some time, and it sounds a bit back to the future to me.
Or maybe I just need to wait till they publish “Heart Disease for Dummies”.

Normalising HIV tests

It doesn’t seem long ago that testing a patient for HIV was a seriously big deal that could take half a doctor’s morning if you followed the rules to the letter.
Obligatory pre-test counselling had to cover everything from travel insurance to job discrimination, and results had to be delivered face-to-face regardless of the pre-test probability of a positive result.
From memory, a one-size-fits all approach was recommended which made little distinction between testing a regular at a gay sauna and a pimply adolescent after a furtive encounter with a classmate behind the home economics block.
As well, the specimen had to be anonymously labeled which meant dealing with multiple tubes and forms – when few of us had a computer – as rarely was an HIV test ordered in isolation.
The “special” status of HIV testing always seemed a bit odd to 6minutes, and perhaps politically motivated, given that tests for more immediately life-threatening illnesses came with no “special” regulations, and other potentially stigmatised illnesses with distressing implications , such as hepatitis B and C, were totally exempt from exceptional consideration.
Indeed, the years have seen the "special" rules about HIV testing watered down as sense has prevailed.
But even so, we were surprised by a Lancet comment piece, which alerted us to new CDC guidelines that recommend routine opt-out HIV testing in all health-care settings in patients aged 13-64.
Prevention counselling is not required under the guidelines, and negative results may be conveyed without direct contact between doctor and patient.
Strategically, the guidelines make public health sense in the US where it’s estimated around one-quarter of HIV-positive people are unaware they’re infected.
Even so, write The Lancet editorialists, public health benefits must be weighed against risks.
With an opt-out system in a busy clinic in areas with low literacy, there is “the danger that testing could become so customary and habitual that patients do not realise they can decline”, they write.
Moreover, will the move be a disincentive for primary health-care workers to provide risk-reduction counselling or gather information that can identify higher-risk individuals who require more frequent testing?
And what provisions are in place to help a 13 year old to cope with a diagnosis of HIV?
While the trend to normalising HIV tests is healthy, there's probably a middle ground, and these question must be answered.
In Australia, our record on HIV control has been so good, especially among intravenous drug-users, that it's a debate we hopefully wont have to have.

Is my talent wasted?

As well as doing this blog, I am the exec ed of a new Aussie online medical newsletter and site called 6minutes, published by Reed-Elsevier, dubbed by some the evil empire of publishing.
Before that I was Medical Editor of Australian Doctor for around 8 years, where at least one doctor obviously thinks I should have remained.
Here's Dr Deepak Malhotra's email:
"What is the objective of 6 minutes?
Is it 1/10th of Sixty Minutes?
Apart from enhancing the CV's of Michael and Kerri what is its purpose? You might as well have the Kerri and Michael show on one of the Drs networks. Dr Parnell was doing a wonderful job on the previous publication. Now she might as well start writing for the Sunday Telegraph. As for you Michael, regrets specially when you waste editorial space on talking about your visit to the pharmacy. What is about editors and journalist that given a platform they seem to talk about everything. Next week Michael visits a Greek restaurant ands he tells us all about its decor. For gods sake get a life and stop publishing rubbish."

Ouch, oh well at least he's reading. From memory he's a stirrer from way back, and was the GP who took the pics on the Pfizer showboat, you've gotta love his work.

By the way, a shame the Pharmawatch blog is now invitation only. Last week I was chuffed to see Pharmawatch had linked to a 6minutes article.
Now I'm out of the group.
Michael, let me in!!!

Antibiotic evidence too strong to resist

Until today I’d not realised there were members of the scientific community not convinced that antibiotics cause antimicrobial resistance, but apparently the many studies demonstrating an association haven’t been enough to persuade some the relationship is not coincidental.
The reason, put simply, is that the evidence so far has mainly come from population, or ecological, studies – far cruder instruments than randomised controlled trials of individuals when drawing cause and effect conclusions.
Nonetheless, I would have thought the jury had been in on this one for quite a while; I’ve never met a microbiologist who appears to harbour any doubt on the relationship between antibiotic prescribing and drug resistance.
Of course, tobacco companies maintained an unshakeable public denial of the causal links between smoking and lung cancer long after Richard Doll and colleagues provided robust epidemiological evidence – but this was “ignorance” of the convenient variety that kept companies in business.
Some politicians’ long-standing reluctance to link carbon emissions with climate change is perhaps another example of a conversion it was expedient to delay.
Still, I’ve no reason except perhaps a journalist’s skeptical bent to suspect there’s an agenda behind non-believers.
In any case, doubting Thomases on the antibiotic issue will have nothing to stand on now last week’s Lancet delivered the smoking gun in the form of an elegant piece of individual research.
The randomised, double-blind, placebo controlled trial of over 200 volunteers clearly shows that the macrolide antibiotics, azithromycin and clarithromycin, caused drug resistance in streptococci for up to six months.
Worryingly, clarithromycin conferred resistance not only to macrolides but also to tetracyclines and other antibiotics.
The key message, according to an accompanying editorial, is that “antibiotic prescribing affects the patient, their environment, and all the people that come into contact with that patient or with their environment…We have to do act before ‘the antibiotic era finally grinds to its apocalyptic halt”.
Lancet 2007;369:482-490

Health prevention or death-postponement?

