views & REVIEWS Do we neglect patients with multiple health problems? PERSONAL VIEW Rahij Anwar, Nitish Gogi, Syed Neshat Anjum
“T
reat the whole patient, not just a particular disease” used to be the guiding principle for most clinicians until the government decided to reconfigure the way in which healthcare services in England would be offered. Under its new plans, primary care trusts or general practitioners would directly commission specialised services. The trusts would pay for the treatment of their patients in hospitals—and this, in due course, would become the hospitals’ main source of income. The aim of such commissioning was to save huge sums of money by using hospital services as sparingly as possible. Since its implementation this policy has not only jeopardised the future of many hospitals but has also led to considerable frustration and disappointment among patients. Perhaps the worst affected patients are those who have more than one condition at the same time. To primary care trusts these are very “expensive” patients, and therefore some of their problems might be “downplayed” to be managed in the community, and referrals to specialists are filtered. Constant reminders to comply with trusts’ policy in relation to clinic times and referrals mean that patients are often sent back to their GPs if they have a Patients are often new problem for sent back to their which a referral has GPs if they have a not yet been made. One of us recently new problem for saw a patient with which a referral has not yet been tennis elbow in a follow-up clinic. Her made elbow symptoms had almost completely resolved, but a new shoulder problem seemed to be causing her major discomfort. Examination showed that she had a rotator cuff disease, which required her to undergo magnetic resonance imaging and then, possibly, surgery. She was given a local steroid injection to relieve her symptoms (at least temporarily), and then a letter was written to her GP asking for a fresh referral so that this new problem could continue to be 670
Number crunching: the new commissioning plans aimed to save huge sums of money but have left patients frustrated
managed. Further investigation and treatment of her shoulder disease would have counted as a “new episode” in the current referral system. Direct treatment from us might have resulted in no payment to the hospital, because this service was supposedly not commissioned by the fund holders. It is possible that patients use the opportunity of a visit to a specialist to get all their problems seen to at the same time. They may do this for several reasons: they may not want to go through the whole referral system again; some of the problems may have appeared only while they had been waiting for their appointment with the specialist; and they may not have had a chance to discuss their other problems with their GP when the first referral was made. However, it must be remembered that there is not much opportunity for a proper dialogue between doctors and patients at such visits, because the appointment times are so strictly regulated now. Therefore patients are often told to book another appointment if they have more than one ailment at the same time. Many of our colleagues have had similar experiences in their clinics, and a great majority of them believe that the weaknesses in the referral system mean that their patients are not receiving appropriate care. In consultant to consultant referrals in hospitals for associated problems, patients are not being
treated as a priority, because many primary care trusts do not seem to show much interest in such cases. Irrespective of the reason, the crux of the matter is that these patients could well have received better care had they been treated in the traditional system, where there were no “time bound appointments,” “designated payment pots,” and “referral politics.” Although proponents of the new commissioning policy leave no stone unturned in selling their ideas, they have little insight into the problems associated with the system in relation to patients with multiple disorders. The Department of Health’s 32 page document Who Pays? Establishing the Responsible Commissioner, released in September 2007, fails to tackle this issue (www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/ DH_078466). Patients should be given sufficient time and opportunity to discuss their problems properly, so that the problems may be dealt with concurrently, not consecutively. This may, of course, mean longer appointments for some patients and fewer referrals to hospital in some cases. Also, hospital specialists should be allowed to generate a fresh “episode of treatment” if a patient develops a condition related to the same specialty while he or she is waiting for an appointment. This will not only significantly lessen the workload of general practitioners but would also help to reduce waiting times, paperwork, and inconvenience to patients. Although we all are expected to use the meagre resources of the NHS wisely in these difficult times, we should not forget that our foremost duty is to safeguard the interests of our patients. We should continue to question all policies that adversely affect the care of patients, and we believe that “one way healthcare commissioning” is one such policy. Rahij Anwar (
[email protected]) is a specialist registrar, London; Nitish Gogi is a registrar, West Midlands; and Syed Neshat Anjum is a registrar, London BMJ | 22 march 2008 | Volume 336
VIEWS & REVIEWS
“‘Conviction politicians’ may be popular, but conviction doctors are potentially dangerous” Medical classic p 673
