ozdocblog

More to health than hospitals, Mr Rudd

2007-11-27T17:15:00.000-08:00

It’s been widely reported that one of Kevin Rudd’s first moves as Prime Minister elect was to send all Labor MPs back to school. Under instructions to visit one government and one non-government school in their electorates over two days, the MPs will test the waters of Labor’s Education Revolution.
Specifically, the plan to put a computer on the desk of every year 9 to 12 student, and the increased emphasis of trades education in schools will be on the agenda of meetings at schools today, as MPs prepare to report back to the partyroom tomorrow.
To his credit, Mr Rudd has wasted no time, although it does seem a big call to expect MPs and schools to think through such weighty issues in such a limited time. It’s also not clear how much input he’s inviting from state education departments, who might be thought to know a thing or two about the issues at stake.
So when it comes to firming up the party’s health policy, I’m hoping for a more considered approach, as well as one that recognises hospitals are not the only component of our health system. Mr Rudd has announced he will meet with premiers within three months to discuss health, but he must be careful.
It’s an understandable trap for young players with an ER mentality to equate the health system with busy hospitals and big machines. Hospitals may well be at the pointy end of the system, as well as generating most of the scary headlines feared by politicians, but the majority of health care takes place in primary, not secondary, care. Good evidence now exists to show that it’s accessible, high quality primary that has most influence over the state of the nation’s health.
Encouragingly, Labor has promised to develop a long-awaited National Primary Health Care Policy, but on the other hand has already announced GP clinics which may not be in the best interests of patients if they fragment care.
So please Mr Rudd, remember two things when it’s health’s turn.
Take it slowly. When sending out the troops to gather information, allow more than two days.
And please don’t focus on hospitals alone. Sit in with GPs and private specialists, outpatient mental health units, and boarding houses where the mentally ill sit alone smoking themselves to death.
Otherwise, you’re going to get a very warped view of what Australians need and what they’re getting.

Large shoes to fill for new health minister

2007-11-26T19:38:00.000-08:00

A few Saturday nights ago I saw Don’s Party for the first time and realised I’d totally misunderstood what it was about for the last thirty something years. With election night 1969 the setting for the play, I was keen to see it because of the political similarities between the two elections, mainly a feeling that Labor could snatch victory from a longstanding Liberal government.
Boy, was I wrong. Williamson’s play was much more about personal rather than party politics, especially the social context of the times, predominantly boorish men who thought feminism was just a good excuse to get a bit of skirt.
The two election parties I attended last Saturday night were both much more like those I’d expected Don’s to be, except of course for the outcome.
But while Saturday’s landslide election settled the big question, there are still questions and debates aplenty.
For a start, who will be our next Health Minister? There’s still no clear indication Nicola Roxon will get the spot, and while I might not make many friends saying this, Tony will be a hard act to follow.
Sure he wore his Catholicism too much on his sleeve. His comments that it didn’t matter if hospital boards further distanced hospitals from primary care because GPs could deal with it didn’t sit well with me either.
On the other hand, his handling of the indemnity crisis, early funding of the cervical cancer vaccine in international terms, and some financial wins for GPs, such as the 100% rebate for GPs, can’t be ignored.
And according to the SMH today, he was often rolled in cabinet, so maybe he was trying to do more.
However, while he says he’s sad not to continue in the role, I’m not sure I believe him. Those in the know have told me the last year or so saw him looking increasingly distracted, but at least unlike many of his predecessors, Liberal and Labor, he seemed to not dislike doctors.

Male menopause confirmed a myth

2007-11-12T18:36:00.000-08:00

I have to admit I’m a skeptic. Not in general, but about the male menopause, sometimes called the “andropause”, “male climacteric” or even the “viropause”. More recently, even more names have emerged, including “late onset hypogonadism” and “partial androgen deficiency in older men” (PADAM).
I’ve just read a study and editorial that’s only confirmed my skepticism.
Acknowledging that “menopause in women is an unquestionable condition caused by ovarian failure, with a number of symptoms related to decreased sex steroid production, hot flushes being the most common symptom”, the researchers go on to postulate a male climacteric, whereby age-related decreases in testosterone in men can develop a clinically relevant hormonal deficit.
Of course, the symptoms of male menopause would be subtle, the authors say, and its recognition could be obscured by normal ageing. Convenient really.
And another thing. Call me old-fashioned but I’d always considered the journal Menopause was aimed at doctors gynaecologists, and am not so sure this group is interested in aging men, unless they are one.
Anyway, in a nutshell, the Swedish study found that in men aged 55 to 75, symptoms thought perhaps due to androgen deficiency, including low libido, lack of energy, decreased strength, loss of height and less strong erections, were generally not associated with blood testosterone concentrations.
You’d think this finding would put a significant dent in the researchers’ confidence in the existence of the syndrome.
But in the words of a brilliant editorial in the journal, the issue has been repeatedly examined and shows little evidence of life. “It is now time for a decent burial.”
According to the editorial, the current researchers “describe the syndrome as a natural consequence of ageing”. “What is surprising is the need to revisit the body after so many death certificates have been issued”, it says. “What concerns us is the despondency produced by the results”, the editorial says in response to the following statement by the authors – “Unfortunately, and in line with others, we could not find any connection between those symptoms and circulating androgen levels”.
One can only speculate why researchers are so attached to this syndrome, which smacks of a me-too mentality, just like men who claim they have labour pains.
I suppose there’s money to be made by some drug companies if doctors are allowed, or even encouraged, to prescribe androgens for men without identified androgen deficiencies.
Maybe researchers in this area are so entrenched, their careers depend on it.
Whatever the reason, surely we’re at a point where there are more worthy targets of research.
Menopause 2007; 14; 999-1005.
Menopause 2007; 14; 973 - 5.

Are criminal charges apt for medical mishaps?

2007-10-29T19:07:00.000-07:00

Have you been sued yet?
I say if rather than when, because the stats indicate that the majority of doctors will be sued at least once in our working lives, and our recent story on the issue received many personal and sympathetic responses.
A usually diligent lot who primarily have the interests of patients at heart, doctors take perceived failures, whether real or not, much to heart.
Which probably explains my reaction when I hear of doctors undergoing criminal charges for a medical procedure gone wrong – not the Patel serial error-type story – but the one-off event where there’s no suggestion of a pattern of offending.
The reason for my focus on doctors and the law is the charging of prominent Queensland gynaecologist, Dr Bruce Ward, yesterday with the manslaughter of a 30 year old woman who died in hospital in 2002 just days after a radical hysterectomy for cervical cancer.
Mother-of-two Ms Nadia Cvitic reportedly collapsed three days after surgery and subsequently died of multi-organ failure. The inquest, which ended 18 months ago, found a pelvic drain had pierced a vein, which went unidentified by Dr Ward who began treatment for a suspected pulmonary embolus. The vein was repaired by a second surgeon who found over a litre of old blood in her abdomen.
As in all such cases, there are no true winners. Ms Cvitic’s dead and the $175,000 out-of-court settlement to the family won’t bring her back. For his part, Dr Ward must have spent a rotten five years and now he’s on bail, about to begin a probably lengthy criminal manslaughter trial with the prospect of subsequent incarceration. Even if he gets off, his practice is probably ruined.
None of this is to say that such deaths shouldn’t be vigorously investigated or that I have a view as to whether he was negligent or not.
But after seeing an Australian Story program where a drunken youth confessed to killing another chap with an unprovoked punch but walked out of court with an unblemished record after acquittal of manslaughter, I’m just not sure there shouldn’t be at least some distinction in the way these two quite different types of cases are death with.
There are other jurisdictions, such as Medical Boards or civil actions, to deal with doctors involved in a single medical tragedy. And if a doctor loses their licence to practice, there’s little likelihood of them harming anyone else.

Stop drip-feed funding for BEACH

2007-10-18T19:28:00.000-07:00

Many readers have come to the defence of BEACH, the only independent source of data on GP consults, since my blog on Monday about the federal government’s dragging the chain on funding.
For instance, Andrew (yes it’s the blogosphere and first names and pseudonyms are de rigeur) wrote that the government’s lack of commitment to general practice research is one reason all our bright stars of General Practice research are either working overseas or in salaried tenured positions.
As Andrew says, the government has left BEACH hanging on several occasions, and it’s true that as a journalist I’ve written almost this very same story for several years.
So to keep readers up to date, here’s exactly where things stand as of today.
Funding for BEACH comes via the Australian Institute of Health and Welfare (AIHW) and is assured for the 07/08 year, albeit belatedly.
But given the long lead time for projects such as BEACH surveys, the key question is what happens next, ie will I be writing the same story again next year or will the small group who work on BEACH be able to get on with what they do best?
As it happens, the funding stream for BEACH is a bit convoluted, with the Department of Health and Ageing contracting with AIHW, which in turn gives a share to BEACH via the University of Sydney’s School of Public Health.
According to the school’s head, Professor Glenn Salkeld, an options paper for funding is being prepared by the University in conjunction with AIHW re funding beyond 2008.
“The BEACH survey is terribly important for public health. The data derived from the BEACH survey is crucial for good public health policy and in every sense funding BEACH is a bargain for government”, says Professor Salkeld, who’s hoping for funding agreement by year’s end.
By the sound of it, the ball’s in DoHA’s court.
Let’s hope they do the right thing.

Short ED wait poor measure of hospital health

2007-10-01T20:20:00.000-07:00

Although I work close to the now infamous Royal North Shore Hospital, I’ve never advised a patient to vomit so they’d get past triage, as other local GPs admit to in today’s Australian. However, I do routinely recommend patients not “be too stoic” at the triage desk, so the extent of their discomfort is obvious.
As well, I often wait until the patient has left the surgery before ringing the admitting officer to avoid the grilling designed to make me change my mind about the patient’s need for hospital assessment. And more than once, I’ve resorted to asking a particularly resistant admitting officer what they’d do if we were talking about their mother or father.
But although last week’s case of an unfortunate woman delivering a live fetus in the toilet at the hospital has created thousands of column inches and a war of words between politicians, over-stretched hospitals are not just a North Shore Hospital problem, or limited to NSW.
So in some ways, the federal government’s new plan to fix the hospital crisis by forcing states to appoint hospital boards is appealing. So far, it smacks a bit of “policy on the run” and a return to the past, but any move to put the needs of patients before bureaucrats and their financial targets deserves serious consideration.
However, serious questions emerge. For a start, the health system is not just about hospitals, and it’s not clear the proposed move would address the current disconnect between primary and secondary care. Intuitively, the plan also risks severing established and useful networks between hospitals, and between hospital and community based services.
As well, the plan is being sold not as a federal, but a local, takeover of hospitals, with “local people grabbing power”, according to a federal source quoted in the Australian, which makes this local doctor nervous.
Understandably, local communities don’t take a big picture view of the health system, but are concerned about what’s available in their own patch.
As doctors and voters, we need to watch this one closely, and remind ourselves and our elected representatives that there’s more to an efficient and caring health system than a short wait in the ED.

Tooth extraction not so wise

2007-09-04T18:20:00.000-07:00

Until a recent dental X-ray, I’d assumed I had no wisdom teeth. To be perfectly honest I’d worn my lack of wisdom teeth with somewhat of a badge of honour, and rather than worrying that wisdom may have eluded me, had arrogantly wondered if my lack of vestigial third molars might signify a superior level of evolutionary advancement. In a few thousand years maybe no-one would have them, I’d figured.
Sadly, radiology shattered my pompous, tongue-in-cheek illusion. Rather than being absent my wisdom teeth were “impacted”; rather than being advanced, I was impaired.
Although many people choose extraction, it only took me a nanosecond to decide to keep my newly-discovered teeth, and I was fascinated to read an article yesterday about this very issue.
Writing in the journal, Health Policy and Ethics, retired US dentist, Dr Jay Friedman is scathing about the unnecessary prophylactic removal of wisdom teeth, which he labels a public health hazard.
“At least two thirds of these extractions, associated costs, and injuries are unnecessary, constituting a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability”, he writes.
According to Friedman, the evidence to justify preventative surgery simply doesn’t exist, although it does line the pockets of the dental profession, especially oral and maxillofacial surgeons who earn on average over half a million US dollars a year from the eight minute procedure.
Instead of evidence, misinformation and myths drive the multibillion-dollar industry, Friedman says, one of the most common being that wisdom teeth have a high level of pathology, whereas in reality no more than 12% of impacted teeth are affected. This is similar to the incidence of appendicitis and cholecystitis but we don’t routinely remove these organs just in case.
Neither is it true that the pressure of erupting wisdom teeth causes crowding of other teeth, he claims, saying it’s just not possible for one tooth which develops in spongy superficial bone with little firm support to push over 14 other well-implanted teeth.
Furthermore, third molar extractions are far from harmless, with sixteen known complications including infection, permanent paraesthesia, dry socket, trismus, pain and swelling, he says.
Far from the standard of care, prophylactic extraction is a silent epidemic, Friedman says and I’m convinced.
What about you?
Health Policy and Ethics 2007; 97; 1554-59.

