Quincy, M.E. – a homage

This is a re-written version of a blogpost that I put up on northerndoctor.com back in 2008. The death of Jack Klugman seems an appropriate time to post a small tribute.

Kick back and enjoy the classic opening theme for a minute. It’s a proper little earworm – I’ll be humming it for days now. Doo doo-doodoo doo dooo!

One of my resolutions when teaching medical students is to stop making cultural references that are likely to be met with blank looks.  Partly because it baffles the students – most of them were not born when Quincy was in his pomp – but mainly because it is mildly depressing for me.

Quincy, M.E. is the reason I am a doctor.

With no doctors in my family, and in the pre-internet universe (how did we cope?), my view of the medical profession was limited to 1980s television. That really didn’t extend much beyond Quincy, early Casualty and that programme, Doctors to Be, that followed some St Mary’s medical students through their course. That really was it. Exposure to Quincy at such an impressionable age meant that I initially assumed I would go on to be a forensic pathologist. The postmortem scenes may look tepid by today’s maggot-ridden standards but at the time they were thrillingly morbid. However, when I arrived at medical school in 1992 I was very quickly disillusioned after about 5 minutes into our first histology lesson. Squinting down microscopes at pinkish-purplish blobs with my defective colour vision meant pathology quickly lost any glamorous associations with Quincy.

Klugman was magnificent as the character and Quincy remains a great, albeit fictional, role model. He was phenomenally tenacious with exemplary clinical skills. Most importantly, he had a moral compass second to none. All of this was allied to an ability to sniff out a corporate murder from the other side of the county. He was also a bit of a one for the ladies and he enjoyed a good rant at stifling bureaucracy. What a legend.

Read More

Northern Doctor’s Antidote and the new blog

I used to have another blog, Northern Doctor’s Antidote, that I started in 2008. When it kicked off I can recall reading in one blogging guide that it was inexcusable to let a blog slowly languish, to let it atrophy and die a slow lingering web-death. I felt that was indeed happening so I pulled the plug. No valedictory message and no fuss. After all, let’s not over-egg it, no one really cares. Or very few anyway.

I had a lot of fun with the blog. The ‘antidote’ bit of the name came from Adam Smith’s quote:

Science is the great antidote to the poison of enthusiasm and superstition.

I still believe that but my views since 2008 have, perhaps, become more nuanced. The way the science is presented to the world is a serious problem and medical journals are, in many ways, deeply flawed. In addition to that there is a lot of nonsense out there; it would be a lifetime’s work to debunk all the myths, half-truths, woo, Big Pharma and media guff in the world. I certainly plan to continue blogging in that vein and doing my wee bit but I needed a new home. I have posted a handful of the old Northern Doctor posts here just to kick things off.

Read More

The GP business model – a delicate balance

The GP business model – a delicate balance

Posted on Thursday, May 26, 2011 at northerndoctor.com

I can remember Andrew Lansley making the case at the last RCGP conference that one of the reasons that GPs are ideally placed to be intimately linked to commissioning was because of their independent status within the NHS.

The GP business model is frequently misunderstood. Most GPs are independent contractors who work in their own self-contained partnerships, employing staff and often owning their own premises. GPs have a great deal of independence in how they run their business but many wouldn’t be viable if they weren’t shackled to the NHS. They are not true free-marketeers by any stretch of the imagination. Most GPs have never really been involved in competition and they have enjoyed the privileged position of being in a business that is, collectively, too big to fail. A recent opinion article in Pulse written by Dr Paul Charlson (a Tory) pushes the case for opening up competition and claims that GPs ‘conveniently ignore they are private practices’. He, like many others advocating competition, conveniently ignores the current limitations on the GP business model.

Another article in Pulse suggesting ways GPs might seek to increase their practice list size also highlights the problem. One of the biggest factors in a practice’s income is the size of its list of patients. Therefore, getting more patients may seem like a great idea. Of course, it takes about two seconds to work out that this a zero-sum game. There are no extra people to register and no spares just sitting around waiting to be swept up by a diligent GP. The bottom line is that if one practice takes more patients then it does so entirely at the expense of a neighbouring practice that will lose the income.

The RCGP has been opposed to a relaxation of the rules on practice boundaries. A lot of patients find this irksome – particular commuting types who are rarely in their home areas within working hours. Many GPs will oppose practice boundary abolition out of naked self-interest as maintaining the practice boundary system retains their position of provider privilege. However, the restrictions around practice boundaries have provided a financial safety net for general practice and is one of the factors that helps to ensure a universal service.

The private practice status of the typical GP business is an awkward tension held together by the need to provide that universal service while allowing local flexibility. It isn’t a true blue, devil-take-the-hindmost competitive world and there are good reasons for that. Practices do make a profit but in most cases it is a modest one that pays GPs and their staff a reasonable salary. Most practices can’t make a significant profit above this but the quid pro quo is that they are unlikely to go bust. Don’t be persuaded by the straw man argument that GPs are already private providers and the NHS reforms are a natural development.