review of the week
An Englishman abroad A fly on the wall film about an English surgeon has been a surprise hit on the festival circuit—largely because it shows doctors as fallible humans and not just slick professionals, says Khalid Ali cal dilemmas. Deciding when to operate to remove a large brain tumour is always going to be a risky undertaking. We see the patient, a young man, agonising over the decision to have only a local anaesthetic Rarely has a documentary film about doctors while his tumour is removed, to ensure that and patients been such a hit with audiences. the removal of brain tissue does not result in The English Surgeon, which follows Henry limb paralysis. In spite of his fears the patient Marsh, the neurosurgeon of the title, from St totally trusts his doctors. How much informaGeorge’s Hospital in London to the Ukraine, tion a doctor should tell a patient can be a enjoyed standing ovations at its screening at difficult dilemma. To be totally honest withlast year’s London Film Festival. The film is out giving false hope, while also not being compelling viewing—not least because the swayed by emotions, is a daily challenge for central character is so likeable and engagthe two surgeons. “Making these decisions ing, like an older George Clooney. The will always be a difficult task that needs comfilm follows a three stranded narrative: that passion, time, and training,” Marsh says. involving Marsh, another about Ukrainian Doctors tread a fine line between being neurosurgeon Igor Petrovich, and the story of brave and reckless or between being wise a patient waiting for brain surgery to remove and timid. The film compares neurosurgeons a large tumour. The action flits between Britto mavericks playing Russian roulette (the ain and the Ukraine, which Marsh visits regfilm is also known by the title Russian Rouularly. When Marsh first visited Kiev in the lette). This well illustrates the difficulty of the early 1990s he was shocked by the inefficient decision making process—is it justified to and bankrupt medical system. Meeting the undertake a risky brain operation knowing enthusiastic young surgeon, Petrovich, Marsh that the patient might lose his personality, took it upon himself to lend support to the intellect, or ability to walk? Alternatively, is Ukrainian system through regular visits, perit humane or professional to leave a patient forming difficult operations, training young suffering with epilepsy, allowing him to die surgeons, and donating surgical equipment. slowly from a growing brain tumour? In the The film tackles some complex clinicurrent media climate in which doctors are often accused of being little more than income obsessed business people, it is refreshing to see a portrayal of doctors as human beings, agonising over clinical decisions as much as their patients do. This warts and all documentary does not suggest that doctors always make the right decision. The doctors’ An older George Clooney: neurosurgeon Henry Marsh fallibility is poignantly
The English Surgeon BBC 2, 30 March, and on UK cinema release until 28 March Rating:
****
BMJ | 22 March 2008 | Volume 336
portrayed in the case of a young girl who dies from complications of brain surgery. The two neurosurgeons travel to a distant village to visit her family and share a meal with them, and in the process they share their sadness, suffering, and loss. Despite the sad ending to their daughter’s life, the family are still grateful for the hope of cure the surgeons gave them. Confrontation over medicolegal issues and disqualification are serious threats for doctors who practise in such a difficult specialty. The surgeons are totally aware of the high risk of complications and death in such operations: “We may and probably will kill patients.” However, their determination to continue operating and their plan to build a big neurosurgical centre in Kiev, calling it their “field of dreams,” can only be admired. Exploring the fundamental theme of the ethos of medicine as a profession, the two surgeons argue whether successful doctors are those who dedicate their life to saving patients or those high flying academics who accumulate letters after their name and a long publication list. The question is left unanswered, something for the audience to think about. The film does not shy away from exposing the frustration that doctors experience when they are faced with bureaucracy, professional rivalry, and financial restraints in the face of ever expanding waiting lists. It makes pertinent comments on commercialising medical practice and considers both sides of this argument. The English Surgeon ends on an optimistic note with the surgeons’ insistence that they will never stop trying to make things better. The question “What are we if we don’t try to help others?” may come across as a bit sentimental but fits nicely with the film’s theme of doctors as revolutionaries fighting for a better future for patients. Khalid Ali is senior lecturer in geriatrics, Brighton and Sussex Medical School
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A life more ordinary FROM THE FRONTLINE Des Spence