Stop whinging - it might be your life that's saved

2007-08-30T19:04:00.000-07:00

I took my daughter for her first driving lesson this week - one hour down and one hundred and nineteen to go. Lots of learner drivers, and their parents, are having a whinge about the increased number of supervised hours mandated in several states, and for those like my friend with twins, teaching your kids to drive must indeed seem daunting.
Other rules in some states include a total ban on the use of mobile phones for newly licensed drivers, and a limit on the number of passengers aged under 21 late at night.
Yet despite their unpopularity, a quick perusal of the literature appears to generally support the new driving rules.
For a start, according to a paper on the topic from Monash University Accident Research Centre, although novice drivers represent only a minor proportion of the licensed driving population, eg 14% of drivers in Victoria in 2002, they are around four times as likely to be involved in fatal and injury crashes than older, more experienced drivers.
And it’s not only age, but inexperience, that relates to crash risk, the paper says, with “errors in attention, visual search, speed relative to conditions, hazard recognition and emergency manoeuvres” being contributing factors.
On a more positive note, the Monash centre reports Swedish research which found that about 120 hours of supervised driving results in around a 35% lower crash risk than 40 hours. In fact, in 1993 when Sweden made a single change to the licensing system - lowering the age a learner permit could be obtained from 17 years 6 months to 16 years and therefore prolonging the training period – the country experienced a 17% reduction in crashes for all novice drivers.
Other US research, published in JAMA found that in young drivers, fatal injuries increased with the number of passengers in the car at the time.
In any sphere, new rules are almost invariably unpopular.
But as with any public health initiative, the number of beneficiaries can be estimated but not identified by name. Just as we’ll never know who among our hypertensive patients may have had a stroke without our treatment, none of us will ever know who would have lived or who would have died without a change to the rules.
It might be someone we love.

Surrogate sore point

2007-08-26T20:46:00.000-07:00

If you had osteoporosis, chances are you’d be happy if offered a drug known to increase bone density. But astute readers would be even happier to take a drug that had been shown not only to make bones denser, but decrease fracture rates.

This distinction between surrogate endpoints such as bone density, and clinically relevant endpoints such as fracture risk, is hardly new, and it was twenty years ago that the FDA shifted the barrier for osteoporosis drugs to reflect the difference.

Right now, diabetes drugs are in the spotlight after reports that while patients on rosiglitazone (Avandia) may have good glycaemic control, it may come with an increased risk of myocardial infarction.

An FDA subcommittee met on 30th July to discuss the cardiac risks associated with rosiglitazone, and voted to recommend that the drug stay on the market but with warning labels and extensive education. In Australia, the Therapeutic Goods Administration has said stronger warnings will be included in the product information for the drug but the exact wording hasn’t yet been determined.
But according to an article by the FDA committee’s chairman in this week’s NEJM, we need a total rethink about the regulation of diabetes drugs.

Endocrinologist Clifford Rosen says it’s not surprising that glycaemic control has been the centerpiece of treatments for type 2 diabetes for many years, with several drugs shown to reduce glycosylated haemoglobin being approved.

“However, change in the glycated hemoglobin level is a relatively poor surrogate for cardiovascular outcomes in type 2 diabetes, accounting for only 5 – 15% of the variation in ischemic risk”, writes Rosen, who urges a “regulatory sea change” on diabetes drugs.

Without one, five years down the track we’ll be in the same position of having a new wonder drug designed to treat a devastating chronic disease but that does more good than harm, he says.

While testing new drugs using real clinical measures such as cardiac events rather than surrogates such as blood tests is costly, in the long run it will save time, money and probably lives.

NEJM 2007 Online 8 August.

Diminishing returns for preventive care

2007-08-26T20:39:00.000-07:00

My delightful patient, Mrs M, is now 89. She’s on three antihypertensives and also has high cholesterol – or so we discovered when she had a thrombotic stroke. I felt awful because I hadn’t checked her lipids for ages, and it was several months before she could return to her major past-time of which I’ve been a beneficiary each Christmas – crocheting coathanger covers. (They truly keep your clothes in much better shape.) Maybe if I’d treated her lipids, she wouldn’t have had a stroke.

Anyway, I was reminded of Mrs M on reading an article in this week’s BMJ calling for a rethink on preventative health care in the elderly.

The preventative push doesn’t deal with the problem of how it applies to people who’ve already exceeded an average lifespan, say the GP authors, who claim that fears of ageism have led us to provide treatments which merely change the cause of death rather than prolonging quality life. They use the example of statins to illustrate their case.

Evidence for using statins in the elderly to prevent heart disease is scant, and the largest relevant study is the PROSPER trial, they say. Yet while showing a small positive effect on cardiac mortality and morbidity, the trial also showed a higher rate of death and cancer diagnosis in the treatment group.
Further, the authors question the morality of selecting out and preventing specific causes of death, such as heart disease, leaving older people to die of other conditions that cause more distress. For example, many people regard coronary heart disease as a “good way to go”, they say.

“The best interests of elderly people, who have paid a lifetime of taxes, might lie in investing that money in health care that will genuinely relieve suffering. Cataract operations, joint replacement surgery, and personal care of people with dementia are obvious examples”, the authors say.

It’s an appealing argument, and Mrs M’s had bilateral cataract ops and a knee replacement which have certainly improved the quality of her life. But she’d also like to have avoided a stroke which came close to stealing her independence.
BMJ 2007; 335;285-7.

Super GP clinics not health panacea

2007-08-26T20:32:00.000-07:00

It’s like some sort of trump card dragged out by pollies of all persuasions before each election – “GP clinics”. Now Kevin Rudd’s promising us “GP super clinics”; “super-duper GP clinics” will probably be next.
While it’s great that health, especially primary health, is so firmly on the agenda in the upcoming federal election, I can’t be the only one with a sense of déjà vu.
But while overall the clinics have much to recommend them, what really troubles me about the promises, regardless of which side of politics is doing the promising, is the underlying muddy thinking.
To listen to Kevin Rudd you’d think “GP super clinics” are the panacea for all the health system’s ills.
For instance, Mr Rudd says they will reduce the pressure on emergency departments and people will no longer have to go to A and E for every little thing. He’s on thin ice here. For a start, GPs and emergency doctors agree on this one, only a minority of patients attending A and E are in the most serious categories. As well, the clinics are to be set up in the bush and outer suburbs, not necessarily where ED and hospital overcrowding is at its worst.
Nor will new clinics, whether super or not, fix the politicians’ problem of patient demands for medical access 24/7 for non-emergency care.
Furthermore, according to reports most of the funds would go to infrastructure, in other words for the actual buildings by providing grants of between $1 million and $10 million. But lovely as a large purpose-built clinic might be, the lack of them is not our main problem – which is a shortage of GPs willing to work in rural and outer metropolitan areas. The health system won’t be improved significantly by clinics pinching the doctor down the road.
On the other hand, some of the claimed benefits are real. True integrated, multidisciplinary care benefits patients with chronic illnesses, regardless of where they live. And such clinics would be great for training some of the upcoming flood of medical graduates, so long as they’re in the right hands, which brings us to the need for quality assurance. Funding issues are another unacknowledged stumbling block which needs to be overcome.
So bring on “GP super clinics”, but let’s be very careful about expecting them to solve all our problems, and even more careful about how they’re set up and by whom.

Pork-barrelling or meeting community need?

2007-08-02T20:44:00.000-07:00

How about this for a great political dodge?
ABC reporter asking the Prime Minister about his dark of night Youtube rescue of a Tasmanian hospital:
“Now Tasmania’s spent years preparing and now implementing a Clinical Services Plan for Tasmania, did you or your office read that before deciding to intervene in Mersey Hospital”.
Like a deft winger sidestepping an unsuspecting defender, Mr Howard’s replied: “Look, we’re aware of what the Tasmanian Government’s plan was, and that was to downgrade the hospital in Devonport”.
As if this was the entire master plan Tasmanian Health has been able to come up with. Sadly, the reporter let him get away with it.
Mr Howard went on to say that communities don’t care which level of government provides health services, and he’s right, but surely some one has to have a big picture view.
In the health-care arena, as in all areas of life, you can’t always get what you want no matter how often Mr Howard may say that “every community in the country should have a ‘legitimate expectation’ of a full range of services”.
But it’s simply not possible to have a fully equipped hospital in every small community given the workforce shortage, finite health dollar, and the need for practitioners to perform a sufficient volume of work to maintain their skills.
Of course, I haven’t fully read the Tasmanian plan either, but it appears to be the efforts of a small state with few doctors trying to best balance the budget and needs of all its constituents, not just those within the boundaries of the marginal electorate of Braddon, currently held by a 1.2% majority by the Libs.
As I understand it, the plan was to downgrade Mersey to a general practitioner care and a day-surgery unit, with patients having to travel 60km for further surgical facilities. The federal government is promising an ED, aged-care facilities obstetrics and surgery, although it’s yet to be seen where the staff will come from.
Whatever your political colours, operation Mersey must be seen as a piecemeal, Bandaid solution for a small community rather than a comprehensive, integrated health plan, which is what we need.
You’d think negotiating a new health care agreement with the states might be a good starting point, but Tony Abbott says there’s no point before the election, which to the government probably is the big picture.

Practice measures not answer to violence against doctors

2007-07-19T17:52:00.001-07:00

No-one could have failed to be moved by the tragic and brutal murder of Melbourne GP, Dr Khulod Maarouf-Hassan, in her surgery last year, and since her death at the hand of a patient there’s been much debate within the profession about violence in the medical workplace.
Yet as GPs Professor Michael Kidd and Associate Professor Leanne Rowe write in this week’s MJA, the discussion has been largely limited to measures individual doctors can take to protect themselves and their staff, such as ensuring secure physical practice environments, installing alarm systems and taking self-defence courses. While such strategies are important, tackling violence against health professionals is a bigger picture issue, they argue, and they’re right.
For a start, individual protection measures can only be so effective; an alarm wouldn’t have saved Dr Maarouf-Hassan from her frenzied attacker. Similarly, making sure the patient is never between you and the door is often unrealistic.
But apart from a lack of effectiveness of some individual practice measures, Professors Kidd and Rowe rightly say that violence against doctors isn’t just a personal threat, but a wider public health problem paralleling increasing community violence.
Moreover, there’s an identifiable subgroup of people more likely to be perpetrators of violence – “young men with active delusional psychosis, persecutory symptoms and disorganised thinking, who may be using substances, lacking insight, resistant to engagement, non-compliant with treatment and socially disadvantaged”, who paradoxically are also most likely to be rejected by mental health services and be denied help.
Of course, we in the medical profession must be careful not to get too carried away with the importance our own safety compared to other workers. All members of society deserve to return home alive from work each day, and just in the last week I’ve read about two rail workers, a construction worker and a truckdriver who weren’t so lucky.
But the ways to protect against violence, whether or not the victims are medically trained, are quite different to protecting against the physical accidents that claimed these workers’ lives.
According to the professors, we need a groundswell of concern by GPs for those at risk of becoming perpetrators or victims of violence. They’re right, but it’s a big ask to expect general practitioners to solve this problem on their own.
MJA 2007; 187; 118-9.

How to decide who's fit to drive.

2007-07-05T00:09:00.000-07:00

I’m a bit of a Nazi about people who aren’t fit to drive but continue to get behind the wheel. While aware what a bummer it would be to lose your license, surely running over innocent people is even more of a bummer for all concerned.
Of course I might be particularly sensitive about the Mr Magoo types who struggle to park in our surgery carpark because I live in the same street. The idea of my children sharing a road with these incompetents is positively scary.
But a review in last week’s BMJ is a reminder against stereotyping the ability of older drivers. According to the article, the association between age and crashes per mile has been shown to be more related to low mileage than age and surveys reveal drivers over 80 to be consistently prudent behind the wheel.
Even people with early dementia are acceptably safe for around three years after diagnosis, the authors claim, by which time most have stopped driving. Which is lucky, because cognitive testing can’t discriminate well between early dementia patients who are safe on the road and those that aren’t.
One way to detect unsafe drivers is to ask family and friends about specific behaviours, such as driving the wrong way around roundabouts, getting lost in familiar areas, miscalculating speed and distances and poor judgement, the authors suggest. Sounds good in theory, but in my experience loyalty to the patient is often a barrier to honest disclosure about their driving ability. Similarly it seems doctors sometimes turn a blind eye out of concern about a patient’s loss of independence.
In short, recommending a patient lose their license is a balancing act between patient independence and population safety, and it’s probably among the harder decisions we have to make as doctors.
At least in our area there’s now a subsidised cab system for the elderly, and it’s this type of system that should be expanded so that independence and mobility isn’t totally dependent on being able to drive.

BMJ 2007; 334: 1365-69.

