Reviewing a Doctor's Performance Every Five Years

In the news recently an article caught my eye on the subject of appraisals for doctors in the UK every five years. The health secretary, Jeremy Hunt, says that the system hopes to address gaps in the care that doctors give their patients. If a doctor does not pass their appraisal, they would be prevented from practising until the issue is rectified. The change in the system has come as a result of years of discussion centered around maintaining high quality care given to patients, and making sure doctors perform consistently informed, compassionate and intelligent care. The secretary was keen to emphasise that the evaluation of doctors would be a process, and procedures would be put in place to rectify any deficiencies in care and address them early on.
The disadvantages put forward by this article and another (both links are below) are that there is already too much bureaucracy in the NHS and there are concerns that this system may just add to the piles of paperwork that already exist unnecessarily. However, there are also clear advantages to the new system, mainly that this focuses on a preventative measure and does not need a mistake before an investigation takes place, which is better for patients in a doctor's care. Overall, the system itself will be reviewed with time, and as Sir Bruce Keogh, medical director of the NHS put it, "Implementation will be quite difficult to begin with and I suspect it will be imperfect but it is better to start than to wait for perfection."


Article on BBC News: here
Article on The Telegraph: here
To find out more about the revalidation system: here
Image taken from: here

Thank you for reading!

Orthopaedic Surgery: My First Experience

When the work experience coordinator said that I would be "in theatres" at a number of points during my week's work experience at the R.N.O.H, I was very excited indeed, but also nervous, as I had never watched surgery take place before.

Theatre implies a show, and what a show there was. The first drama was the very sight of the patient. When I walked in, all scrubbed up, the patient was asleep with general anesthetic and covered up with sterile blue sheets. He was entirely covered from view except for his left leg, which was being coated in yellow plastic, (I later learned from a nurse that this was to minimise skin shedding of the patient, that may get into the wound). Then came the first incision. It felt like my legs had gone from underneath me. The sheer shock of a person being cut up in front of me, albeit anesthetised, is a momentous one. Furthermore, as you look at the patient, in this case a small boy, you can't help but plead in your head that they'll leave him intact.

However, after the initial shock of the mechanics of the procedure, I soon calmed down. Even now, my first observations seem incredibly naive, in hindsight that is, but I've included them here for perspective. I was comforted by the conversations I had with the lovely anesthetists during the rest of the surgery. Having someone there to explain what is happening is immensely reassuring, and takes the nightmarish qualities out of the experience.

Likewise, seeing the measured cooperation and calmness of the team around me filled me with an equivalent composure, and I began to appreciate the complex surgery that was being undertaken in front of my eyes. Indeed the rest of the week followed and I saw a dozen surgeries, I am hugely grateful for the experience and became so accustomed to the blood and gore of that week that I am slightly concerned for my mental wellbeing as I doubt it is normal for a human being to be unperturbed by an entirely open leg, arm or hip of their fellow man. 

Regardless, I enjoyed the fascinating experience, and my first exposure to surgery.

Image source: http://ossmig.orthop.washington.edu/Portals/1/OR1.jpg

Out of Sight, Out of Mind: New Smoking Display Ban

Figure 6.1: Smoking Prevalence and Lung Cancer Incidence, by Sex, Great Britain, 1948-2010

Today on BBC News I read an article about how cigarette displays are to be moved and placed below counters in large shops and supermarkets. The move will happen in England this year, cigarette displays will be banned in shops that are over 280 square metres, with the ban extending to smaller outlets in 2015.

The thinking behind the move is that by not having the cigarettes readily visible to the public, particularly young people under 18, it will discourage potential young smokers from taking up the unbelievably unhealthy habit. Furthermore, it is hoped that the ban will help those smokers who are trying to quit by removing the temptation from weekly shopping trips. Harrowing figures from the website say that a fifth of adults in the UK smoke - a figure which has remained steady in recent years after decades of rapid falls. At the beginning of this post I included a graph from the Cancer Research UK website showing the smoking prevalence trends in Great Britain by sex, from which we can see that while the number of adult smokers had rapidly declined since around 1974, the rate of this decline has slowed in recent years. Of course, this graph only shows adult smokers, and does not take into account the number of young people who take up smoking every year.

From the Cancer Research UK website, we can learn the following about child smokers:


"It is illegal to sell any tobacco product to under 18s in the UK. However, while less than 1% of 11 and 12-year old children smoke, by the age of 15 years, 12% of children in England report being regular smokers (usually smoke at least one cigarette per week). (23) According to these figures, the Department of Health has met its 2011 target of reducing smoking among 15-year-olds in England to 12% .(52) However, there is evidence that actual smoking rates among 15-year olds may be higher than reported, based on measurements of cotinine in saliva, with 21% of 15-year old boys and 19% of 15-year old girls having cotinine levels indicative of active smoking. (24) "

If you're interested, the titles of papers they used to obtain the figures are linked to the numbers in parentheses in the above paragraph.

