Thursday, 17 April 2014

The Great War and M.A.S.H.

I am writing a piece for a pamphlet to be published that highlights the involvement of Sheffield medics in World War One. The doctor who asked me to do this  is one of a team who is organising this venture and  is a retired Sheffield physician. He just happens to be my consultant when I did my first house job after qualification in 1983. He got in touch after reading a piece published in the Sunday Telegraph that highlighted the early attempts at surgery on cardiac injuries. I was closely involved in the story, which featured a soldier from Sheffield. One of the important sources of information for the story was a paper published in the Journal of the RAMC ( Royal Army Medical Corps) in 1918 by the surgeons involved. They describe the clinical course of the soldier in great detail from the moment he was admitted to hospital in Malta to the day he died of mediastinitis, a frequently fatal complication of a deep sternal wound infection. The findings at post mortem are also extensively described.The details in this  published paper are quite extraordinary and made me think of how this soldier would have been managed in wars which have occurred since that great conflagration of 1914-
Coincidentally I watched a few episodes of MASH on a transatlantic flight recently - I had forgotten what a good programme it was, with servings in equal measure of pathos and feel good factor. What with all the wars British and American forces have been involved in since the Korean War, maybe a new MASH needs to be produced.  

Wednesday, 16 April 2014

The Unstoppable Risk Creep

  • This registry report, at the recent annual meeting of the American College of Cardiology, on outcomes after TAVI (or TAVR) is a marker for the future.  TAVI (Transcutaneous Aortic valve Implantation) , a percutaneous treatment of aortic stenosis,  is making headway into 'surgical' territory. No-one should be surprised by this. 
    At the moment, within the English NHS, TAVI cannot be offered to a patient with aortic stenosis until that patient is turned down by surgeons - originally 2 and now locally in Yorkshire that seems to have dropped to one. Risk creep i.e. offering TAVI to lower and lower risk patients is real - especially so in the UK, where cardiac surgeons have become risk averse. As lower risk patients are operated on, results invariably get better turning a creep into a canter!
  • What is slowing down the inevitable expansion of TAVI in the National health Service is cost - many institutions are still making a loss with the currently offered tariff.  That will change when the market does open up and unit costs will come down. Edwards, maker of the first TAVI device are clearly trying to delay that time with their silly (IMHO) legal action against Medtronic.
  • As younger and fitter patients undergo TAVI, there will come a point when the patient will start to outlive the prosthesis, which is after all a limited life pericardial prosthesis which has been crushed and deformed!.
  • When that happens will we go back to the extraordinarily safe, effective and long lasting surgical operation or shall we see more TAVI in TAVI procedures? I know what industry would like to see!!
    tags: TAVI aortic stenosis aortic TAVR
Posted from Diigo. The rest of my favorite links are here.

Thursday, 20 March 2014

I'm Your Doctor, Can you Trust me?

  • Then came Doctor Death - or Harold Shipman. He was a General Practitioner or Family Physician who over a 30 year career murdered hundreds of elderly women with overdoses of opiates. He was imprisoned for life and a few years after committal, he committed suicide.

  • The fallout of the Harold Shipman affair led, as significant events often do in British public life to a very long and expensive Judge led public inquiry. It took more than 10 years for a new system of medical oversight to be devised. The General Medical Council (GMC) the body in place for registering and policing the medical profession since 1858 came very close to disappearing altogether. Vested interests such as the powerful British Medical Association, doctors' trade association in the UK and the government occupied contrasting stances. There was a lot of soul searching but after what seemed an age, a settled view of how doctors need to be regulated was reached. This is the Strengthened Appraisal I.e. an appraisal system that is obligatory and that needs to include review of evidence that the doctor was doing the right thing I.e. Practicing according to principles and domains set out in Good Medical Practice - the 10 Commandments of being a good doctor as laid out by the GMC. This uniquely includes feedback, not just from colleagues and workmates but also from an unselected group of patients.

    Doctors now need to be appraised annually in the new system if he or she wants to be re validated and therefore retain the right to practice in the UK.

