It has come to my attention that over the last year or so the Tories have been checking out the medical blogosphere and making discrete contact with influential medical bloggers. I haven't heard of Labour or the Lib Dems making similar overtures. This may reflect the Tories' cutting edge online strategy or just that Labour have completely conceded the ground to them.
What is interesting is the pattern that has seemingly emerged. Rather than outright endorsement of the Tories* there is just explicit condemnation of Labour and what it has done with the NHS. This chimes rather well with the attitude amongst doctors within the NHS. Although naturally leaning towards the Conservatives as upper middle class high earners doctors also have something of an old fashioned public service ethos and are understandably concerned with public service provision (being public sector employees, directly or indirectly, themselves). However, in recent times, after the euphoria of the early years died down, doctors have been fairly vocally critical of Labour's 'reform' agenda, from PFI to patient 'choice'. This is an attitude that you can see daily being expressed by doctors to patients, and this must have a real influence on regular health service users.
But it is only half the story and there is a danger that by failing to spell out what an alternative to Labour's unpopular policies would entail doctors are giving tacit endorsement to the Tories who, in many ways, want to extend and entrench exactly those policies which have proved so unpopular and unsuccesful. I wonder whether the Tories have already figured this out.
* Although perhaps a little nearer the election this will change, with nose peg style 'change' rhetoric.
Saturday, 13 March 2010
Sunday, 28 February 2010
A case study in nurse practitioners
Let us consider a hypothetical district general hospital, we will call it Fairylandshire NHS Trust (FNT), they have identified a suitable area for the creation of a new nurse practitioner role to help facilitate clinical care and free up the time of doctors to do other tasks. Sounds great doesn't it?
What the managers and senior types at FNT had noticed was that a very large proportion of new referrals to the Medical Admissions Unit (MAU) were suspected DVTs. These took up a lot of doctors time but were generally fairly straightforward to deal with - so much so that a nice little flowchart for how to manage these cases was created.
So how did the MAU work before? Well the triage nurse (a sister/charge nurse) would take a GP referral* and then the patient would, eventually, come in to the unit to be triaged by said nurse (including taking bloods). Once triaged** the patient is seen by a junior doctor who takes a history and examines the patient and then arranges any additional tests that may be needed (x-rays, venous ultrasounds etc.), usually after having waited a little while for the blood results to come back. Once this is done the junior doctor decides on a diagnosis and management plan, then at some later point*** the on-call consultant comes and reviews the patients and management plan.
For suspected DVTs the more experienced juniors (SHOs and registrars) may decide to discharge the patient without consultant review if they do not suspect anything sinister going on and the tests are negative (FY1 doctors can do the same if they discuss it with a more experienced junior doctor first). Once all the management has been decided and if the patient can go home the doctor then writes a discharge summary for the GP, medical notes, and patient, and prescribes any necessary medications to take home and arranges any follow-up. If a patient has a pulmonary embolism (a blood clot that has gone to the lungs) the consultant will need to see them anyway, and all the findings and management plan will be discussed. If it isn't a DVT and isn't serious the junior doctor will discuss the findings and management with the patient and send them home or back to their GP's care. All this takes place on a severly overcrowded ward with a single triage room and a single assessment room (the latter for the junior doctors to use to see the patients), a spare bed may or may not be available on the ward if more than once doctor needs to see a patient at the same time (there are usually 1-4 junior doctors available to see patients depending on the time of day and whether they are needed in A+E or on the wards).
So, what is the wonderful new innovation that will speed up this process? The 'Thromboembolic Nurse Practitioner' (DVT nurse to you or me). She will see any suspected DVT instead of the triage nurse (and see them in the single assessment room usually used by the doctors), take bloods and do obs as the triage nurse does and then...measure the calf circumference on each side. There is a lovely long pro-forma for DVTs with lots of wonderful sections for the doctor to then fill out once the DVT nurse has seen the patient, they have to take a full history, they have to examine the patient (there is even a section for rectal examination findings!), they then have to reach a provisional diagnosis, calculate a Wells score (assessing the pre-test probability that the patient has a DVT), they then have to interpret the D-dimer test (a blood test for DVTs) based on the prior probability, they then have to arrange further investigations such as venous ultrasound if indicated by the 'DVT pathway', then finally they have to interpret all these tests and reach a final diagnosis (most of these patients do not actually have DVTs). If the patient is short of breath or has chest pain then a pulmonary embolism has to be considered and ECGs, x-rays and even lung perfusion scans arranged by the junior doctor (and a much more detailed history squeezed into the tiny history box on the DVT pro-forma).