ACCC ruling divides doctors

2007-07-05T00:05:00.000-07:00

The 6minutes story story on new rules to make details of every drug company do attended by doctors public has attracted a divided response from readers.
Some of you are outraged the ACCC ruling will force companies to divulge the professional status of attendees, hospitality provided, cost and educational content on a public website.
One concern is about an invasion of privacy when practice or hospital details are published. “I absolutely object to my privacy being stomped on by the ACCC”, wrote Dr Mason Stevenson.
I see his point but suspect patients have better things to do than trawl the net for examples of largesse bestowed upon their doctor. On the other hand, such info will probably make sexy copy for the lay media who always relish a “greedy doctor” story.
Other correspondents are enraged the medical profession has been singled out while other professionals are lavishly entertained ad nauseum.
“In any other industry entertainment of clients is an accepted part of customer relations…. Get off our backs”, wrote Dr John Lutz.
Again, he’s right, and I sheepishly admit traveling as a journalist to Paris courtesy of a drug company and Africa courtesy of a travel company, a vast contrast to the meager offerings I’ve received as female part-time GP.
And for the record if I sacrifice a home-cooked meal with my family to attend an educational function at night, I expect a hot meal not a sandwich. Who has sandwiches for dinner?
What’s different between the medical and other professions, according to ethicists, is the concept of information asymmetry, where a “knowledgeable” doctor chooses a drug for a patient who depends on them for drug info - quite a different process than a patient making their own informed decision about which car to buy.
Another major objection to the new ruling is the argument that hospitality and gifts don’t influence prescribing behaviour, and on this one there’s quite good evidence – they do.
In fact, it appears that the more gifts a doctor receives, the more firm their belief that seeing drug reps doesn’t affect their prescribing.
As they say, drug companies aren’t stupid. If it didn’t work, they wouldn’t do it.

What's your favourite medical myth?

2007-06-19T19:51:00.000-07:00

“It was really hot in the office, Doctor, but it was freezing outside. I had to keep going in and out and now I’ve got the flu”.
As a general practitioner, this variable ambient temperature-induced respiratory virus hypothesis is probably the most common myth I hear from my patients.
A medical blog features other prevalent myths presented at the Pediatric Academic Societies’ Annual Meeting in Toronto this year.
While physicians routinely endorse the constant acquisition of new knowledge, the authors said, continuing education focuses on a quest to stay up-to-date with the latest medical breakthroughs.
“While striving to stay current, physicians seldom pause to examine the beliefs that they already hold as true”, they argued, outlining “Ten medical myths even doctors believe”.

1. People should drink at least eight glasses of water a day.
2. We only use ten percent of our brains.
3. Hair and fingernails continue to grow after death.
4. Reading in dim light ruins your eyesight.
5. Shaving hair causes it to grow back faster, darker, and coarser.
6. Eating turkey makes people especially drowsy.
7. Wireless devices create significant electromagnetic interference in hospitals.
8. Some physicians are black clouds.
9. Rectal temperature can be accurately estimated by adding 1degreeC to the axillary temperature.
10. Halloween candy tampering presents a significant health risk to children.

The authors concluded all of these beliefs ranged from unproven to untrue on the basis of expert consensus, extensive literature reviews or clinical trials.
I’d heard them all, with the exception of number six which just sounds plain crazy, and number eight which I don’t claim to understand.
And I’m particularly glad if the researchers are correct about number one because despite my best intentions my water intake is definitely suboptimal.
The blogger who brought the list to my attention, a US neonatologist, had a myth he’d like tested - whether or not eating sugar causes children to become 'hyper'.
What's your favourite medical myth?

Would you get into med school today?

2007-06-19T19:47:00.000-07:00

Ever wonder how you’d fare getting into medicine these days?
Try this sample Australian Undergraduate Medical Admission Test (UMAT) question:

A woman reflects on the treatment of her husband, who has Alzheimer’s disease, in the emergency department.

“The job of the emergency team was to keep my husband alive. The problem: he was in the final stages of Alzheimer’s. It was time for him to die; his mind was gone, his body failing. He spent his days in diapers, spoon-fed, bed-bound. For 24 hours, despite my protestations and his carefully-written will, the doctors transfused him with pint after pint of blood. I have since forgiven them; they were only doing their job. They have one mission: to save lives. That my husband had Alzheimer’s was not their concern; that he was bleeding to death was”.

From the wife’s perspective, the emergency team was
A diligent but misguided
B negligent and incompetent
C sympathetic but indecisive
D competent and understanding

Which of the following would have most helped the wife in this situation?
A having the various medical procedures explained to her more fully
B being reassured that her husband was getting the best treatment available
C being given permission to leave the emergency room if she found it distressing
D feeling that her concerns were understood and appreciated by the medical staff

You get the idea, good questions, but part of me can’t help wondering how I would have performed when I was just 17. Or whether these are the sorts of issues you’re meant to learn to deal with and understand in medical school, rather than know at a tender age.
If you believe the Australian Council for Educational Research, the group that develops the UMAT, the expensive coaching that’s become almost de rigueur for candidates doesn’t help students do well at the tests.

On the other hand, the Australian Medical Student Association says the courses, costing up to $1700, threaten to undermine the integrity of admission tests for medical schools.

AMSA sounds so convinced coaching works that it has claimed the “exploitative” and “commercially-driven” programs raise questions of equity because they’re expensive and infrequently delivered in rural and remote areas.

My question to ACER is this. Do we have rigorous research that proves coaching doesn’t improve results? If so, can we see it?

(If you answered A and D, you are correct)

Just stick to the massage please

2007-06-05T17:03:00.001-07:00

For me few experiences are as relaxing as a massage, or at least I thought so until last week. With an hour free before a stressful medical appointment, I’d booked a massage at a local Ella Bache shop.

Within seconds of my arrival, it went horribly wrong when the masseuse handed me a mostly medical form titled “Confidential Client Information”.
Some of the questions were entirely reasonable, for instance my name, address and phone number, and whether I had any “specific areas of pain”. I would have even been happy to state any conditions people massaging my body should be aware of.

But why she needed to know my occupation, let alone the name, address and phone number of my “physician” was beyond me, especially given I was not asked permission for my “physician” to be contacted, presuming I had only one.
It got worse.

“Please list any recent or past injuries or medical conditions, including surgery” the form asked above a small space, in other words “give me your entire medical and surgical history in thirty words or less”.

Then came a rag-bag list of symptoms and diagnoses, such as headaches, insomnia, epilepsy, diabetes, cancer, numbness, dizziness, fatigue and “cold/flu/fever”, asking if any “of the following are relevant to you”.
My entreaty for a massage sans paperwork fell on deaf ears in this “No form, no massage” environment. Exactly who made the rules wasn’t clear, nor whether anyone actually read the form closely or what actions would be taken if I had ticked one of the aforesaid boxes, for instance declaring that a cold was “relevant” to me.

My reluctance was obvious. “But what if you’ve had a stroke?” the masseuse asked, to her credit trying to maintain her composure while I progressively lost mine and left.

An hour later I’d had a massage 10 minutes longer and $10 cheaper at a Chinese establishment with no questions asked.

Friends have since suggested the paperwork is an insurance requirement, but if so, it merely prompts more questions.

Why do some massage outlets get away with asking lots of stupid questions while others ask none? How qualified are those asking the questions, and how does having the information protect their customers?

Would you get into med school today?

2007-06-05T16:59:00.000-07:00

Ever wonder how you’d fare getting into medicine these days?
Try this sample Undergraduate Medical Admission Test (UMAT) question:

A woman reflects on the treatment of her husband, who has Alzheimer’s disease, in the emergency department.
“The job of the emergency team was to keep my husband alive. The problem: he was in the final stages of Alzheimer’s. It was time for him to die; his mind was gone, his body failing. He spent his days in diapers, spoon-fed, bed-bound. For 24 hours, despite my protestations and his carefully-written will, the doctors transfused him with pint after pint of blood. I have since forgiven them; they were only doing their job. They have one mission: to save lives. That my husband had Alzheimer’s was not their concern; that he was bleeding to death was”.

From the wife’s perspective, the emergency team was
A diligent but misguided
B negligent and incompetent
C sympathetic but indecisive
D competent and understanding

Which of the following would have most helped the wife in this situation?
A having the various medical procedures explained to her more fully
B being reassured that her husband was getting the best treatment available
C being given permission to leave the emergency room if she found it distressing
D feeling that her concerns were understood and appreciated by the medical staff

You get the idea, good questions, but part of me can’t help wondering how I would have performed when I was just 17. Or whether these are the sorts of issues you’re meant to learn to deal with and understand in medical school, rather than know at a tender age.
If you believe the Australian Council for Educational Research, the group that develops the UMAT, the expensive coaching that’s become almost de rigueur for candidates doesn’t help students do well at the tests.
On the other hand, the Australian Medical Student Association says the courses, costing up to $1700, threaten to undermine the integrity of admission tests for medical schools.
AMSA sounds so convinced coaching works that it has claimed the “exploitative” and “commercially-driven” programs raise questions of equity because they’re expensive and infrequently delivered in rural and remote areas.
My question to ACER is this. Do we have rigorous research that proves coaching doesn’t improve results? If so, can we see it?

Answers are A and D.

Tragic tale with many victims

2007-04-19T00:03:00.000-07:00

“Doctor too tired for golf ball victim”, “Doctor fears he was too tired at hospital”, “Flaws in care of girl hit by golf ball” – headlines referring to the tragic case of Vanessa Anderson, who died in Sydney’s Royal North Shore Hospital during a seizure two days after being hit by a golf ball.
With the inquest into the 16 year-old’s death in progress, the accusations have been flying thick and fast. If the newspaper reports are correct the case is another symptom of a system in trouble.
According to the Sydney Morning Herald, the court has heard that “Vanessa’s CT scan went missing; doctors and nurses failed to keep appropriate notes; a nurse did not tell anyone when Vanessa could not move and suffered memory loss a few hours before her death; and doctors involved in the case failed to tell each other when they changed her drugs”.
Furthermore, a postmortem revealed four times the therapeutic level of codeine in her blood and high levels of Endone, the paper said.
But perhaps the most telling report was a tiny newspaper report which claimed administrators had been warned the neurosurgical ward would be three doctors short at the time of Vanessa’s admission. I’m not sure what options the bureaucrats had to make ensure patient safety, but it sounds as if an unreasonable burden fell to a female intern on her eleventh neurosurgical shift.
She’s had her name and photo in the papers. She’s admitted making mistakes and she’s expressed her sympathy to the parents.
When I googled the case, the top entry made me cry.
It was Vanessa’s death notice:
Vanessa Anderson
Suddenly, late of Hornsby Heights.
Beautiful and cherished daughter of Michelle and Warren, loving sister of Amanda and Nathan. …
11.9.1989 - 8.11.2005 "Ness your legend"
Vanessa was just three days older than my own son, and I imagine her parents’ lives will never be the same.
Life, too, will have changed for those involved in her care.
And without wanting to preempt the coroner’s findings, it seems to me the system is largely made up o good people doing their best in a system that feels increasingly as if it’s going off the rails.

It’s coming from inside the hospital

2007-04-15T22:29:00.000-07:00

The introduction of concentration camps into an argument is a sure sign the speaker is all out of reasonable arguments and the discussion is headed seriously downhill.
So this quote in a newspaper about the mandatory vaccination of health-workers probably shouldn’t be graced with a response, but having had seriously ill children in hospital, I can’t help myself.
“These are the sorts of [immunisation] tactics you would expect in concentration camps, not the sort of tactics you would expect in the Australian Health Care system”, said the president of the Australian Vaccination Network about a NSW Health policy that requires health workers to be immunised before they have contact with patients.
For those who don’t know, the Australian Vaccination Network (AVN), quoted high up in the newspaper story as if an expert medical organisation, is against immunisation, or in their own words believe “governments all over the world have abridged or denied the right to free choice when it comes to vaccinations and immunisations for our children or ourselves”.
I’ve spoken to some of their members on the phone in the past, and like many zealots, they’re well-intentioned but unfortunately firmly believe they’re doing the right thing by saving children from dangerous doctors and vaccinations.
Pictured alongside the newspaper article are a brother and sister who the journalist says are “paying the price of not being immunised”.
Andrew, 25, has had to drop out of a nursing degree and Esther, 19, has had to transfer from nursing to naturopathy.
Bravo, I say, unless they can prove natural immunity to all relevant diseases.
It’s a disgrace that NSW Health didn’t have this policy in place before, and I’d be interested to hear about the policies of other states.
Why on earth should the government allow patients in our hospitals to be treated by staff who might give them diseases such as pertussis, incidentally misspelt on the AVN site?
Further, I can’t see why this pair’s non-immunised parents should be allowed to work as nurses in private nursing homes among the vulnerable elderly.
Andrew claims the policy “takes away any choice I had”. Sorry Andrew, but no it doesn’t, it takes away your choice to work closely with sick people. And so it should.

