More to health than hospitals, Mr Rudd

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

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

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?

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

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

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

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.