After all this, if it does turn out to be a DVT the doctor then needs to prescribe low molecular weight heparin for the patient and start warfarin. At this point the DVT nurse will then talk to the patient about the treatment they will be receiving, adds them to a database for 'audit purposes' and arranges a clinic follow-up for them. If if is a PE the patient will be seen by the consultant and if it isn't a DVT then the same process as above will happen with the DVT nurse playing no further part.
So what does the DVT nurse (or rather what do the two DVT nurses) bring to the table? Well she only works 9am-5pm, costs about £10,000 per year more than the triage nurse, she clogs up the single treatment room usually used by doctors to see patients thus slowing them down, she gets an extra office on the same corridor preventing that being used for something more useful (the doctors office has, of course, be converted into bedspace), she harrasses the junior doctors busy seeing sicker patients to see her suspected DVTs as soon as possible, she does some minor counselling and arranging of follow-up for the few patients with DVTs, she does some follow-up clinic work and she undertakes audits and other ephemera to do with 'thromboembolic prophylaxis' around the hospital (note that there are two DVT nurses to do this extra work, one doing the assessments, the other doing the other ephemera). She saves maybe 10 minutes per confirmed case of DVT.
An FY1 doctor could nearly double their salary doing a DVT nurse practitioner role, I wonder if there are any locum jobs going?
* This is madness in itself, massively inflating the number of accepted referrals, having a doctor take the referral would allow them to refuse unsuitable referrals at an early stage decreasing the overall workload - but that isn't my focus here.
** In this unit triage actually means the presenting complaint is briefly noted and bloods are drawn and perhaps a cannula is inserted, and basic observations are taken (blood pressure etc.) No actual triage of severity is undertaken and the patrient is then seen by the next junior doctor available, whether they be FY1 house officer or registrar.
*** This can be very many hours later, and is also madness, since very sick patients can be seen by the most junior doctors without any review by more experienced seniors, and this may even include patients referred from A+E being seen by the FY1 doctors.
What the managers and senior types at FNT had noticed was that a very large proportion of new referrals to the Medical Admissions Unit (MAU) were suspected DVTs. These took up a lot of doctors time but were generally fairly straightforward to deal with - so much so that a nice little flowchart for how to manage these cases was created.
So how did the MAU work before? Well the triage nurse (a sister/charge nurse) would take a GP referral* and then the patient would, eventually, come in to the unit to be triaged by said nurse (including taking bloods). Once triaged** the patient is seen by a junior doctor who takes a history and examines the patient and then arranges any additional tests that may be needed (x-rays, venous ultrasounds etc.), usually after having waited a little while for the blood results to come back. Once this is done the junior doctor decides on a diagnosis and management plan, then at some later point*** the on-call consultant comes and reviews the patients and management plan.
For suspected DVTs the more experienced juniors (SHOs and registrars) may decide to discharge the patient without consultant review if they do not suspect anything sinister going on and the tests are negative (FY1 doctors can do the same if they discuss it with a more experienced junior doctor first). Once all the management has been decided and if the patient can go home the doctor then writes a discharge summary for the GP, medical notes, and patient, and prescribes any necessary medications to take home and arranges any follow-up. If a patient has a pulmonary embolism (a blood clot that has gone to the lungs) the consultant will need to see them anyway, and all the findings and management plan will be discussed. If it isn't a DVT and isn't serious the junior doctor will discuss the findings and management with the patient and send them home or back to their GP's care. All this takes place on a severly overcrowded ward with a single triage room and a single assessment room (the latter for the junior doctors to use to see the patients), a spare bed may or may not be available on the ward if more than once doctor needs to see a patient at the same time (there are usually 1-4 junior doctors available to see patients depending on the time of day and whether they are needed in A+E or on the wards).
So, what is the wonderful new innovation that will speed up this process? The 'Thromboembolic Nurse Practitioner' (DVT nurse to you or me). She will see any suspected DVT instead of the triage nurse (and see them in the single assessment room usually used by the doctors), take bloods and do obs as the triage nurse does and then...measure the calf circumference on each side. There is a lovely long pro-forma for DVTs with lots of wonderful sections for the doctor to then fill out once the DVT nurse has seen the patient, they have to take a full history, they have to examine the patient (there is even a section for rectal examination findings!), they then have to reach a provisional diagnosis, calculate a Wells score (assessing the pre-test probability that the patient has a DVT), they then have to interpret the D-dimer test (a blood test for DVTs) based on the prior probability, they then have to arrange further investigations such as venous ultrasound if indicated by the 'DVT pathway', then finally they have to interpret all these tests and reach a final diagnosis (most of these patients do not actually have DVTs). If the patient is short of breath or has chest pain then a pulmonary embolism has to be considered and ECGs, x-rays and even lung perfusion scans arranged by the junior doctor (and a much more detailed history squeezed into the tiny history box on the DVT pro-forma).