    Now that I am a trained appraiser and understand how the system should work, there is no doubt in my mind that this will help weed out the 'bad apples' (apologies for the mixed metaphors!) It does however need investment in time and money which at the moment is forthcoming - both from central government and from individual doctors whose registration fees have shot up over the past 5 years.

    The new system is excellent at assessing generic qualities a doctor must have, communication skills, quality improvement activities, mandatory training etc. One area where I think the new system is worryingly weak is test of knowledge - in essence there is none. You are not obliged to have an appraiser who is in the same specialty as you. All you have to demonstrate is that you accrue sufficient CPD (continuing professional development) points per year. This informs the appraiser that I 'attended' a course or meeting or that I 'read' a paper. A different approach is taken by American doctors who have had to re-certify in their specialty at regular intervals for a long time. This article in the Wall Street Journal as highlighted above reports how this recertification process is being strengthened. There is clearly a lot that British regulators can learn from our American Cousins. However when one remembers the lengthy and protracted course that led to the development of the strengthened appraisal system, I do not think there is any appetite for further reform - which is a great pity.



Tuesday, 25 February 2014

Should we be Formally Testing Surgeons?

This is fascinating stuff. In the United states, it is common practice to go and observe the surgeon you want to appoint, operate. In the UK, it is virtually unheard of - until recently that is.  I was representing the Royal College of Surgeons at a  appointments advisory committee to appoint a Consultant Heart Surgeon at a London Hospital. The medical director told me that it was common practice for him (the medical director - a non surgeon) and a senior surgeon to observe the potential appointee in their current workplace.
A formal assessment of surgical skills is made when trainees are interviewed for appointment to specialty training, both at ST3 level and at ST1 level. And yet, no formal assessment is made at the end of training when they are about to enter the scary real world or further on in their career as consultant when they are being assessed/appraised for revalidation. This paper suggests that there is value in doing so and I am sure the public would expect it.
Posted from Diigo. The rest of my favorite links are here.

Bonkers But Impressive.

Do Blood Flow Patterns have an Effect on Aortic Size and Shape?

  • Bicuspid Aortic Cusp Fusion Morphology Alters Aortic Three-Dimensional Outflow Patterns, Wall Shear Stress, and Expression of Aortopathy  - This paper from Chicago seems to suggest that the nature of flow is as important as genes to the genesis of aneursymal changes in the Ascending Aorta. Leonardo Da Vinci appreciated the importance of flow patterns in the proximal aorta. The paper highlights the emerging consensus that genes on their own do not determine disease states but work in conjunction with what is around them The role of blood flow patterns on ascending aortic daimeters may be relevant in those patients whose native valves are replaced by mechanical bilealfet prostheses. These look nothing like the valve designed by the Creator or bioprostheses and must surely generate very abnormal blood flow patterns.
Posted from Diigo. The rest of my favorite links are here.

Monday, 30 December 2013

Doctors Delaying becoming Cogs in the Wheel

BMJ Careers - Planning an “F3” year: opportunities and considerations for aspiring surgeons
I was interested to read about the increasing popularity of taking a year out between the F2 year, the second 'compulsory year' of British (and Maltese) medical graduates and the beginning of specialty training.
One should not be surprised by this - to be 'forced' to make such an important life lasting career decision barely 36 months after leaving med school is just too early.
In the past (or when I were a lad  - said in the most Monty Pythonesque of Yorkshire accents), you could delay starting proper specialty training for as long (within reason) as you liked. It is strange, is it not, that doing extra things in your life like a Duke of Edinburgh award or taking a gap year before University, maybe working on a ward, is seen as an asset whilst after graduation there is an almighty mad rush to get you on the specialty register and working for the greater good of 'THE SERVICE' as soon as possible.
I don't think that is a good thing - medical graduates are not just NHS fodder - they need time to plan a fulfilling career for themselves and this may involve looking at different options. Young doctors are now increasingly saying so by voting with their feet.