We only need to pull a few small threads to unravel the whole fabric of our primary care.

Read More

Professionalism – turning dolphins into whales

Professionalism – turning dolphins into whales by northerndoctor

Posted on Sunday, June 20, 2010 at northerndoctor.com

Professionalism is an explicit outcome in most medical curricula yet remains a nebulous concept. Some medical students recently asked for my opinion on body piercing and tattoos. Would having a tongue piercing or a tattoo constitute an unprofessional act?

The many systems being developed to assess and measure professionalism can feel oppressive. Paradoxically, patients thrive on the traits of a doctor they come to know over many years. My hairdresser can give me a detailed rundown of the personal flaws of the doctors at her practice. Their eccentricities are well documented and they may well struggle to ‘pass’ a modern test of professionalism but a stable primary care system allows patients to drift toward the GP that matches their own foibles. It’s worrying that early exposure to some consultation models and the systematic medical history homogenises students. It would hardly be surprising if they felt coerced, pressurised to conform and nervous of expressing their own individualism. We all have to find a way of feeling comfortable in our own skin when we practice medicine.

And what is the prevalence of body piercing? Rather helpfully, there was a study in the BMJ in June 2008 which set out the prevalence of non-ear lobe piercing.

Adults aged 16-24 had a prevalence of 27.4% (95% CI 24.8 to 30.0) for any kind of piercing. The most common were navel (14.8%), tongue (6.5%) and nose (6.1%). A proportion of over 1 in 4 with a piercing suggests to me that it is normal behaviour for some young people.

Of course, there is a downside to tattoos that goes beyond the potential to cause a fit of the vapours in venerable consultants. Blood-borne viruses aside there is little to guarantee that the subtle, philosophical motif that elegantly symbolises your personal credo will be so appropriate in ten years time. How about fifty years hence when you are drawing your pension? They are a highly visible sign of the ageing process and the clear lines of youth are remorselessly smeared out into the blurry edges of old age.

One of the answers to professionalism, at least in primary care, may be to concentrate less on the individual and to spend more time ensuring continuity in the system. Fragmentation of care may ultimately make people less tolerant of normal human eccentricities in their doctors.

My final word of caution would be for the female students: before you get a dolphin tattooed on your abdomen, spare a moment to consider the effects of the gravid uterus on your body art. As one young pregnant woman bewailed: “Look at my tattoo; it’s not a dolphin, it’s a bleeding whale!”

Bone, A., Ncube, F., Nichols, T., & Noah, N. (2008). Body piercing in England: a survey of piercing at sites other than earlobe BMJ, 336 (7658), 1426-1428 DOI: 10.1136/bmj.39580.497176.25

Read More

Tobacco harm reduction – no smoke without fire

Tobacco harm reduction – no smoke without fire

Posted on Wednesday, November 18, 2009 at northerndoctor.com

Smoking kills millions of people every year and yet the medical community seems pathologically opposed to any measure to tackle the issue other than through the promotion of total abstinence.

Carl Phillips suggests in his paper in the Harm Reduction Journal this month that smoking for just one month is more dangerous than switching to a smokeless nicotine product for a lifetime. Take a moment to take a deep drag on a few breathtaking statistics. Across the world approximately 1.3 billion people use tobacco products and by 2030 it is estimated that 10 million people will die annually from smoking-related diseases and 70% of these deaths will be in developing countries. We’ve known about the harmful effects of smoking for over 50 years and yet over that same period 6 million Britons have died of tobacco-related disease.

It’s no secret that it’s hard to stop smoking. Bandolier published an interesting little analysis of trials which included smokers and heroin addicts. They asked: which is the most addictive? In a rather elegant twist they looked at the cessation rates in the placebo arms of all the relevant trials. Cessation rates for smokers were around 8-9% yet for opiates users were around 43%. No surprises there – smoking is extraordinarily difficult to stop. Even in those that are highly motivated 12 month cessation rates are often no better than 10%. Opposing a harm reduction approach might be doing a grave disservice to those that just find it too tough to stop.

I am intrigued by the concept of tobacco harm reduction – not least because it requires a considerable effort of will to put aside a pathological distrust of Big Tobacco. Some of this post is taken from one I posted over at doc2doc a few months ago. The very first comment on the blogpost at doc2doc sums up the gut reaction of many doctors:

I think we should dismiss this out of hand! This argument is like low tar cigarettes are healthier..so you can smoke more of them. There is no such things as a safe(r) cigarette. The safer cigarette makes no sense given my understanding of how nicotine receptors work, not to say addiction. Do not trust Big Tobacco who have a vested interest in not losing their customers.

End of. Decision made. One suspects that the notion of smokeless nicotine products is simply not endorsable by the scientific orthodoxy in any shape or form. Phillips addresses all the arguments and using a back of a fag packet (though he prefers an envelope) calculation suggests that:

Whatever the explanation for it, the present analysis shows that anti-THR [tobacco harm reduction] activism is deadly. Hiding THR from smokers, waiting for them to decide to quite entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.