After all this, if it does turn out to be a DVT the doctor then needs to prescribe low molecular weight heparin for the patient and start warfarin. At this point the DVT nurse will then talk to the patient about the treatment they will be receiving, adds them to a database for 'audit purposes' and arranges a clinic follow-up for them. If if is a PE the patient will be seen by the consultant and if it isn't a DVT then the same process as above will happen with the DVT nurse playing no further part.
So what does the DVT nurse (or rather what do the two DVT nurses) bring to the table? Well she only works 9am-5pm, costs about £10,000 per year more than the triage nurse, she clogs up the single treatment room usually used by doctors to see patients thus slowing them down, she gets an extra office on the same corridor preventing that being used for something more useful (the doctors office has, of course, be converted into bedspace), she harrasses the junior doctors busy seeing sicker patients to see her suspected DVTs as soon as possible, she does some minor counselling and arranging of follow-up for the few patients with DVTs, she does some follow-up clinic work and she undertakes audits and other ephemera to do with 'thromboembolic prophylaxis' around the hospital (note that there are two DVT nurses to do this extra work, one doing the assessments, the other doing the other ephemera). She saves maybe 10 minutes per confirmed case of DVT.
An FY1 doctor could nearly double their salary doing a DVT nurse practitioner role, I wonder if there are any locum jobs going?
* This is madness in itself, massively inflating the number of accepted referrals, having a doctor take the referral would allow them to refuse unsuitable referrals at an early stage decreasing the overall workload - but that isn't my focus here.
** In this unit triage actually means the presenting complaint is briefly noted and bloods are drawn and perhaps a cannula is inserted, and basic observations are taken (blood pressure etc.) No actual triage of severity is undertaken and the patrient is then seen by the next junior doctor available, whether they be FY1 house officer or registrar.
*** This can be very many hours later, and is also madness, since very sick patients can be seen by the most junior doctors without any review by more experienced seniors, and this may even include patients referred from A+E being seen by the FY1 doctors.
Sunday, 31 January 2010
The drugs do work?
An interesting article in the NY Times by psychiatrist Richard Friedman:
My analysis could only correct for baseline severity on a per trial basis whereas the above study was a patient level meta-analysis which is a better approach when available. So while the above study did include only two antidepressants (one of which was the older tricyclic class, although these are thought to be similarly effective to the newer SSRIs, just with more side-effects) it is consistent with the study by Kirsch et al, even given the criticisms of it I've previously raised.
So I don't think Friedman's criticism holds up, I think a more sensible attack is that the NICE threshold is entirely arbitrary, an argument I made at the time of Kirsch's paper.
Last week, The Journal of the American Medical Association published a study questioning the effectiveness of antidepressant drugs. The drugs are useful in cases of severe depression, it said. But for most patients, those with mild to moderate cases, the most commonly used antidepressants are generally no better than a placebo.Neuroskeptic has blogged about this study before (Fournier et al 2010 JAMA 303(1)), but it is worth noting that, despite my criticisms of Irving Kirsch's meta-analysis of the FDA data on antidepressant efficacy, even when I reanalysed the data I found that the NICE threshold for 'clinical significance' was met at around a baseline severity of 26 points on the Hamilton scale. In this study by Fournier et al the threshold was met around a baseline severity of 25 points.
...the authors of the new analysis gave themselves an additional handicap: they decided to exclude a whole class of studies, those that tried to correct for the so-called placebo response.
...
Another drawback of the study is that its conclusions are based on studies that included only two antidepressants — when there are 25 or so on the market. By contrast, when the Food and Drug Administration wanted to investigate the safety of antidepressants, it analyzed data from some 300 clinical trials, with nearly 80,000 patients, involving about a dozen antidepressants.
...
Every once in a while, a landmark study comes along and overturns everyone’s cherished ideas about a particular treatment. But the current study is not one of them. So it would be a shame if it discouraged depressed patients from taking antidepressants.