If I hear the words, “Prevention is better than cure” in relation to health once more, I’ll scream. Glib jibes that our health system is simply a sickness system also get on my nerves, as does the new-age-tinged ‘wellness’ movement, not for their underlying sentiments but their naivity.
It’s bleeding obvious we’d all like to avoid getting sick. And that we have an aging population likely to have chronic diseases that’ll cost us a fortune in monetary terms not to mention human suffering.
The question though is not whether we should try to prevent illness, but one of balance. Are we, as some claim, in danger of allowing efforts to this end fail those who are ill now?
According to a doctor in the BMJ, an excessive commitment to preventing sickness could destroy our capacity to care for those who are already sick.
Policymakers are in danger of shifting the focus of health care away from the needs of the sick towards those of the well, from the old to the young and from the poor to the rich, claims UK GP Dr Iona Heath.
“Doctors are colluding with politicians and journalists in the systematic exaggeration of the power of preventive medicine”, Heath argues, “underestimating the role of luck and contingency in human health”.
“They want to believe that health is the simple opposite of sickness … and that it can be delivered to order”.
Heath’s article sparked a vigorous debate that’s well worth a look, with one GP arguing that despite preventive efforts, it’s likely we’ll all need ‘a sickness service’ eventually, no matter how unfashionable the concept is and regardless of how long we live.
‘It is highly likely that before we die we will be subject to symptoms and morbidities from that disease. Of course we want a public health system that keeps as alive as long but it must not be at the expense of a sickness service which will help us deal with the symptoms of disease when it inevitably comes along’, he wrote.
Of all the medical disciplines, illness prevention and treatment come together most in the realm of primary care, where preventive efforts such as health check-ups for the middle-aged are appropriately now being rewarded.
Talk to patients though and timely, accurate diagnosis of their symptoms and safe, effective treatment are high on the list of characteristics they want in their doctor.
Heath, I (2007) In defence of a National Sickness Service BMJ 2007; 334: 19

Ouch! Was it something I said?

I wasn’t surprised to get a few grumpy emails from rural quarters after Fridays’ story on ACRRM’s initial approval for its training program.
Readers wouldn’t have had to read far between the lines to realise I think dividing general practice training into two is a bad move for general practice, and therefore the community, in the long term.
I’m happy to cop flack – it comes with the territory.
But some of the correspondents seemed to argue with a position we hadn’t taken, so let’s be clear.
• No, I don’t think urban practice is exactly the same as rural practice, and never have. (Mind you city practices aren’t all the same either, but let’s leave this to the side for now.) Many, by no means all, rural doctors do extra stuff that city docs now don’t choose to or don’t have an opportunity to do, eg obstetrics. As I understand it, for this and hospital work such as anaesthetics, those that do it are rightly rewarded for doing a great job, both financially and in job satisfaction terms. If they’re not paid well enough, let’s pay them more.
• Yes, as an urban GP, it does wear thin after a hard day at the surgery to hear supposed colleagues on the radio referring to urban general practitioners as pen-pushers and referral factories. It would get up the noses of my patients too, who are usually grateful for my time, attention and skill. People do actually get sick in the city too! By the way, I’ve never heard an urban doctor criticise the clinical skills of a rural colleague or belittle them for what they do in their surgeries.
• Good general practice, wherever it takes place, is not merely about procedures. I recall one rural GP offering to swap places with then RACGP president Professor Michael Kidd, implying the latter couldn’t cope in the country. Maybe not, but I suspect the correspondent may have also struggled prescribing anti-retrovirals in an inner city HIV and hepatitis C practice.
• No, 6minutes is not associated with the RACGP as suggested in one email, and has criticised the college in the past. We are not affiliated with any organisation.
The heart of this debate is not which group’s best or cleverest, but whether the overall community will be best served by rural and urban general practitioners having a totally separate training pathway.

Here a clinic, there a clinic, poor patient care

While not convinced brown’s the new black, I’m in full agreement with those who say heart clinics are the new skin clinics – they both advertise widely, using the selling points of bulk billing and no need for a referral.
There seem to be at least two groups of heart clinics around, including four Sydney clinics run by Your Heart Clinic
offering on its website ‘Heart disease assessment and lifestyle prescription, stress testing, assessing circulation and BP, prompt referrals to heart and diabetes specialists, advice on diet and exercise and health checks for 45 to 49 year olds”.
Another group, featured in Australian Doctor this week, is called Heart Check and are sometimes co-located in Advanced Medical Institute practices around the country, NZ and Asia.
There may be others.
After operating under the radar for some time, some of the clinics are now getting doctors hot enough under the collar to start speaking out on behalf of their patients and there’s a pattern in the complaints.
For instance, complaints from members to the NSW AMA have concerned quality of care, unnecessary testing and the initiation of new medications with no follow-up planned by the clinic, which advised patients to return to see their own GP. In response, the organisation has written to the NSW Health Care Complaints Commission and Medicare Australia about inappropriate use of item numbers.
An email from a GP tells an almost identical story.
Even if the standard of care and follow-up procedures are top notch, this is Medicare rorting at its worst – radio advertising luring worried people to spend the Medicare dollar on services best done in the context of comprehensive general practice.
In any case, the 45 to 49 year old health assessment is intended to be performed by the patient’s usual GP, not a one-off check by someone they don’t know and never will.
Federal health minister, Tony Abbott, told Australian Doctor he may consider legislation banning the advertising of Medicare items, and wonders “whether these services are clinically necessary”.
They’re not, Mr Abbott.
Don’t ever forget there’s good evidence that countries with strong non-fragmented primary care have lower overall costs and generally healthier populations.
As usual, we welcome comments and feedback from all sources.