When science ain't science

2007-03-22T21:22:00.000-07:00

A stimulating article in this week’s Nature challenged readers to date the following two exam questions.
1. Describe the preparations of Sulphur used for cure of itch insect. Give the different methods of applying them.
2. Psorinum and Sulphur are Psoric remedies. Discuss the ways in which the symptoms of these remedies reflect their miasmatic nature.
According to the author, David Colquhoun from the Department of Pharmacology at the University College London, the former question was first set at his own institution in 1863, at a time when the London cholera outbreak was thought to be caused by vapours (miasmas).
The second question was part of the 2005 homeopathy exam at London’s University of Westminster’s.
Apparently, three UK universities now offer science degrees in homeopathy, and of 61 university or college level complementary medicine courses, 45 are BSc honours degrees.
A long term skeptic of complementary medicine, Coulquhoun has his own website devoted to publicising “assorted dubious, erroneous, nutty or downright fraudulent claims about drugs and other sorts of treatment”.
His particular beef is CAM making its way into universities, who he claims have a duty to ensure science degrees are scientific. Most CAM is not science because the vast majority of it is not based on empirical evidence, he says. Even worse, he claims many of its doctrines and practitioners are openly anti-science, and challenge the notion of objective evidence.
At least, says Colquhoun, other “mickey mouse” degrees, such as golf-course management and baking, offered at the “new” universities are honest, and what you see is what you get.
On the other hand, antiscientific science degrees may be a good way for universities to make money, he says, but in doing so are becoming the antithesis of what a university should be.

You've got to love general practice

2007-03-21T18:03:00.000-07:00

Saturday morning surgery and the receptionist – medical record in hand – sheepishly asks if I know Mrs M. My reply in the negative attracts a vigorous description of a 94year-old housebound woman who rules her world from the confines of her bed.
The colourful introduction left me with no doubt that despite her age, Mrs M was one demanding and persuasive lady. Apparently, we’ve even received calls from the local MP when Mrs M’s decided our services weren’t quite up to scratch.
“Last time doctor was just about to visit Mrs M, she called to remind him not to forget the bulb he’d promised to buy and replace in her fridge”, the receptionist said. “He’s even started clipping the ivy around her front door”.
On this particular Saturday morning, the problem according to Mrs M at least, was an errant community nurse who’d forgotten to instill her eye-drops. As well, she’d run out of sleeping tablets, and hadn’t slept for a week, she testily informed the receptionist.
Furthermore if, as the only doctor working that day, I didn’t come and put them in, she’d threatened to call the media.
Strangely, I couldn’t wait to visit.
On a not-very-serious level, as a medical editor, I was bemused to be in a position to offer her a doctor and media representative at the same visit, but was also fascinated by her feistiness.
On arrival, I negotiated the clutter and detritus of a long, and recently immobile, life.
I cleaned her eyes, instilled her eye-drops, and copped a serve for not delivering a script for sleeping tablets rather than the tablets themselves. But she had a back-up plan, and like most of the people in Mrs M’s life, I found myself following her instructions to the letter.
“Call the chemist on this number, and tell them to get Angela from the fruit shop next door to bring the tablets down on her way home”.
We did and they did.
You’ve got to admire her pluck.

Market sidelines care

2007-03-15T17:44:00.000-07:00

Dr Kerri Parnell
Jan, 26, presented with URTI-like symptoms, and being a new patient got all the usual questions – medical, family, social history and so on.
Within minutes, her eyes filled with tears, and our subsequent chat revealed, apart from a minor illness which can sap the defences of the best of us, that her job was the problem.
A newbie pharmacist in a major teaching hospital, Jan felt condescended to by her pharmacy colleagues and the junior doctors “who felt pretty special” now they’d been accepted to an institution with kudos.
But her main gripe was the piecemeal treatment she believed patients received.
“I see these same young doctors on the wards cowering before nurses telling them to prescribe drugs which often aren’t indicated”, she told me. “They’re not game to say no”.
“And then although pharmacists are meant to see patients before they go home to explain their medications, they’re often discharged when we’re not around. We’re understaffed, the nurses are understaffed, and the doctors are too”, she said, by now quite distressed.
Jan’s working day bore little resemblance to that she’d anticipated, and her picture of a leading hospital was indeed bleak, marked by overworked staff in a disconnected system that allowed little continuity of care.
An opinion piece in today’s Lancet reminded me of her dilemma.
The ascendancy of market rhetoric has diminished the value of relationships between health-professionals and patients, says Dr Iona Heath, allowing access to the health-care system to be “prioritised over the need to sustain a relationship with a known and trusted professional”.
I’d like to think Jan was just having a bad day. That our hospitals encourage and reward sustaining human interaction as well as technical expertise.
And that the management culture pervading our hospitals won’t dissuade kind and intelligent professionals like Jan from its corridors.

GP clinics unjustified

2007-03-11T20:57:00.000-07:00

GP clinics unjustified
Dr Kerri Parnell
No prizes for detecting an election in the wind in NSW with an opposition leader giving press conferences in his speedos while the Premier madly announces things he hopes will give him the edge. Last week it was digital mammograms, something about the Pap smear registry, 2500 more nurses and plans to plonk twelve extra GP clinics in emergencey departments.
This latter idea has worked well in some areas for specific reasons, such as the lack of an after-hours deputising service leaving GPs to provide after hours care or lose accreditation points.
Premier Iemma hopes GP clinics will solve two problems – perceived public desire for extended-hour medicine and ED overcrowding.
“If you’ve got a sick child late at night, and you’re looking for a doctor, often the only place you can get that service is an emergency department at a hospital”, the fully-clothed Mr Iemma told journalists.
Maybe I'm wrong but I suspect late night GPs a "nice-to-have" not a necessity. Given access to sensible phone advice, such as from a children’s hospital, few children can’t wait until morning, and the ED isn’t a bad place for this group. Finding quality GPs to work in the clinics will be challenging to say the least.
On ED overcrowding, a letter to a newspaper last week put it well: GP clinics won’t fix ED overcrowding because a lack of GP care isn’t the problem. Dr Tony Joseph, NSW chairman of the emergency medicine college says most patients present appropriately to EDs, where the real problem is access block due to a shortage of inpatient beds.
6minutes suspects that emergency physicians also fear that a drop in numbers will mean less dollars for their department.
In the spirit of collegiality, I’ll let Dr Joseph’s parting shot at GPs – “an expensive and untrained locum workforce” - go through to the keeper.

Whispers in the dark disempower parents

2007-03-06T14:31:00.000-08:00

It’s said “a picture tells a thousand words’, but sometimes language conveys the better story. In other cases, such as a piece in last weekend’s newspaper called “The Sleep Whisperer”, a good writer can send a bad message.
After a brilliant, if hyped, word picture of an exhausted new mother, the article portrayed parenthood as a nightmare of epic proportions. Even the first sentence - “At 3am, no-one can hear you scream”, was a take on the tagline from the horror movie, “Alien” - “In space no-one can hear you scream”.
After sleeping, or not sleeping, for weeks “on a crappy mattress on the floor of her room so my husband could sleep undisturbed in our giant bed”, our new mother was seduced by tales of a woman with “magic powers to make babies sleep through the night” when they reached six months old. And unlike parenting services such as Tresillian, the baby-whisperer did all the work, and in the comfort of your own home.
It worked a treat, so why did the piece leave me so angry?
My first though was jealousy; this couple had dodged emotional responsibility sipping Chardonnay in the lounge-room whereas I’d done the hands-on version.
On reflection however, what upset me was that the article disempowered parents. Many new parents struggle with a baby disinclined to sleep, but the last thing they need is a magician.
As my wise cousin Julie taught me, except for in exceptional circumstances, almost any committed couple can teach their infants to go to sleep unaided.
Choose a weekend when no-one’s working, put the baby to bed, make a strong cuppa and put Rage on the TV”, the mother of four wonderful children advised. “Check them after one song, then two, then three … you’ll get the idea”.
She was entirely correct, and it came much cheaper than baby-whisperers at $20 to $35 an hour.
GW 2007;3-4 March

Quiz me

2007-03-02T20:04:00.000-08:00

I love a quiz. Some better than others, factual quizzes that arent too hard and have a pop culture element, such as the SMH Good Weekend quiz, are my faves.
But almost any quiz will do, or games or TV shows - Trivial Pursuit, trivia nights, anything with Eddie McGuire ...
On car trips with the kids, I've done "Are you a back-stabber?" and "Who's your red carpet twin?". FYI, I'm not and Hilary Duff.
But I couldn't resist this one -

What Medical Specialty Is For You?
A few minutes later and after taking the Hippopotamus Oath, here was my result.
"The medical specialty for you is.... Ophthalmology Ophthalmology is the best of all specialties. As an ophthalmologist, you will be unable to spell the name of the field you went into. You will loudly assert the difference between your field and optometry, but eventually, you will be making too much money to care."

Funnily, I did do a stint at an eye hospital and considered ophthalmology fairly seriously for a month or two.
Maybe I should have stuck it out.

If it quacks like a duck ...

2007-03-02T16:58:00.000-08:00

Here’s a riddle.
The AGPN’s for it, the AMA says it’s full of holes. The RACGP’s keeping fairly mum about it. What is it?
Yes, the Access Card, aka an identity card, an iPod or according to Joe Hockey, a place to put your shopping list.
Currently before parliament, the controversial legislation arouses strong emotions on both sides. For some, the mere thought of a unique identifying number for every individual is anathema, but unless the card is canned, this will be the case – although whether the number is printed on the card or on the chip inside is still under debate.
For a transcript of an excellent ABC radio program on the card, click here.
A major and legitimate fear is ‘function creep’, described on the program by Professor Alan Fels, head of the government’s Access Card task force, as a card set up for a particular purpose acquiring many other functions over time.
For example, the UK ID card set up in 1939 with three particular purposes, including to prove the owner wasn’t German, had 39 functions when it was abolished in 1951. For this reason, AMA President Mukesh Hakerwal, says the purposes of the card must be specified in the legislation.
The touted advantage of people entering their own medical details on the card seems to me a furphy; I can’t imagine it’ll really allow doctors to skip a group and cross-match, for example.
The under 18 issue is confusing. While the Department of Human Services says “what occurs today will occur with the access card”, the AMA’s still got its knickers in a knot.
And let’s not waste words on whether the card is voluntary, in reality it isn’t. there’s also little doubt that at some stage a clever hacker will get data they shouldn’t have.
Finally, the justification for including place of birth completely eludes me.
Apart from all of the above, the card sounds like a good idea!

Bite worse than bark

2007-02-25T22:07:00.000-08:00

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

2007-02-22T16:57:00.000-08:00

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

2007-02-18T16:00:00.000-08:00

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?

2007-02-14T17:17:00.000-08:00

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

2007-02-11T19:57:00.000-08:00

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?

2007-02-08T23:03:00.000-08:00

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?

2007-02-04T20:16:00.000-08:00

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

2007-02-01T17:01:00.000-08:00

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.

Colleges vie for divine right to patients

2007-01-28T17:08:00.000-08:00

The tragic and widely-reported death of a Melbourne woman last week three days after liposuction predictably attracted calls for regulation of what's been unkindly dubbed 'the vanity industry'.
Twenty six year old Lauren James had undergone a same-day thigh and buttock procedure at the Centre of Cosmetic and Plastic Surgery in Caulfield North , and the case, now before the Coroner, has prompted the usual suspects to pronounce they're the only College qualified to perform such procedures.
For example, Dr Norm Olbourne, a spokesman for the Australian Society of Plastic Surgeons, says "doctors performing cosmetic surgery should be members of the Fellowship of Royal Australasian College of Surgeons".
But the doctor in this case, Dr Tam Dieu, is a plastic and reconstructive surgeon according to the Medical Directory. and according to the Centre's website its chief surgeon, Dr Gerard Sormann, is a fellow of the RACS with a long and distinguished career in cosmetic and plastic surgery. The facility is registered with the Victorian Department of Human services.
It's no wonder the punters are confused about who should do what
A Choice article a few years back highlighted the problem, listing the organisations claiming to train and represent doctors performing cosmetic surgery in Australia:
Australia Society of Plastic Surgeons, a sub-speciality of Royal Australasian College of Surgeons;
Australian College of Cosmetic Surgery;
Royal Australian College of Ophthalmologists, a sub-speciality of the Royal Australasian College of Surgeons;
Australian Society of Otolaryngology/head and Neck Surgery, a sub-speciality of the Royal Australasian College of Surgeons;
The Royal Australian College of Surgeons;
Australasian Society for Aesthetic Plastic Surgery;
Australasian Academy of Facial Plastic Surgery;
Australasian College of Dermatologists;
Cosmetic Physicians Society of Australia; and
Sclerotherapy Society of Australia.