If you are inclined to read the paper then flick to the back first and read the competing interests statement. Not for our Carl a bland ‘nothing to declare’ and instead it reads like a heartfelt plea that we pause, ignore the gut reaction and consider the evidence. It also speaks volumes for the ignominious role of mavericks in the scientific world; they may occasionally be lauded as heroes but more often they will be squeezed out of funding, shunned at the peer-review review stage and ostracised by their own community.

Within the wider medical community tobacco harm reduction remains an exercise in thinking the unthinkable. Doctors recommending it may be vilified and it opens up a researcher to accusations of acting as an industry patsy; labelled as a dull-eyed lackey in the pay of malignant giants. Yet it could save millions of lives and it certainly merits wider debate.

Phillips, C. (2009). Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments Harm Reduction Journal, 6 (1) DOI: 10.1186/1477-7517-6-29

Read More

IV heroin – I predict a RIOTT

IV heroin – I predict a RIOTT

Posted on Tuesday, September 15, 2009 at northerndoctor.com

There is almost a sad inevitability about the discussion in the media around the issue of giving heroin to heroin users. When it come to heroin-assisted treatment (HAT) it is inevitable that any reasonable discussion will be drowned out by the clamouring commentariat.

The UK has been using heroin as part of the treatment of users in one form or another since 1926. More recently, there have been studies of HAT in Switzerland, Germany, the Netherlands and Canada which have shown benefits in health, psycho-social adjustment and illicit drug use to socially excluded heroin dependent patients resistant to other treatments.

However, it’s inevitable that ill-informed parallels will be drawn with alcohol, smoking and the funding of almost anything else in the NHS deemed more worthy. It’s even possible to drag in ‘our boys’ fighting the drugs (spot of mission creep here) war in Afghanistan if one wants to work up a proper lather. The RIOTT study (I am assuming the obligatory acronym is an ironic nod to the impact this study will have on Daily Mail readers) isn’t even published yet and already the hysteria begins…

Is it even worth discussing the science amongst this hubbub? It might be better to crawl back under the duvet, let the dust settle and have a more rational discussion when we actually have the results of the UK study.

But there is some science to look at and consider. It is only last month that the New England Journal of Medicine published the results of NAOMI, the North American Opiate Medication Initiative (another tortured acronym) which looked at exactly this issue and it’s probable that RIOTT will have similar results. NAOMI compared oral methadone versus injectable diamorphine. It was open-label and there was no attempt to blind users to their treatment. They had better retention in the diamorphine arm at 88% versus the methadone arm at 54%. The reduction in rates of illicit drugs were 67% in the heroin group and 48% in the methadone group. Overall, the diamorphine arm tended to do better.

There were clear benefits but it wasn’t without issues and there were serious adverse events. There were 18 events in the methadone group (n=111) but none of them were felt to be related to the treatment. In the diamorphine arm (n=115) there were a total of 51 serious adverse events. However, it was reckoned that 27 of these were directly related to the diamorphine and included overdoses and seizures. This has to be put in context: a total of 89,924 doses of diamorphine were self-administered during the course of the study so that’s 0.03% of injections causing an event.

There are some issues around the methodology. Users know what kind of trial they are entering and many will drop-out when they get randomised to methadone rather than injectable. Indeed, this was the case in this study and it raises some issues around bias. The methodology of RIOTT was published in the Harm Reduction Journal in 2006 and is available for free.

The final conclusion of the NEJM paper is a reasonable one:

In this trial, both diacetylmorphine treatment and optimized methadone maintenance treatment resulted in high retention and response rates. Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmor-phine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system.

It will certainly need to be given in a specialised environment so it is likely to remain a very limited intervention. The headlines have tended to highlight that crime rates fall. How can this be surprising? UK studies have shown reductions in criminal activity across all treatment modalities for years. Part of the reason for this emphasis is presumably to make it as palatable to the public as possible. It’s not enough for it to be a useful option to improve health in a limited group of treatment resistant users. There has to be a fringe benefit to society as well.

There is an excellent paper by the authors of NAOMI commenting on some of the controversies around HAT. Again, it is freely available at the Harm Reduction Journal and will give you as good a background knowledge of the issues around HAT as anything. The authors commented on the media:

Treating heroin addiction with heroin tends to evoke a knee-jerk reaction. Lack of understanding, restrictions on time and resources, and the need for a catchy headline often lead to sensationalism by the media. As previously mentioned, opposition both within Canada and the US also contributed to misleading reports from local, national, and international media. The resulting focus has been on a seeming shift in Canadian drug policy in direct contradiction to the US war on drugs, rather than on the scientific or medical merits of the NAOMI study.

Much hand-wringing will be provoked by these studies for the simple reason that some will perceive that the logical development of this whole debate is that the next step will be de-criminalisation of drugs. It is entirely possible that we are waging a phoney ‘war on drugs’ but that’s really not what these studies are all about.

Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, & Schechter MT (2009). Diacetylmorphine versus methadone for the treatment of opioid addiction. The New England journal of medicine, 361 (8), 777-86 PMID: 19692689

Read More