I have met a few celebrities—musicians and actors with extraordinary talent—and was always struck by just how ordinary they seemed. How did they become so talented? Through hard work and luck, you might think, but it seems that most “could just do it.” Medicine is like that. There is some hard work and luck, but like most doctors I was born wearing spectacles, never needing any tutors or additional lessons. I could just do it. However, I have failings: remembering people’s names, finding items of clothing, foreign languages (I am left shouting loudly in English), and I can just about run in a straight line. The CVs of today’s medical students are faultless: they are fluent in Mandarin and Spanish (possibly at the same time), they play many musical instruments, they are Olympic athletes, and they were all the narrator in the school nativity play. I feel inadequate, but mainly I feel uneasy. Nowadays children are always “special” and “winners.” But lest they be dangerously average, we now have the rise of the omnipresent private tutor and lessons in, well, everything. We see armadas of four wheel drive vehicles ferrying children from club to club and tutor to tutor—a generation of children miserably getting every opportunity that their parents hap-
pily never had. Car time is the day’s “quality family time.” This parental aspiration and relentless drive for improvement are not in our children’s best interests. Unfortunately, our extraordinary children will become mere ordinary adults. But it is too late for many, trapped in the vast schism between expectation and reality, never living up to their dreams and left instead with a pervading sense of failure. Medicine offers only a cocktail of cold chemical comfort. We all have different and extraordinary talents, most of which are not valued in this superficial success society. True talent is a gift, not something that can be manufactured or bought. So, liberate the kids from the prison of the car and let them play in the park. Cast talent and flair adrift in the sea of free expression. Fear not, for without tuition teenagers will still pick up a guitar and write songs, the geeks will still swot, and the athletes will hit an overhead kick from a 40 yard pass. Perhaps the forgotten talents of generosity, kindness, and sensitivity will begin to gain the recognition they deserve. It is time to allow the “extraordinary” to be ordinary and to welcome the return of the solid, if totally tedious, medical CV. Des Spence is a general practitioner, Glasgow
[email protected]
Resurrection in Rome IN AND OUT OF HOSPITAL James Owen Drife
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Winter holidays used to be for the idle rich. Then they became the norm for junior doctors. Now even consultants (the least idle of hospital staff) sneak off for a week or so. But we feel guilty about it. With Christmas lasting longer every year, half term looming, and Easter following on, can we justify more rest and recreation? My wife and I, raised as Scots presbyterians, avoid beaches or ski slopes and head for town, seeking somewhere stern and mind improving. This year it was Rome, which turned out to have everything we wanted: art galleries, museums, pouring rain, and a gale whipping up the Tiber. Rome is refreshingly unselfconscious, with nothing left to prove. Or almost nothing. Her biggest monument is to a king who unified Italy in the 19th century. Leadership at last, it
proclaims—no more squabbling and being pushed around by others. People dislike the huge memorial, but as British doctors we sympathised. Western Christian art is everywhere. You can have too much of it. In gallery after gallery saints were sadistically martyred, babies were massacred, and Christ rolled his eyes in agony on the cross. We were familiar with the theology that justifies all this stuff, but it was never very convincing. We longed for some Orthodox icons to cheer us up a bit. It was music, not pictures, that had attracted us. Our group, mainly senior citizens and Radio 3 listeners, walked to churches and palazzi to experience the delights of the Baroque. The local musicians, stocky men with shaven heads and designer stubble, nipped out for a smoke in the interval, and when they left,
carrying violin cases and dressed in black, people got out of their way. The climactic performance was Handel’s Resurrection, with full orchestra and chorus. The soloists, including an angel, St John, and Satan, sang in Latin, but you got the gist without looking at the translation. Despite his wonderful bass voice, bags of personality, and appeals to the audience, Satan was never going to get a result. “Strange,” wrote Noel Coward, “how potent cheap music is.” He didn’t comment on expensive music, and Handel’s power surprised me. It made the Easter story seem almost logical. The triumph of goodness was inspiring, even to jaded doctors. And when we emerged the sun was shining James Owen Drife is professor of obstetrics and gynaecology, Leeds
[email protected] BMJ | 22 march 2008 | Volume 336
VIEWS & REVIEWS
The last laugh I have always Towards the end BETWEEN regarded critics of the of the play, Argan’s THE LINES medical profession as brother, Béralde, ill informed, ill intenwho is not a believer Theodore Dalrymple tioned, or ill adjusted in medicine, tries —or, of course, all to wean him from three. I have known his dependence on several newspaper doctors. He advises editors, for example, him that it would who were profoundly be a good thing if anti-doctor, a hostilhe were to attend ity I ascribe to the some of Molière’s fact that doctors are plays on the subheld in far higher ject of doctors and public esteem than medicine. Argan journalists. If journalexclaims: ists cannot improve “Devil take it! If I their own reputawere only a doctor, tion, they can at least I would revenge Molière acted Argan in the try to destroy that myself on his first four performances of others. Politicians [Molière’s] imperof Le Malade Imaginaire, are of the same ilk as tinence. When he but he