According to its website, fellows of the The Australasian College of Cosmetic Surgery must have three years basic surgery training and a further two years specific cosmetic surgery training. Doesn't sound so bad to me.
So to set the record straight, today 6minutes emailed the various Colleges requesting details about their training requirements.
We'll publish all responses.
And can we please put to rest the ridiculous claims that doctors working exclusively in cosmetic medicine or surgery can be 'general practitioners'? Whatever you might call them, general they ain't.

Lose-lose situation for GPs

2007-01-21T22:47:00.000-08:00

Every time I think I’ve got my head around the UK health system, yet another reincarnation emerges.
The most recent large-scale change was the introduction of new GP contracts in late 2004, aimed at propping up a GP workforce dwindling under the pressure of high workloads, 24 hour on-call duties and significantly poorer pay than their hospital colleagues.
Under the new contracts, around two-thirds of GP pay became linked to meeting ‘quality targets’, such as predetermined immunisation rates and optimal blood pressure management.
In this latter area alone, it was estimated GP care would save 8,700 patients from a stroke, heart failure, a heart attack or angina, according to a BBC report.
So you’d think the government would have been happy when instead of meeting 70% of targets, GPs reached 90%.
But dollars, rather than patient’s lives, seem to take priority for Health Secretary, Patricia Hewitt, who now says GP profits should have been capped.
With average GP pay reaching over £100,000, Ms Hewitt claims she didn’t realise GPs would “take” so much of the increased earnings as profit, but wanted them to plough it all back into practices.
In the words of GP blogger, Dr Rant, "Who does the Secretary of State for Health believe should be allowed to make 'a profit' from the NHS?
a) The private companies that are set to share a risk free bonanza of £23 billion for being awarded contracts through the private finance initiative.
b) The 'management consultants', many of whom work for your old company, who deliver nothing yet cost the NHS more in total than the medical consultants who deliver the actual 'service' bit (as in National Health Service).'
c) GPs who run their own businesses and manage 90% of day to day NHS activity, and who were were given a legally binding contract to deliver extra work for the benefit of NHS patients.
Deputy chairman of the BMA's GP committee also hits the nail on the head. "Is the Secretary of State saying she wishes GP practices had not performed so well on quality targets thereby improving the delivery of top quality care?", he asks.
"The government signed off the contract which ties income to quality performance. She should be proud of the achievements of general practice, not denigrating doctors for delivering quality patient care."
Will make interesting reading for those in this country pushing for more blended payments.

Drug info decades old

2007-01-16T14:57:00.000-08:00

If you’re like me you rarely look at a drug’s formal product information, or PI. For detailed drug queries my computer software fails to answer I turn to sources other than the PI, such as the Therapeutic Advice Information Service (TAIS).
Nonetheless, I would have expected Product Information, supplied by the manufacturer and approved by the Therapeutic Goods Administration (TGA), to be accurate and up-to-date.
Unfortunately, according to two articles in this week’s MJA such assumptions are misguided. While the accuracy of information provided by the drug’s sponsor company is likely at its zenith at the time of registration, it may soon be outdated and should have a compulsory use-by date, says Australian Prescriber editor, Dr John Dowden.
With the pressure to approve drugs quickly, sometimes after phase II trials, new information will probably emerge soon after marketing, he says, quoting a US review of over 500 new drugs that found over 10% were subsequently withdrawn or acquired a ‘blackbox’ warning.
And while out-of-date PIs may not directly individual clinicians, Product Information is often the source people turn to when seeking detailed drug information as well as setting boundaries for advertising, consumer information (CMI) and forming the basis of MIMS.
In Australia, it is the sponsor’s responsibility to update product information, a costly exercise which may not take top priority especially in the case of old, less profitable drugs, says Dr Dowden.
And although previously government-funded, the TGA now relies on income from fees and charges from industry, resulting in a ‘risk management approach’ to regulation, he says.
Supporting this view, a prominent endocrinologist in the same issue of the MJA says PIs on thyroid medication are frequently ‘inadequate, inaccurate or outdated”, such as advice that thyroxine should always be commenced at a low dose.
Some PIs are around than 20 years old, says Professor Jim Stockigt, of Melbourne’s Monash University, yet financial disincentives currently deter pharmaceutical companies from updating them.
Surely we can come up with a better system than this.

Club-based childcare on the nose

2007-01-14T20:02:00.000-08:00

My first day back today after Christmas holidays on the coast, a vastly more leisurely experience these days with teenagers than smaller children, even if they get a bit bolshie when asked to haul themselves out of bed before midday.
With five families however, eating out is not so easy and we were forced to hit the clubs to find an establishment able to cope with all 23 of us.
And while club food was predictably unremarkable, the extent of gaming facilities in ‘Clubland’ struck me as nothing short of scandalous – cavernous, dimly-lit rooms with row after row of poker machines clinking and blinking as bored-looking gamers pressed their buttons mechanically in the hope of a windfall.
Most shocking of all was the flyer at one club promoting “Kids Fun Days”, where kids are promised “Movie, Disco & Prizes to be won!” for just $6 a day including lunch and a drink.
There’s a catch however; parents must remain on club premises, and given the profitability of gambling, there’s little doubt where clubs are hoping parents will head. I guess it’s a step up from leaving kids in the car.
We’ll probably see more of this type of thing, especially in NSW, now that the NSW government is allowing clubs to open in shopping centres despite its previous and public apprehension about such a move.
Naively, the minister responsible for gaming, Grant McBride, says a requirement for clubs to have separate entrances than the shopping complexes will protect people for irresponsible gaming. Give me a break. For a UK doctor’s honest account of just how insidious gambling can be, see his blog .
So addictive is gambling for some people that they’ll lie, cheat and steal trying to win back their losses - I suspect they’ll manage the separate entrances.
Perhaps craziest of all is that under the new plan, gamblers will simply pop in to the adjacent mall’s ATM to get a cash advance on their credit card, presently not allowable at club ATMs.
Fortunately, gambling leaves me cold. Otherwise I’d be betting it’s the clubs who’ll be the winners in this move.

How green is my reformulation?

2006-12-13T14:20:00.000-08:00

Recently 6minutes reported that the December issue of Australian Prescriber had been delayed and might be pulped over legal concerns about an article on “evergreening” drug patents.
Evergreening is a drug company strategy which aims to extend patents on popular drugs usually by leaving the active chemical entity essentially intact and fiddling at its edges.
For example, the drug may be altered sufficiently to claim it’s a longer acting preparation, has a different salt or is a superior isomer; perindopril (Coversyl) is a well-publicised example.
Such practices are put under the spotlight in a new market analyst report about ‘reformulation’, which sounds awfully similar to ‘evergreening’.
Compiled by Datamonitor, which claims to be the world’s leading provider of online data and analysis, the report’s press release is titled: “Pharma turns to reformulation to maximize ROI”.
For the uninitiated, ROI stands for ‘return on investment’, and is for any profit-making company a core goal, doctors included.
In what’s hardly a new revelation, the report identifies shrinking drug pipelines as a major threat to pharma profits, in addition to the incursion by generics.
Hence, companies guard their remaining blockbusters zealously, seeking to maximise return on investment.
In an industry where abbreviations and jargon rule, “product lifecycle management (LCM) is an integral part of portfolio continuation and preservation”, the report says, with ‘reformulation’ a common technique to achieve this aim.
“From 2002-2005, 39% of the total product launches from the 50 top manufacturers were reformulations”, according to the report, which outlines four types of the method.
“Switch and grow” is an early to mid-stage strategy whereby patients are “switched from the old to a new and competitively differentiated formulation”, the report says, in turn providing a repositioning of the molecule in the marketplace and an opportunity to grow sales.
A related manoevre, “expand and grow”, apparently involves expanding the scope of the drug by gaining approval for extra indications and growing the market.
Further along in a drug’s life cycle, ‘generic defence’ reformulation becomes relevant, and can provide a chance to switch patients to a new formulation and thereby extend the patent.
Lastly, the “market grab” is a late strategy invoked after a patent’s expiry, where companies develop a reformulation or ‘supergeneric’ that can capture market share from a molecule’s original brand franchise and from other manufacturer’s, including generics”, the report says.
Pfizer’s recent experience with torcetrapib shows the extent of the losses companies face when a drug doesn’t meet expectations, so on one level none of the above should be surprising.
Senior pharmaceutical company executives are merely doing their jobs, trying to maximize ROI.
It just sounds a little crass spelt out so clearly, and when one thinks of how the money might otherwise be spent.

Should I have a mammogram, Doctor?

2006-12-07T02:31:00.000-08:00

I’ve always wished there was a simple, definitive answer when women in their forties ask if they should have a mammogram.
But as readers would know, there isn’t.
By my understanding, the closest thing to a correct answer has gone something like this:
“There’s evidence that regular mammography saves lives for women in their fifties and sixties, but we’re not so sure about women in their forties. There’s probably a small benefit, but you have to screen an awful lot of women in their forties to save a life, and on top of that mammography’s thought to cause some breast cancers”.
A study released in the Lancet today was designed specifically to answer this question.
The UK study randomly assigned nearly 170,000 women to an invitation to routine mammography starting at around age 40, or usual care.
After a follow-up of ten years, a small reduction in breast-cancer mortality was shown but failed to reach statistical significance. Over ten years, the absolute risk reduction for breast cancer mortality was 0.40 per 1000 women invited to screening, or in other words 2,512 women needed to be screened for 7 – 9 years to prevent one death over 10 years.
This is a difficult area to study for lots of reasons. For one thing, researchers can only invite women to be screened, not force them. Any study worth its salt will analyse its results on an ‘intention to treat’ basis, and so non-compliance underestimates the effect of mammography. Women in the control group who decide to have a mammogram also dilute the findings.
Furthermore, studies must be huge, and incredibly costly, to have the power to detect small differences. Many, including the Lancet study, fail to recruit the planned number of subjects, thereby reducing the power to detect real differences.
So where do we go from here?
An accompanying editorial says that after ten RCTs of nearly 400,000 women, the current estimate of a small reduction in breast cancer deaths for mammography in this age group is unlikely to change substantially.
Harm, however, must also be factored in, and in this case we’re mainly talking radiation-induced breast cancer, which won’t peak until 10 - 20 years after exposure.
“While the best estimates of harms from screening mammography seem to be less than the benefits, they remain too uncertain to conclude with a high level of confidence that screening mammography in this age-group is associated with a net benefit”, the editorial concludes.
Looks like I won’t be changing my answer any time soon.

Sex with former patients

2006-12-05T15:30:00.000-08:00

We’ve probably all heard the expression: “Once a patient, always a patient”.
I’m not sure who lays claim to the aphorism, but its sentiments clearly relate to the power imbalance of the doctor-patient relationship and the inherent inequality of future transactions, whether of a romantic, sexual or financial nature.
An editorial in this week’s BMJ raises the issue of doctors’ relationships with former patients, prompted by new UK guidelines. The author, a medical ethicist, says the new rules wisely avoid a blanket ban on such relationships, which may be ‘vulnerable to a human rights challenge’. Yet, as with the Australian medical board equivalents, the new rules are far from permissive.
For instance, the NSW medical board rightly bans outright relationships with current patients, but its advice on former patients is fuzzier, or in the words of the BMJ editorialist, “an interpretative nightmare”.
According to the board’s website, the “termination of the doctor/patient relationship prior to sexual activity may be raised as a defence”, but its strength will depend on the degree of dependence in the relationship, evidence of exploitation, services provided and the duration of the professional relationship. As well, the time lapsed since the end of the professional relationship would influence the judgement.
It’s not a new question, and as the BMJ author points out, it was in the fourth century BC that Hippocrates said: ‘Into whatever house I enter, I will go into them for the benefit of the sick and will abstain from mischief and corruption and from the seduction of females or males, of freemen or slaves”.
But is this ‘powerful doctor, vulnerable patient’ view out of date, or even paternalistic in these days of patient autonomy and partnership, the editorialist asks?
Not according to the NSW State Medical Board (and presumably other state boards), which says it ‘rejects the view that changing social standards require a less stringent approach’.
But you’ve got to hope logic, rather than dogma, will rule in appropriate circumstances. For instance, a one-off consult for an URTI shouldn’t forever preclude a subsequent relationship between patient and doctor.
If it does, we’re asking unmarried doctors in one-doctor rural towns to sign a vow of chastity, and workforce considerations aside, it just doesn't pass the commonsense test.

Who's afraid of change?