In 2008, marketing professors Janet Hoek, Phillip Gendall and Jordan Louviere presented research at the Australia and New Zealand Marketing Academy Conference that found:

“tobacco brand imagery functions via respondent conditioning, where brand names, colours and other imagery become paired with psychological and emotional attributes. These peripheral cues act as heuristics (definition here) that do not require systematic processing, but are implicitly relied on by smokers to move from their actual self to their desired self.”

In a nutshell, Jean King, of charity Cancer Research UK, said the ban would help stop children who are attracted to brightly coloured tobacco packaging from taking up smoking but further action was still needed."Of course we want to see the pack branding taken away as well. This is not a normal consumer product, it kills people. We want to protect the next generation of children," she said.

However, while I have presented views that support the ban, there is controversy surrounding the murky waters of suggestive advertising, and there are opinions to the contrary. For example, Andrew Opie, from the British Retail Consortium, said it was wrong to believe the legislation would have a major effect on young people and it was supermarkets and other shops which were bearing the brunt of the costs needed to comply with the ban. He said: "Children are more likely to smoke when they're in a household where parents smoke and also they tend to get their cigarettes from either parents, or older peers, not directly from supermarkets."

My own view is that while it is people's own choice to begin smoking, any move from the government that discourages the habit, or even makes it less obvious on an everyday level, should be wholeheartedly supported. It is also my view that to some extent the tobacco companies actively target the young, which I do not agree with on a moral level. I believe we need to do whatever we can to protect vulnerable and impressionable young people from the marketing and peer-induced "glamour" or "normality" of starting smoking, to prevent the tragic health problems that it brings.

As you can tell, the news article prompted me to do some of my own research into the area; I will be interested to see if the move has an impact upon people on a personal level, and prospective trends to come.

Thank you for reading!

References:

http://info.cancerresearchuk.org/cancerstats/types/lung/smoking/lung-cancer-and-smoking-statistics
http://www.bbc.co.uk/news/health-17626133
http://theconversation.edu.au/plain-cigarette-packaging-will-change-smoking-slowly-737

Can a Daily Dose of Aspirin Reduce Cancer Risk?

Skeletal Structure of Aspirin, featuring skeletal representations of the benzene ring, double bonds and OH group.

Today the front page of the BBC News' Health section proclaimed that "Daily dose of aspirin can prevent or even treat cancer". Along with many others I'm sure, I excitedly began reading the article, as surely anything even suggesting a "cure" for cancer is very engrossing news indeed, even in early research stages. I recommend reading the article in full, and if you're interested take a look over the three new research papers published by the medical journal The Lancet. Aspirin (acetylsalicylic acid) has been used for many years as a painkiller. It can be antipyretic (reduces fever), anti-inflammatory (reduces inflammation) and analgesic (relieves pain). However leading the headline of the BBC article is, it does not hide the harmful side effects (which you can see in full here) of taking aspirin on a regular basis, which include internal bleeding.

It seems that the crucial advice one can take from this news is that whoever is thinking of taking a daily aspirin should talk it over with their GP due to the risk of the side effects. Likewise, critics of the study have pointed out that some of the doses given in the study were much higher than the 75mg dose typically given in the UK. Also, some very large US studies looking at aspirin use were not included in the analysis. The researchers acknowledge both of these points in their published papers.

While I too am excited by the prospect of the new evidence and more studies to follow, I hope that the article on the front page of the BBC News Health section does not prompt anyone to rush out to buy and self-administer daily aspirin without first consulting their GP and talking it over with the health professional who knows them best.

Thank you for reading!

Do not resus?

My view on an article published in the Student BMJ

"Making Decisions about your Death"

Should a doctor presented with a 22 year old unconscious woman with a tattoo that reads 'Do not resuscitate' heed the order that has been inked onto her skin?
On some level, I believe they should not help the patient, it says clearly on her body that she had made this decision about the way she wanted to die, and cared so much that it be followed she had it tattooed onto her skin in case this circumstance arose.
However, a much stronger part of me argues that as a physician one simply cannot take the risk of letting a patient die if that is not exactly what they wanted in such a life-threatening situation. What they may have wanted when planning a tattoo may not cohere with their wishes in the emergency room.
Would the situation be different if the woman was 92 rather than 22? Maybe. From a legal perspective, the three letter phrase is not binding, as the article points out. Considering the situation rationally, in my opinion there is only one course of action that can be taken: to give the patient the best chance at life that a doctor could provide, and the strongest incentive for this argument is beyond the legal and social expectations, it is simply that the risk of letting a patient die who had wanted to live is far too grave a risk.

If you're interested you can read the full article in the Student British Medical Journal
2012;20;e658 Or read it here.

Thank you for reading.