collapsed on stage journalists. fell ill, I would let during the fourth and Of the great critics him die without of the medical profesassistance. He could died within hours without sion, none was more say what he liked, I benefit of medicine ferocious and uncomwouldn’t prescribe promising than Jeaneven the slightBaptiste Poquelin, better known as est blood letting for him, the smallest Molière. The last play he wrote was enema, and I would say to him, ‘Die! Le Malade Imaginaire, and as usual he Die! That will teach you another time makes fun of doctors in it. The hero, to make fun of the Faculty!’” or protagonist, is Argan, the hypochonTo Béralde medicine is nothing more driac who is completely under the sway than a confidence trick: “You have only of his doctor, Monsieur Purgon. to speak in a cap and gown, and gibberThe opening scene has Argan adding ish becomes scholarship and the greatup his apothecary’s bills for all the est nonsense wisdom.” clysters, pills, potions, electuaries and As often happens—it is the saving so forth that he has been prescribed of the profession—the doctors had the and has dutifully taken. He remarks last laugh. Molière acted Argan in the that the bill is so exorbitant that hencefirst four performances of Le Malade forth no one will want to be ill. But his Imaginaire, but he collapsed on stage faith in medicine remains absolute. during the fourth and died within hours “This month,” he says, “I have taken without benefit of medicine. eight mixtures and 12 clysters; last Of course, nothing that the Faculty month I took 12 mixtures and 20 clyscould have prescribed would have ters. No wonder I don’t feel as well this saved him. One has only to read of the month as last.” Argan says he will tell treatment meted out by doctors to dying Monsieur Purgon so that he can put monarchs such as Philip II, Louis XIV, matters right. and Charles II to realise that Molière It so happens that on my way to didn’t miss much; quite the contrary. work I used to pass an establishment, But faith in medicine is not proporin appearance halfway between a hairtional to its efficacy—it might even be dressing salon and an adult bookshop, inversely proportional to its efficacy. I that advertised colonic irrigations as wonder what evidence based medicine the key to wellbeing. Some illusions, it has to say on this subject? seems, die hard. Theodore Dalrymple is a writer and retired doctor BMJ | 22 March 2008 | Volume 336
Medical classics Follies and Fallacies in Medicine By Petr Skrabanek and James McCormick First published in 1989 Petr Skrabanek, a Czech, was in Ireland when the Soviets invaded his country, so he stayed, publishing criticisms of medical humbug while working with James McCormick until his premature death in 1994. The book has been translated into six languages and is on the reading list of medical schools around the world, to encourage an appropriate scepticism about medical dogma. For example, could strict adherence to evidence based practice be harmful to patients? This is the intriguing hypothesis suggested in the first section of this subversive book. It points out that although the placebo effect is powerful, to work best it requires both the patient and the doctor to believe in it. As most of the common conditions that disturb our equanimity are self limiting, arguably the priority is for treatments that make us feel better, thereby boosting our activity (speeding recovery from musculoskeletal disorders) and immune response (hastening recovery from infectious disease). So the placebo effect is an important therapeutic weapon. Unfortunately, while it is invariably maximised by believers in complementary medicine (which Skrabanek and McCormick devastatingly rubbish), it is rendered impotent by those expressing doubt in treatments they know to be ineffective in double blind, randomised trials (where the differential effect of the placebo is neutralised). This may be honest but destroys the placebo effect, thereby denying its advantages to the patient. I find that encouraging patients with a bad cold to keep warm, rest, and dose themselves with honey, hot lemon, and paracetamol results in greater customer satisfaction than saying, “Don’t worry, it will just get better by itself.” Does it hasten Skrabanek: critical recovery? Probably not, but it of medical humbug makes the patient feel better while recovery takes place. Is this being completely honest with the patient? No. Is it ethical? Read this book and then decide. The second section is a humbling account of the many fallacies that beset medical practice. As a clinical teacher I am irritated by those who confuse association with causation or assume that what a senior person says is correct, but to fight the human desire for certainty is difficult. “Conviction politicians” may be popular, but conviction doctors are potentially dangerous. Other sections look at diagnosis and the risk of false positives, and prevention, and show that it is ethically questionable to promote expensive treatments that have not been shown to be substantially effective. Section six points out that we all have a duty to consider the ethical content of our practice. It would probably be good for our ethical health if we all read this book at least once a year. Philip Steer, emeritus professor, Imperial College London
[email protected] Acknowledgment: I thank Susan Bewley for giving me this book and encouraging me to read it. The book can be downloaded free at www.medicine.tcd.ie/public_ health_primary_care/skrabanek/publications.php.
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