2006-11-28T14:43:00.000-08:00

The term most frequently uttered at this week's Australian General Practice Network conference had to be ‘change management’. In some sessions, barely a minute went by without the term working its way to the fore, especially in talks on why information technology has failed to deliver in the health sphere.
Perhaps I’m a tad defensive, but after a while it felt a bit like calls for ‘change management’ were code for ‘bringing those pesky, self-interested doctors into line’.
A presentation by UK IT chief, Richard Granger, was inspiring on one level; for details look at the Connecting for Health website. For instance, 98% of UK GPs are connected to the largest virtual private network in Europe, and all radiological images in two hospitals every week are being completely digitised, and therefore transmissible to other health providers at the touch of a key.
I wasn’t the only one in the audience who felt some speakers laid the blame for our poorly connected and incompatible system at GPs’ doors.
To quote one GP addressing an expert panel, which included a high-level federal government health advisor: ‘The problem’s not at our end, it’s at your end”.
Of course, it’s not about blame, and there’s no doubt a plethora of reasons we’re nowhere near as advanced as the UK.
But if I had to name one advance that would improve my ability to care for patients who have chronic and complex problems, it’s timely, legible, comprehensive discharge summaries. I simply want to know the results of all investigations performed and their interpretation by the treating specialist, the diagnosis, interventional treatments, what drugs were stopped and started and why.
I don’t have access to Health Connect, still being trialled in several locations, and perhaps this system will help solve this problem.
But by his own admission, even the talented and determined Mr Granger hasn’t managed to pull this one off in the UK.
So let’s stop blaming GPs. All those I know say if there’s a high-quality, connected information-sharing system that’s also secure, bring it on.

Personal or political or both?

2006-11-23T14:35:00.000-08:00

Whether doctors carry a social responsibility to address health-related matters beyond the care of their individual patients was the subject of an article in this week’s JAMA.
In particular, the authors investigated doctors’ attitudes to community participation, political involvement and advocacy through professional organisations.
Reading the article, I was reminded of my first, and inauspicious, foray into the community with my doctor’s hat on – a P & C meeting many years ago when my first child was in kindergarten.
Having volunteered as vice-president, my first objective was a healthy canteen, and somewhat nervously I addressed the meeting of strangers, giving them the usual spiel about obesity, diet etc.
Maybe it was because the woman who ran the canteen was morbidly obese, or because I was a brash newcomer threatening the shaky power structure of the organisation, but my speech was met with icy glares all round.
Only the school vice-principal spoke.
“Look love, brown bread’s just white bread with colouring in it anyway”, he told the meeting.
Needless to say, this wasn’t a battle easily won. Neither were my children always enamoured by my public health efforts – they never quite forgave me for the introduction of the broad-brimmed hat at their primary school, although I suspect they were secretly impressed when my dogged determination to get a road narrowed and pedestrian crossing installed near the school paid off.
Whether in small issues such as these, or on a larger stage, we doctors can make a difference.
Over 90% of doctors in the JAMA study agree, and support physician involvement in wider health–related issues, while a new UK GMC document says doctors should ‘protect and promote’ individual and public health.
We welcome your suggestions on how here.

Health check raises 'usual GP' question

2006-11-21T15:11:00.000-08:00

Recently a kind and patient person from my general practice division guided me through the murky and confusing waters of the simultaneously new, old and disappearing GP item numbers.
Apart from the countless nuts and bolts involved, a few issues deserve special mention.
Firstly, patients will rightly be the winners of the November 1 psychologists’ access to Medicare, but employee GPs registered with Better Outcomes and who took home their SIP payments will be among the losers.

Patients of this group of doctors - and I admit to a conflict of interest here, I’m one of them - already had free access to six to twelve psychologist sessions via ATAPS (Access to Allied Psychological Services) if a mental health assessment and plan had been completed. On top of the associated consultation fees, a $150 SIP was paid to the consulting doctor after the third visit under the scheme, which will wind up in April next year.
Overall, however, the move is a probably a good one for the mental health of the community. After all, why should access to a psychologist depend on how many hurdles your GP’s jumped?
Nonetheless, I was glad to learn that other SIPs, such as those for performing a pap smear for women not smeared for over four years, will remain in place, as I fail to see how an incentive payment can be an incentive for someone who doesn’t get the payment.
Equally interesting, or annoying depending on your point of view, is the arrangements surrounding the new 45- 49 health check.
A call to the hotline confirmed it’s a once in a lifetime check to be performed by your ‘usual GP”, defined as the GP you’ve seen most frequently over the previous two years.
But just as patients who pop into a medical centre with a sore toe on holidays end up unwitting recipients of care plans, now they’ll likely end up with the only rebatable health check of their lives by a doctor who’ll never see them again.
My question is this:
How is it that ACIR can identify ‘usual GPs’ when it comes to withdrawing PIP payments for practices who’ve slipped below an immunisation target, but when it comes to rewarding doctors for performing a preventative health check, it’s suddenly too hard?

The dollars and sense of self-care

2006-11-15T20:11:00.000-08:00

For some time, I’ve been grappling with the concept of ‘self-care’, a term slowly but surely creeping its way into the medical lexicon. This week the MJA fast-tracked an entire article on the topic, but I’m still not much the wiser.
Apparently ‘self-care’ is now one of four main approaches to chronic disease along with prevention, early detection and treatment, and integration and continuity of prevention and care. And government is behind the move to the tune of $515 million over five years starting this year, in addition to $36 million spent on something called the Australian Government Sharing Health Care Initiative.
The alleged theory behind self-care is that informed, empowered patients have a better quality of life, although the evidence appears weak. Of 15 meta-analyses listed in the MJA article, only six showed any effect, and an Expert Patients Program in the UK has also apparently enjoyed only limited success. Indeed much of the self-care literature appears to be devoted to investigating why the approach has failed in various environments.
Unfortunately, it seems GPs are largely carrying the can on this one – apparently they haven’t engaged sufficiently with the idea, nor endorsed it.
Most scary of all was the $250,000 allocated this financial year to an ‘education, training and support program targeted’ at GPs and others - I think I’ll take a rain check on attending this one.
No sensible or compassionate person would argue against informed, empowered patients, but they’re also convenient to governments because they’re cheaper than their less informed counterparts; a reduction in GP visits is a frequent outcome measure in the research literature.
I’ve even read of overseas proposals to ration health care to those who participate in self-care programs. Let’s hope there’s no such agenda here.

The Deregistration Board?

2006-11-12T15:07:00.000-08:00

Naming organisations can be tricky. Is it better for example, to call an organisation to tackle incontinence “The Incontinence Foundation”, or “The Continence Foundation” - the former reflecting an individual’s actual condition, the latter an aim, or desired outcome?

Cancer-associated organisations share this dilemma, and there’ve been both ‘Anti-Cancer’ councils and Cancer councils over the years.

In the same vein, a colleague wants to rename his state medical board – the organisation tasked with registering doctors for practice – the Deregistration Board after a recent encounter.

His problems began with advice from Medicare his patients were no longer eligible for rebates because he wasn’t registered as a medical practitioner. This came as a shock, but it turned out he hadn’t received, and therefore hadn’t paid, his last registration bill. Not currently in private practice, the rebate issue wasn’t a big deal, but indemnity certainly was.

A frantic call to the NSW medical board met with a stony, bureaucratic response. Yes, the bill had bounced, marked “Not at this address”, but rather than put in a call or two to track down my colleague – a specialist in a discipline of dire shortage – the board simply advised Medicare to stop his patient rebates. End of story.

At 3pm on a Friday afternoon with a weekend of rural hospital work ahead of him, my friend was keen to sort this out with a credit card over the phone, but again no luck. We only register people before 2pm, he was told. Ring back next week.

Noting that the top message on the home page of the New South Wales Medical Board says the board 'has a statutory responsibility to protect the health and safety of the people of NSW', my colleague wondered whether the medical board was more interested in deregistering doctors than registering them.

As well as protecting patients from dangerous doctors, wouldn’t it be in everyone’s interests – doctors and patients alike – to support safe doctors and make registration easier rather than harder?

Comment here.

To test, or not to test, doctors.

2006-11-07T02:45:00.000-08:00

If we're honest, most of us have at some stage of our careers known a doctor we'd prefer our family didn't see. Maybe it was the on-call surgeon on Friday nights in our intern year. Or the ageing neurology professor whose erratic behaviour attracted corridor whispers but strangely no complaints from his tertiary teaching hospital peers. Perhaps it was a general practice colleague who seemed too rushed to apply himself thoroughly to patients' presenting problems, preferring to fob patients off with a reassuring word.
The questions is, both here and internationally, how to make health care safer, and a recent report by the UK Chief Medical Officer, Sir Liam Donaldson, addressed this very question.
Revalidation, relicensure and recertification have become familiar words to UK doctors even predating the Shipman affair, and the CMO's report, although controversial in some repects, significantly advances the debate.
You can hear Sir Liam being grilled by UK doctors here, but the thrust of his argument is that underperforming doctors are inevitable and regular appraisal is needed in some form. Currently, a doctor is not assessed between the time of receiving their specialty qualification and retirement, whereas in the same time frame, an airline pilot would be assessed over 100 times, the report says.
So far, Australian doctors have had to jump hurdles, such as continuing medical education requirements and practice accreditation, but our clinical skills have escaped scrutiny.
I guess none of us enjoys being assessed, but on the other hand, the public surely deserve a guarantee of a safe and careful doctor, and some form of routine appraisal seems inevitable in the long run.
So long as those who don't quite make the grade receive remedial assistance rather than ridicule and blame, it's hard to run the line doctors should be allowed to practice for four or five decades with no checks in place.
Comment here.

Don't pass the buck Tony.

2006-10-31T01:56:00.000-08:00

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.

2006-10-24T16:16:00.000-07:00

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

2006-10-18T19:08:00.000-07:00

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

2006-10-17T16:45:00.000-07:00

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

2006-10-12T20:45:00.000-07:00

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

2006-10-10T17:26:00.000-07:00

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

2006-10-07T17:22:00.000-07:00

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.

2006-09-20T17:32:00.000-07:00

Karen, 25, had been on Yasmin for years without problems but now had three weeks of spotting. No missed pills, pregnancy test negative, seemed like just one of those things until she told me about her 'other doctor'.
It turned out her wa of the alternative ilk, and Karen had visited him for tiredness on the recommendation of her sister.
After a blood test, she was told her DHEA level were abnormnally low, "the level of an 80 year old", and advised to take DHEA to counteract the pill and boost her energy. At no time was it mentioned that DHEA was an androgen or that it could have side effects, although interestingly she complained of worsening acne.
She was also sold a multivitamin preparation, DHEA and three other vitamin/mineral combinations, and I'm sure they didnt come cheap.
Without knowing exactly whether DHEA was a likely cause of Karen's spotting, the sensible thing to do was to stop it and see what happened. A kindly endocrinologist agreed, observing that DHEA levels were useless and taking an androgen plus an anti-androgenic pill made little sense.

Is it just me?

2006-09-14T19:04:00.000-07:00

Article in the BMJ today re whether long or short needles are best for infant vaccinations, including at 2 months. Found that longer needles same for immunogenicity, and caused less local reactions at the 1, 2 and 3 day follow-up, but not at six hours. The needle calibre, previously thought to matter, didn't.
Now, I love evidence as much as the next GP, and am well aware that the recommendation is for longer needles, but admit to being slightly worried about these findings when confronted with some full-term 2 month old babies, you know the one's without much padding.
The technique referred to in the BMJ article is stretching the skin flat between thumb and forefinger, inserting needle at 90 degrees and pushing down into muscle.
Did the authors push down until they thought they had hit muscle? Or did they go all the way in until hub met skin? If the former, not very scientific, if the latter, in some full term but petite babies I see, I'd hit bone or end up in the biceps femoris.
The accompanying editorial notes that 'if the subcutaneous and muscle tissue are bunched to minimise the chance of striking bone, as some have recommended, then a 25 mm needle is required to ensure intramuscular administration in infants'.
Yet this is not the technique used in the study.
Furthermore, at six hours after vaccination, when the greatest number of local reactions were seen, there was no statistical difference between longer and shorter needles. This seems to be glossed over in the paper.
I havent had the pleasure of visiting Birmingham, maybe they make 'em bigger than in Sydney.
Or maybe it's just me?

Name and shame but dont give me excuses

2006-09-14T16:24:00.000-07:00

Fascinating cloak and dagger tale in the BMJ (link) recently told by researcher Iain Chalmers. Searching for studies in the late 80s to include in a systematic review about epidurals, Chalmers found a paper that was, for the large part, identical to an earlier paper by other authors, but not unacknowledged. Not just a few words here and there, but over half the text and some of the actual data was pinched.
Concerned by his findings, Chalmers contacting John Beazley, one of the paper's authors, who was even more concerned - he knew absolutely nothing about the paper he'd supposedly coauthored. Chalmers wrote to the remaining author and obvious culprit, Asim Kurjak, Professor of obstetrics at the University of Zagreb, as well as reporting the matter to the relevant bodies. Unfortunately, it was only the WHO that seemed to take action, with the university effectively sweeping the matter under the carpet, replying it would appreciate Chalmers's 'tactful handling of the case'. Chalmers now regrets acquiesing in this request.
To cut a long story short, Kurjak's paper was discovered to be an amalgam of two papers - he'd committed not just plagiarism, but scientific fraud. In addition, a book chapter he'd had published was lifted from someone else's PhD thesis.
As Chalmers puts it, universities, journals and professional associations 'need to expose very publicly those found guilty of this form of scientific misconduct'.
I'm not so sure though I agree with the thrust of an accompanying piece by psychology professor, Miquel Roig, who runs the line that teaching ethical writing would prevent much of the problem. Roig says writing can be an arduous task, and he's right, and yes universities should make sure their students know the rules.
But let the responsibility for this behaviour rest where it belongs.
When Professor Kurjak, and others of his ilk, decide to cobble together a publication with pinched data rather than do the hard yards, they know exactly what they're doing.