My analysis could only correct for baseline severity on a per trial basis whereas the above study was a patient level meta-analysis which is a better approach when available. So while the above study did include only two antidepressants (one of which was the older tricyclic class, although these are thought to be similarly effective to the newer SSRIs, just with more side-effects) it is consistent with the study by Kirsch et al, even given the criticisms of it I've previously raised.
So I don't think Friedman's criticism holds up, I think a more sensible attack is that the NICE threshold is entirely arbitrary, an argument I made at the time of Kirsch's paper.
Wednesday, 27 January 2010
30-year old women only able to conceive 30,000 times
Scientists have discovered the reason why women find it difficult to conceive later in life - they have used up 90 per cent of their "ovarian reserve" by the age of 30.
...
The new research by the Univeristy of St Andrews and Edinburgh University is the first to colate the actual decline of the "ovarian reserve" - the potential number of eggs women are born with - from conception to the menopause.Oh dear. I haven't read the original research, maybe it does demonstrate what the authors claim, but not on this evidence. Given that the average woman has 4-500 menstrual cycles in her lifetime then losing 90% of these eggs hardly makes a dent. Over 90% of eggs formed in gestation are lost by birth, does this explain why newborn and pre-pubescent children are infertile?
It shows that on average women are born with 300,000 potential egg cells but this pool declines at a much faster rate than first thought.
By the age of 30 there is only 12 per cent left on average and by the age of 40 just three per cent. Dr Hamish Wallace, the co-author, said: "Our research shows that they are generally over-estimating their fertility prospects.
...
The researchers said many women make the mistake of thinking that because they are still producing eggs that their fertility remains constant. But this new research shows that it delcines rapidly.
Friday, 15 January 2010
Dick swinging braggadocio
As I noted last year:
If swine 'flu turns out to kill a lot of people this Autumn then Jenkins should really be forced to confront his words. Of course, it probably won't, further inflating his dick swinging braggadocio, until we finally do get a pandemic viral illness (which we will eventually) - when he'll be clamouring to know why more wasn't done. Ah, the privilege of consequence free comment pieces, the life of a journalist is so easy - you get to feel so important while doing fuck all.As I feared the colossal arsehole has taken the fortunate avoidance of a pandemic flu as further proof of his omniscience:
This is why people are ever more sceptical of scientists. Why should they believe what "experts" say when they can be so wrong and with such impunity? Weapons of mass destruction, lethal viruses, nuclear radiation, global warming … why should we believe a word of it? And it is a short step from don't believe to don't care.Why indeed should anyone pay attention to scientists and doctors when our always right Dr Simon Jenkins is there to keep us informed. What was that about AIDS again Simon?
"Aids has been confined largely to homosexuals and drug abusers, whose activities put them at risk of blood contamination and leave them vulnerable to lethal disease. There are some Aids cases outside the “high-risk” groups, but numbers are tiny: 60 at most in Britain. As far as Britain is concerned, the plague appears to be passing."
Thursday, 14 January 2010
Iceland, a morality play
Quoted for truth as they say on teh internets:
There really, really is no case to be made for the "plucky lickle Icelanders". It's notorious in the Nordic region for being a boastful little country with a selfish streak a mile wide, and when they elected successive governments of neoliberal chancers, they knew what they were doing.From D-squared digest. The grown-up version is at Crooked Timber.
Sunday, 3 January 2010
Just found this in my email:
The IPA launched the Diagonal Thinking Self-Assessment last September and as we approach its first anniversary we are carrying out a review to assess its progress, the results of which will be used to further develop the Diagonal Thinking Self-Assessment.I can't believe that I failed to share my views on the 'Diagonal Thinking Self-Assessment' with them - to recap:
As one of the 3,500 people who have completed the Self-Assessment, we would be very grateful if you could take a few minutes to give us your feedback on your experience and subsequent use of the results. As a small incentive to you we will holding a prize draw for an i-pod nano (8gb) among those who send back their completed questionnaire by 18th September 2009.
The questionnaire should only take you a few minutes to complete and all replies that we receive are much appreciated.
The link to access the survey is:
http://snaponline.snapsurveys.com/surveylogin.asp?k=125240289817
Many thanks for your help
Roger XXXXXX
Finance Department Research Consultant
One might be inclined to think that people in advertising know fuck all about logic and linear thinking, they certainly appear unable to figure out that despite physicists being a subset of scientists we can't tell whether any of them have high levels of intellect (and thus lack interpersonal skills) from these statements. Diagonal thinking my arse, smug self-congratulating tosspots more like.
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