Saturday, 12 November 2011

Score one for Sertraline

On the basis of some accumulating evidence of dose dependent QT prolongation with citalopram the manufacturer Lundbeck has issued new guidance on its use. The long and the short of it is that they advise the maximum dose is now 40mg (20mg in the elderly), that it shouldn't be used concomitantly with drugs that also prolong the QT interval (e.g. methadone, tricyclic antidepressants, amiodarone and sotalol), and that it should only be used with caution in those at risk of Torsade de Pointes (CCF, recent MI, bradyarrhythmias, predisposition to hypokalaemia or hpomagnesaemia, including due to medication). This risk also likely applies to escitalopram.

Citalopram is probably the first-line antidepressant in medical practice, partly due to the lower rates of interactions, but give recent evidence that sertraline is more effective, at least compared with straight citalopram (rather than escitalopram), I think sertraline is going to become the go to SSRI of choice now, particularly in the elderly (the maximum dose of 20mg is also the minimum therapeutic dose - so not much scope for increasing it).

Friday, 4 November 2011

Yet more tales of woe from the medical Gestapo

Another affair where the GMC demonstrates how it pisses away the hundreds of pounds in fees paid by doctors to hound those self-same doctors for minor mistakes (highlights below, my emphasis in bold):
The appellant...submitted an application on 8th December 2005 for the post of specialist registrar in plastic surgery in the Oxford and Wessex Deanery. Candidates were required to complete an application form in full.

On 17th May 2011 the panel found that the application form submitted in December 2005 contained seven inaccurate statements which were both dishonest and misleading; that her fitness to practise was therefore impaired; and that she should be suspended from practice for 12 months. She appeals against those findings and the sanction.

Section 6 of the application form required the candidate to list her postgraduate medical qualifications. One of the bullet points states "if you are in the process of working towards a higher degree please say so, indicating expected completion date". [She]..."MD; Leeds University Medical School, UK, Thesis and Viva"; and then, in the final column, which is headed "date passed":
Completion January 2006"
 the panel's finding was as follows:
"...The truth was that far from a VIVA being awaited, your thesis had not even been completed. To imply that is was, applying the test in Ghosh, the Panel is satisfied was dishonest. In reaching its decision the Panel took account of the seriousness of the allegation and your good character. The Panel did not accept your evidence that it could have been worded better. The Panel was satisfied that it was worded in such a way to convey to the reader that your VIVA was expected and by inference your thesis completed and submitted"
Section 7 of the form required the candidate to state what relevant medical or professional courses other than those leading to a post graduate degree or qualification she had attended. [She] listed seven of these. The first was ATLS (advanced trauma life support), which she stated had been attained at the Mayday Hospital, Croydon. Under the heading "date certificate attained" she wrote "2001 C [ie completed] (recertification booked)".

...had in fact successfully completed a 3 day ATLS course at the Mayday Hospital from 13-15 September 2000. The certificate states that it expires on 15 September 2004, that is to say on the fourth anniversary of the last day of the course.

The panel found:
    "...The Panel is satisfied that it was untrue to say that you completed your ATLS course in 2001. In the context of an important job application, truthfulness is expected. You knew this to be untrue. The Panel did not accept your evidence that this was a mistake. This was a certificate relevant to the application. Your application form implied that it was current when it was not. Applying the test in Ghosh, the Panel is satisfied that this was dishonest."
The last entry stated that from August 2004 to December 2005, a period of 17 months, she had worked at Pinderfields Hospital, Wakefield in the speciality of plastic, reconstructive, hand and burns surgery as a "Research Registrar" funded by Action on Plastic Surgery....Section 9 is a single line reading "time in full-time research" and seeking an answer in years and months. The answer [she] gave was 1 year, 5 months. Section 11 asks about "time in plastic surgery (do not include research)". [She] answered that she had spent 24 months as an SHO and 17 months as a registrar. In oral evidence (Day 8, page 378) she said that during this period she spent 50 hours per week on research and her clinical hours were between 40 and 90 per week.

The panel found:
    "...The Panel determined that it was not true that you spent 17 months in a full time research post and spent 17 months in a full time clinical post. That is what your application form conveys to the reader. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh, the Panel is satisfied that this was dishonest."
Paragraph 3(g) of the list of allegations made by the GMC against [her] referred to a statement in the application form "that, during your research project, you had (1) produced 11 publications, (2) produced 21 national and international presentations". This was alleged to be dishonest and misleading. The findings of the panel were as follows [emphasis added]:
    "The period of your research was from August 2004 to December 2005. There were fewer than 11 publications related to your research within that time frame...There were fewer than 21 national and international presentations related to your research within that time frame...The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh the Panel is satisfied that this was dishonest."
In a narrative section headed "Other achievements" in the "additional information" section of the application form there were 8 sentences, the fifth of which was "I have produced medical video packages for television which was broadcast internationally on CNN". The charge in relation to this was that it was a dishonest and misleading claim.

The Panel had before it a letter from CNN dated 29th October 2010 which confirmed that [she] "worked as an intern in the medical news department at CNN Atlanta in 1998 and was involved in writing, production and editing of medical news packages produced for CNN Health which were broadcast nationally and internationally." 

In their findings after referring to this letter and the application form the Panel went on:
    "...The Panel determined that it was not true that you had produced medical video packages for television that were broadcast internationally on CNN. It was not true that you were solely responsible for the production of these packages. You were involved in the production with others as part of your internship. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh the Panel is satisfied that this was dishonest." [emphasis added] 
    The findings of the appeal judge were a little more reasonable:
    The above paragraphs of the judgment were circulated to the parties in draft on 1 November 2011. Counsel are agreed that in the light of their contents there would be no reasonable prospect, in the event of remission of the case to the GMC, of a Panel finding that her fitness to practise is impaired, nor of a warning being issued under section 35D(3) of the Medical Act. Accordingly the finding of impairment, the sanction of suspension and the direction for immediate suspension pursuant to section 38(1) of the Act will also be quashed. The GMC must pay the appellant's costs of the appeal, which have been agreed in the sum of £22,000
    What a farce. "Protect, promote and maintain the health and safety of the public" my arse - it's a self-perpetuating and self-interested quango which acts as a tool of the medical and NHS bureaucracy to keep the footsoldiers in line.

    And yet, compare:
    A GUILDFORD doctor who was suspended from medical practice for misconduct last year will be allowed to practise from next month following a case review by the General Medical Council.
    Last year, the GMC found that between 1995 and 2003, Stephen Carr-Bains entered into sexual relationships with two of his patients - both of whom were vulnerable and suffering from mental health problems.

    Dr Carr-Bains, who worked for the Guildowns Group Practice at the University of Surrey, got one of his patients pregnant and then helped her to arrange a termination.
    Following the abortion, the doctor did not put a letter from the British Pregnancy Advisory Service into the woman's records, failed to make any record of the abortion and did not refer her for post-termination counselling.

    Several years later, in 2005 and 2006, the doctor pressurised the woman not to reveal her relationship with him to her counsellor.

    The 56-year-old GP had sex with the other woman while ­‘staying over’ at her university accommodation.
    And contrast:

    The Panel is of the view that you have shown contrition for, and insight into, your actions...the original misconduct took place several years ago in the context of an otherwise unblemished record. Taking into account these matters and all of the public interests at stake, it has, therefore, determined that your fitness to practise is no longer impaired by reason of your misconduct.

    I will leave a comparison of age and ethnicity to the reader. The GMC is not fit for purpose.