Is that a facial nerve palsy or are you just sad to see me?

2006-09-12T05:16:00.000-07:00

It's always satisfying when your memory kicks in when it's needed. Fortunately, this happened yesterday when I saw an elderly gentleman for the first time, carefully escorted into the consulting room by his wife.
While husband and wife agreed Mr A wasn't quite himself, more specific details were difficult to elicit. Eventually I gleaned that Mr A had prostate cancer with bony metastases, was considered stable by his specialist, but had been 'sleepy' for a few days. No vomiting, no headache. Strikingly, neither husband or wife mentioned the bleeding obvious, Mr A's facial assymetry.
My questions on this point revealed that Mr A didnt know what on earth I was talking about but that Mrs A had also noticed her husband's mouth had taken on a certain diagonal quality.
This is where the memory banks came in, for the immediate question was whether he had an upper or lower motor neurone lesion. Sure, it's medicine 101, but to be honest it had been a while since an instant verdict was needed on this one.
Fortunately, the bilateral upper motor neurone innervation of the upper face was still somewhere in my brain's deeper recesses, and the presence of a left sided pronator drift confirmed the probability of an intracerebral lesion, although on this one my memory perplexed me by suggesting prostate metastases rarely went to brain.
Interestingly but sadly, a head CT revealed multiple metastases, perhaps prostate but most likely melanoma. Unbenown to our practice, Mr A had had a melanoma removed decades before.
If you'd like a brush up on upper versus lower motor neurone lesions, go to
http://clinicalcases.blogspot.com/2004/09/stroke-or-bells-palsy-facial-droop.html

You're killing people, Mr Abbott

2006-09-11T00:14:00.000-07:00

A few decades ago, it became clear drink driving was costing lives, lots of lives, and predominantly taking its toll on our young. An education program telling drink-drivers they were silly, naughty and dangerous didn’t work, and hence the advent of random breath tests.
Predictably, RBT was at first unpopular in some circles, attracting criticism about nanny states and lost civil liberties. Now, however, it’s accepted as a necessary and successful public health measure. Who knows if you or I or one of our loved ones might be dead today if not for random breath testing?
The same goes for a myriad of other public health programs. Compulsory fitting and wearing of seat belts, compulsory bicycle and motor cycle helmets aim to save us from ourselves, as do divided roads, rest stops and registration checks on cars.
In the health sphere, think no-smoking areas and legislation forbidding the sale of tobacco products to under 18’s.
The big question on everyone’s lips right now, especially since last month’s Obesity conference (link) is why we don’t use a similar approach for obesity, an epidemic of gross proportions.
Sure, telling people they should exercise more and eat less is wise advice, but that doesn’t mean it works. In the words of two people who should know, the ‘decades-long reliance on health promotion and intense media coverage of obesity have had virtually no effect”. Writing in the MJA, Professor Paul Zimmet and UK Professor Philip James call for evidence-based approaches to the ‘unstoppable Australian obesity and diabetes juggernaut’ (link). And despite the mounting pressure for GPs to pack a brief intervention for just about every lifestyle illness into a 20 minute consultation, our effect on the weight of the nation has been negligible.
Thousands of people will die as a result of the Federal government’s preference for ideology over evidence on this issue, we just don’t know which ones. Tony Abbott may not find his stance so justifiable if the beneficiaries of government intervention were identifiable.
Given he’s shown no sign of yielding despite public pressure from countless Australian and international experts, perhaps the next step should be the creation of a cenotaph (link) in memory of those who’ve died from obesity and its complications, listing the names of the dead.
I wonder how long politicians would allow the toll to grow?

MJA 2006 Vol 185 Number 4

Doctors ain't doctors

2006-09-07T23:33:00.000-07:00

As a GP, I've generally got better things to do than worry about the plight of surgeons, although polishing the Merc must be kind of tough at times. But in recent weeks, I've found myself in sympathy with College of Surgeons president, Dr Russell Stitz, currently in a stoush with the ACCC over surgical trainee numbers.
It's all too easy for the ACCC to assume the worst of doctors; I guess surgeons, not exactly renowned for their compassion, are easy targets. But it seems a bit stiff to accuse the College of Surgeons of being so greedy it'd limit trainee places just to maintain surgeon's high incomes.
To be honest, I've no idea whether the claim has any truth, but it seems a bit simplistic.
Even the public know there's insufficient operations going on in our hospitals to meet patient demand - headline newspaper stories of long waiting lists, closed beds and nursing shortages are commonplace - let alone provide a flood of new trainees with enough cases to become adept in their art.

Like most people, if I'm going to have an operation, I'd like a surgeon who's got lots of procedures under their belt, not one who's been to the 'see one, do one, teach one' school of surgery.
It's convenient for state governments to deflect blame for long waiting lists onto surgeons, but most surgical training takes place in public hospitals run by the states, and for their part, surgeons complain that hospital bureaucrats constantly cancel or cut short their lists.
Meanwhile some universities, such as Melbourne University, have their eyes on the fries, perhaps in conjunction with state governments, and I'm sure the Feds are watching closely, as it will be their Medicare dollars paying for any increases in surgical procedures.
Maybe it's time the ACCC took off it's 'doctors are greedy bastards' glasses.
If you're running a burger bar, I guess it's pretty much about making money, and a rival shop opening across the road might well influence your customer service and prices.
But doctors arent burgers, and more competition doesn't always mean better quality. Sure, surgeons want to make a good living, but their claims that there's a finite number of training places to train surgeons well makes sense.
It's also hardly greedy to willingly train those who in a year or two will be your direct competitors, yet this is precisely what surgeons, and other doctors, are asked to do.

Plugging the hole

2006-09-05T16:44:00.000-07:00

The big issue in the dailies following Steve Irwin's death are now centred around whether the video of his very public death should be made public. Apparently Irwin, after being hit by the stingray in the chest, can be seen pulling the barb out of his chest before losing consciousness.
At the time of writing this, it is unclear whether the cause of death was the stingray's poison or cardiac tamponade, and this raises another issue.
If the latter, would he have been better of leaving the barb in place to plug the hole?
Anyone thoughts?

death of a doctor

2006-09-04T23:59:00.000-07:00

I didnt even know him, but I'd heard quite a bit about this GP who was helping keep my friend's depressed sister alive and out of harm's way. Many GPs had tried but failed to make a difference during her long battle, but this time something had clicked and a trusting therapeutic relationship had ensued.
Things were looking up despite the inevitable ups and downs. She'd moved out of home at aged 50 and even had a 'gentleman friend' as her mother called him.
That was the last thing I'd heard. Until yesterday, that is, when I asked my friend about her sister's progress.
She's still fine, said my friend, but did I tell you about the GP she liked so much?
Obviously she hadn't, and the news stopped me in my tracks - he'd taken his own life just a few months ago.
It's a sad but well-known fact that general practitioners have higher rates of suicide, substance abuse and marital problems than other members of the community.
But the tragic irony of this particular GP's death really brings these figures home.

Dental illness

2006-08-31T19:07:00.000-07:00

Was aware that bisphosphonates have been linked to 'jaw rot', or the potentially devastating osteonecrosis of the jaw, but hadn't truly appreciated the implications until Ruby, one of my favourite patients, had a disappointing visit to the dentist. Largely edentulous besides a small plate, Ruby's diet is restricted to mush and she'd been hoping the removal of her remaining teeth would allow her a full set of dentures and the ability to chew on a steak. To her distress, once the dentist noted she was on Fosamax, he pulled the plug on any extractions. No discussion was entered into, and what's more, it seems the effect on bone is longlasting, so going off the drug is no help.

Apparently, the risk if far greater with IV therapy, but has been reported with oral treatment, and although rare, there's no predicting which patient's going to be the unlucky one.

According to dentist Peter Foltyn, from Sydney's St Vincent's Hospital, osteonecrosis of the jaw (ONJ) is probably associated with the failure of the extraction socket to heal properly due to a combination of invasion of oral microorganisms and the bone compromise. It is also thought that for some patients it may actually be symptoms related to ONJ, such as tooth pain or tooth mobility, which lead the patient to seek dental care. And while there are common sense measures to limit infection, such as antibacterial mouthwashes, there's no management strategy proved successful so far. Dr Foltyn has put together a useful patient handout on this very issue which he will email to you on request (pfoltyn@stvincents.com.au).

While the absolute risk is small to each individual, given 280,000 Australians take the drugs, it could become a significant problem.

On the other hand, I wonder whether some dentists are taking the easy way out, refusing to perform extractions for all patients on bisphosphonates to avoid legal action.

There's no doubt Ruby needs a bisphosphonate, but I felt bad I hadn't warned her of the consequences when she started the drug. The way she sees it, and I dont blame her, is that by starting her on Fosamax, I've quashed her chances of ever having a decent meal.

Rang my Mum, who's also on a bisphosphonate, and her doctor hadnt warned her either. suspect few of us routinely do so.
Not sure now what exactly to tell osteoporotic patients, or whether I should reconsider my therapeutic options for osteoporosis in future.

Or should Ruby just shop around till she finds a dentist willing to let her make an informed decision?

Not my emergency room

2006-08-31T05:26:00.000-07:00

A busy Saturday morning and I'm the only doctor on duty in my urban practice. My next patient, an elderly woman slowly making her way from the waiting room, has a black eye to rival an opponent of Kostya Tszyu. But she's not concerned about the eye, it's her tongue that's the problem - she bit it last night. On examination, a jelly-like mass where her tongue should be strenthens my suspicion that she's overanticoagulated, and blood oozes down her chin as she tells her story. Pretty switched on despite her four score plus years, she's already had an INR the previous day, which was 3.0, not near as high as I'd expected. I still consider giving vitamin K until I note the plethora of conditions for which she needs to be fully anticoagulated and think again. In all truthfulness, this woman will do better with tertiary level care, located just 5 minutes down the road.
But although my patient and her husband are less than unenthusiastic about a trip to the ED, history tells me that the greatest hurdle to a smooth admission will be a bolshie admitting officer. An INR of 3.0 is pretty unimpressive.
Not that I've ever let such a doctor dissuade me from a well-considered clinical course, but I do resent the tone with which some hospital doctors address their general practice colleagues in general, or me in particular.
Seemingly, the starting point of this species is that GPs are idiots and that our patients shouldn't clutter their emergency department. Even when convinced the patient does deserve admission, they often have one more trick up their sleeve. "Where do they live?" they ask, hoping to be able to play the 'out of area' card.
This time, in an effort to not get annoyed, I try a new tack. Rather than presume to send a patient to their personal emergency department, I'll ask their advice about how I can manage the patient myself.
As expected, and realistically, the ED doctor had no faith that I, a GP, could handle a bleeding woman with a list of conditions including chronic renal failure. "You'd better send her in", he said. A win for reverse pschology.
Sadly, my victory was shortlived, when I had a brush with the other end of the hospital system.
My patient died four days after admission. I have no idea of the cause of her death, and I'll get zip info from the hospital.
And I'm all out of ideas to remedy this recurrent problem.

2006-08-27T02:43:00.000-07:00

If there's one issue the lay media has to get its collective head around, it's that by not making a definitive diagnosis, a doctor hasn't made a 'misdiagnosis'.
Generally, the former will result in a vigilant parent and doctor, whereas the latter will more likely prompt inappropriate monitoring and treatment.
Take for instance the Sydney girl pictured on page 13 of this week's Sun Herald with the caption, "Close call: Brittany Pine, 7, with her mother Kristy, is lucky to be alive after her GP misdiagnosed her symptoms".
At a glance, you'd think the GP endangered this young girl's life. But closer scrutiny reveals that although Brittany's GP entertained the subsequently incorrect diagnosis of measles, they had a sufficiently open mind to send her directly to the ED. In short, they recognised a sick girl when they saw one and managed her totally appropriately. In all likelihood, they saved her life.
This knee-jerk 'blame the doctor' type story doesn't do the public any favours, and ironically increases the likelihood that serious acute illness will be missed. By promoting the idea that parents need only see a doctor to ensure the safety of a sick child, is a dangerous message.
Sick kids can deteriorate quickly, and regardless of a doctor's skills, a one-off visit gives merely a snapshot of the course of an illness. Sometimes that consultation is just too early, and the possible diagnoses extensive.
The best way to keep kids safe is to empower and educate parents to monitor their children rather than rely on a one-off doctor's appointment.
Unfortunately captions like this one send precisely the opposite message.

Transparent PBAC decisions unclear

2006-08-21T05:47:00.000-07:00

It seems I was naive in expecting last year's changes to the reporting of PBS decisions to make for enlightening reading. Although pharma companies were antsy about the rationale behind PBS decisons going public (playing their usual get-out-of-jail free card, "commercial in confidence"), lucid and compelling arguments to the contrary won out (link Aust Prescriber, Ausdoc). While not really expecting the whole story, especially behind a negative decision, I certainly expected more transparency than has been forthcoming.
For instance, when new patent-protecting versions of Coversyl and Coversyl Plus were approved (link to 2 articles on this topic), I expected the public summary on the PBAC website to justify its position. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pbacrec-pbacrecmar06-positive#peri
But alas, it was merely stated - in the minor submission category - that: 'The PBAC had no objection to the Secretariat listing of the change of perindopril salt from erbumine to arginine.The PBAC noted the sponsor’s advice that it will be implementing a communication strategy to inform prescribers of the change.'
The explanation of the approval of a bisphosphonate/vitamin D combination, Fosamax Plus, was no more revealing. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pbacrec-pbacrecmar06-positive#alen
On the one hand, the PBAC notes that 'alendronate plus vitamin D provides access to a combination product for patients with established osteoporosis who may require vitamin D supplementation'. and while the taxpayer will pay no more for the new formulation than the garden variety of Fosamax, notably the submission to the PBAC didn't claim greater efficacy in fracture prevention either.
Furthermore, patients without a vitamin D deficiency don't need vitamin D supplementation, and the 400IU per day in Fosamax Plus is inadequate for those with a vitamin D deficiency, so the patient group who will benefit from the new formulation remains elusive. Apparently, the PBAC was concerned (Radar link) that the product might be inappropriately used to treat vitamin D deficiency, which prompts the question - why did they approve it?

dont worry Hendo

2006-08-14T20:18:00.000-07:00

After a bombardment of emails about the new GPTV from the boys at Genesis Ed, and eventually sorting out the software, I had a good look yesterday. Hate to be one to throw stones at a competitor, and such a nice guy as Dr Michael Johnston, but rivetting stuff it ain't, except perhaps for the GPTV survey of how often GPs want to be updated with news. The very serious Dr Johnson tells us a 'staggering 52% of GPs want their news three times a week'. No details about the number of respondents to the survey, nor acknowledgement that an online survey might just skew the sample a little, but it's bad news for the weeklies, Medical Observer and Australian Doctor, according to Dr Johnson, who interestingly had nothing but a copy of AusDoc on his desk in the previous segment.
If GPs really want 'news' so often, I guess it's all good news for 6 minutes, but I actually dont believe it.
Perhaps we can do our own less than credible survey of 6 minute readers. What is it that GPs want so often that they're not getting elsewhere?
If it's news, why not read the papers? And do you really need to find out about the latest randomised controlled trial on clopidogrel before lunch?
Let us know and we'll try to oblige.

3 rumours about MD3

2006-08-14T19:55:00.000-07:00

Heard a few interesting things about MD3.
If my informant, admittedly far from a technogeek, is correct, the new version throws up ads that stay onscreen until the GP hits the 'go away button'. There's no suggestion, as yet, that the ads are in any way tied to the patient's history or script writing, although reader's comments would be welcome.
From what I hear though, mightn't be too much of a problem n the future, with some of the big advertisers having already stopped advertising on MD, presumably due to price considerations.
And, it could be a coincidence, but an important state based ehealth pilot trial is finding that all of a sudden, GPs involved in the project are converting to MD3. A targeted sales push perhaps? Trouble is MD3 is incompatible with the software used in the project. You've got to think changes could be incorporated into MD3, but sounds like the clever Dr Bateman might just have the relevant health department over a barrel. Chances are, he's not going to do it cheap.

Trust me, I'm a dog owner

2006-08-13T02:05:00.000-07:00

Another week, another dog attack. This time a 9 year old Melbourne boy has undergone facial surgery, and no doubt been scarred for life, after a mauling by a Staffordshire terrier cross labrador. While still outraged, I'm no longer surprised when I read of viscious dog attacks. Are they just reported more lately or are they on the increase?
Anyway, what doesn't surprise me is the response of the owner, quoted as saying the dog's actions were out of character.
If there's one thing I dont expect to hear from the owner of a dog that's just chewed someone's face off, it's this:
"I'm not at all surprised Rex went bezerk. He's a nasty bastard. Why just last week he bit three or four children."

Meanwhile, contrary to my children's belief, it turns out I'm not the world's most extreme food Nazi after all. According to the Sun Herald (link), preschool teachers are now performing random tests on lunch boxes, and sending anything deemed unhealthy home in the lunch box.
It's not clear what the guidelines are, or whether indeed there are any, but cakes, roll-ups, chocolate frogs and lollies are definitely out.
While cross my teenage son's state school still has a Coke machine, telling kids they cant eat the lunch their parents packed for them seems rather a blunt way to deliver parents a message.

is it only specialists who get the pens that work?

2006-08-10T00:45:00.000-07:00

OK, I'm outing myself. There's a skeleton in my closet desperate to escape, so here goes.

In 1996, or thereabouts, but before my days at Australian Doctor, I went to the races. Not just any races, but Randwick Races, sitting in a box and with a free lunch. I got to take my non-doctor husband too. No education, no experts, just a couple of GPs and partners, and a few bottles of wine.

Oh, yes, and a few drug reps. In fact, the event was the most exciting drug company junket I recall attending as a GP.

As a mother of two small children who didnt get out much except to work, and had rarely been to the races, I spruced myself up, dropped the kids at my Mum's, and popped off to Randwick, parking of course in a VIP spot paid for by the company.

Unfortunately, even armed with tips from my patients with gambling problems, I came out behind financially, but who cares?

I can't remember the name of the drug being flogged but it was a non-steroidal. And I have no evidence either way as to the outing's influence on my prescribing habits, but suspect it probably did have one. I'm one of those people brought up to return a favour.

Of course, these days are now gone, and today's junkets, at least for GPs, have to be educational, and not of the 'who won the fifth at Randwick?" or "what wine goes best with the rare duck in pomegranite sauce' variety.

The issue of drug companies 'entertaining' doctors has been splashed around in the lay media a lot lately, with 'investigative' journalists working themselves into a lather about oncologists having a night out on Roche at Guillaume at the Bennelong in Sydney. smh, age url

Dont know what the educational component of this posh do was, but since then there's barely been a day without another 'expose' in the media.

In their defence, many doctors argue that entertaining clients is just standard business practice, and they're right. In most industries, wooing clients with a night out at the theatre, or opera, or Guillaume wouldnt turn a hair.

What I'm not so sure about is whether, in the case of drug companies and doctors, the practice itself is right.

I'm not talking pads and pens here or even cheap torches, paper clip holders or biscuit tins. In fact, given the deteriorating quality of drug company pens, if anything, they influence my prescribing in the unintended direction. But more substantial gifts, such as weekends away, are a different matter. As a part-time GP, I'm never offered gifts of this calibre, but am told they still go on, especially for specialists, and especially the group the industry dubs KOLs, or key opinion leaders. (The rationale here, put simply, is that the views of these doctors at the top of the food chain eventually filters down to us bottom feeders)

But when I'm a patient, I want my doctor to decide my treatment on the basis of what they think is the very best for me, not who took them to Tahiti. Whether it's conscious or unconscious influence isnt the point.

Anyway, most specialists I know earn quite enough to buy their own dinner at an establishment of any calibre.

2006-08-10T00:27:00.000-07:00

You're on your death bed on dialysis and hooked up to the machine that goes beep. No longer blessed with the power of thought, let alone speech. You've made it clear to your family in more lucid times that you dont want your life prolonged in such circumstances, and they gather around to say their teary eyed farewells before the switch is flicked.
But wait, here comes your business partner at the eleventh hour. Seems like you're worth more to him alive than dead, so he calls a halt to the proceedings. The matter goes to the state guardianship board, which rules the machine stays on. Other parties only have the right to approve initiating a life-extending intervention, such as dialysis, they cant authorise its turning off.
Hard to believe, but something very like this just happened in NSW.
Unfortunately, living wills wont necessarily fix the problem either.
Read the judgement at ......

urban myth or heartbreak hotel?

2006-08-05T23:29:00.000-07:00

Ok, this is totally non-medical but it is the weekend, and this is important stuff. I have it on good authority (pop culture junky and guru who lives across the road) that Elvis was a natural blonde. A quick flick on google at least repeats the claim, albeit on a website called suicidegirls, saying that Elvis dyed his sandy blonde hair black.
Any further light on the hue of Elvis's locks would be appreciated.

Medicare Australia stuff-up

2006-08-03T21:24:00.000-07:00

I'm beginning to wonder how many staff Medicare Australia (formerly the HIC) actually employ. In the midst of the "it takes 3 weeks to provide you with computer prescription forms" debacle, now there's 1200 unprocessed applications for provider numbers, leaving some GPs who've moved locations unable to see patients. How would the bureaucrats like to go without pay for 3 weeks? Great timing too for patients in the middle of cold and flu season.
In its defence, Medicare Australia says it's "under-resourced".
Hey, I've got an idea. Hire someone.

patent protection

2006-08-03T07:37:00.000-07:00

Saw the Coversyl rep yesterday and heard the spiel re the new formulations. Hard to know whether she believed her own spin on the reason for the change, to extend shelf life. Have never heard of a shelf life problem but have indeed heard of patent protection - change of formulation, clinically irrelevant change in chemical strutcture, new indication .... the list goes on.
May sometimes have a positive result if a company puts cash back into R and D, but wish the companies would let their reps be honest. It's hard to communicate effectively with someone when you both know they're telling porkies.

2006-08-02T19:06:00.000-07:00

Back to the future.
Writing scripts now by hand after stuff up in our practice meant we ran out of computer scripts, and Medicare Australia says two to three weeks for delivery.
Wonder why it's OK for government to be so inefficient.
According to GP chat line, we're not alone, meanwhile am seeing if I can get away with printing on blank A4 paper, no bounces so far.
Does anyone know if there are any problems for patients with doing this for PBS drugs, especially if concession holders? Authority script has a script number, private scripts obviously OK, but will the patient still be eligible for a benefit if there's no script number?

2006-08-02T06:46:00.000-07:00

Was fascinated to read of the Australian doctor who diagnosed what was presumably a thyroid mass in a Big Brother contestant.
Predictable jokes about university graduates watching Big Brother aside, this he or she may have just saved a life.
Would love to know their identity and subspecialty.
Meanwhile, received my Medical Observer yesterday and was struck by its cover sheet featuring a computer screen with a certain company's professional development program. Only problem is, clicking through to the publication's CPD program reveals the old "this site is under construction' message. Why would a newspaper heavily promote something that doesnt exist? Mmmm.

if i wanted to eat with kids at a restaurant i'd bring my own

2006-08-01T04:41:00.000-07:00

Saturday night at the local Italian. Husband, teenage children and I gathered for quiet 'quality time' dinner for daughter's 15th birthday. No family fights so far and things are looking good. Busy waitress even smiles indulgently when asked by 15 year old to list the manufacturers of all non-alcoholic drinks on the menu - just so she can avoid anything made by the Coca Cola company.
Just into meal and a bit of bonding when two toddlers at a nearby table decide the restaurant has the makings of an athletics track - up and down the restaurant they run, stopping at our table at each lap for a victory screech. Or three.
Oblivious, or pretending to be, the parents chat merrily to their table companions, a young slightly horrified childless couple. Once or twice, Dad makes a half hearted effort to control his offspring, who by now are positively screaming their way between and under the tables.
I tried to curb my rising temper, reminding myself of a radio program I'd heard not long before by an ex-children's magistrate preaching tolerance of children. You know, 'it takes a village to raise a child" yadda yadda.
Echoing the current consensus on prevention, the magistrate stressed the importance of intervening with disadvantaged families before the kids turned three. Much youth crime and distress had its origins in the 0 - 3 age group, and the impact of helping parents at this stage couldnt be overestimated, she said.
"Children are the responsibility of the entire community", the magistrate argued, and she sure had the runs on the board to comment after 12 years on the bench.
Since I'd heard the talk I'd been somewhat inspired, and uncharacteristically offered to help young mothers on trains, buses, in shopping malls, and smiled supportively when 2 year old Michelin men struggled to escape their stoller in the supermarket queue. No more judgemental glances, just a friendly, "I know how hard it is, I've been there too" kind of expression.
But my generosity failed me Saturday night.
This wasnt a disadvantaged couple doing it tough in any sense of the word. Laughing, well-heeled, North Shore thirty-somethings using pasta as baby-sitter. It's not the kids' fault, they were just being kids - noisy and boistrous - and having a ball.
Sadly, they and their family were the only ones.