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Who will guard the guards? Medical leadership and conflict of interest in South African healthcare
To the Editor: Conflicts of interest (COI) arising from the interaction of the pharmaceutical industry with doctors have been described in an SAMJ editorial.[1] The common interests in patient wellbeing, shared by doctors and the pharmaceutical industry, will conflict with the pharmaceutical industry’s wish to sell their products and influence doctors’ behaviour. A number of important measures to deal with COI are described in the editorial, including disclosure of COI, creating awareness of the problem, academic discussions and fostering professionalism by practitioners. A further measure that should be included to complement the above is the use of clinical protocols (standardised care guidelines). This approach avoids negative influences on treatment rec ommendations by excluding outside sources with different agendas and avoiding financial inducements. Other potential negative influences that may arise from discrimination because of age, sex, race, sexual orientation, disease and disability may also be avoided. This approach also reinforces positive influences through trans parency and peer review and having both academic and pragmatic input. Clinical guidelines have become widely available, for good medical[2] and economic reasons A standardised approach allows for a body of experience to be reviewed individually, regionally or nationally to evaluate its effectiveness. For example, in oncology, cancer of the lung and oesophagus presents and responds differently to treatment in South Africa, Asia and Europe. Available resources will also be considered, as well as the marginal gain for new but costly treatments. Clinical guidelines reduce COI and facilitate the documentation of a body of experience on which to base patient care in the future. Raymond P Abratt
Head of Clinical Governance, Independent Clinical Oncology Network, and Professor Emeritus, University of Cape Town, South Africa
[email protected]
S Afr Med J 2016;106(2):129. DOI:10.7196/SAMJ.2016.v106i2.9679
To the Editor: Difficult endotracheal intubation commonly results in morbidity and mortality.[1] To overcome such complications, the airway is assessed preoperatively. An intubation is considered difficult if an appropriately trained anesthesiologist needs more than three attempts or more than 10 minutes for successful endotracheal intubation.[2] The airway is usually assessed using the modified Mallampati test (MMT),[3] head and neck extension,[4] mouth opening,[5] the upper-lip bite test,[6] Cormach-Lehane grading (CLG)[7] and a number of other preoperative tests and models. The MMT and CLG categorise difficulty on the basis of whether the glottis and epiglottis are visualised or not. In some patients, despite the fact that the structures in the oral cavity can be visualised, difficulty is encountered during the passage of the endotracheal tube (ETT) through the glottis, so smaller ETTs are used
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Zahid Hussain Khan, Farhad Tavakoli
Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Iran
[email protected],
[email protected] 1. Cook TM, MacDougall-Davis SR. Complications and failure of airway management Br J Anaesth 2012;109(Suppl 1):i68-i85. [http://dx.doi.org/10.1093/bja/aes393] 2. Langenstein H, Cunitz G. Difficult intubation in adults. Anaesthesist 1996;45(4):372-383. 3. Samsoon GLT, Young JRB. Difficult tracheal intubation: A retrospective study. Anaesthesia 1987;42(5):487-490. 4. Wilson ME, Spiegelhalter D, Robertson JA, et al. Predicting difficult intubation. Br J Anaesth 1988;61(2):211-216. [http://dx.doi.org/10.1093/bja/61.2.211] 5. Saund DS, Pearson D, Dietrich T. Reliability and validity of self-assessment of mouth opening: A validation study. BMC Oral Health 2012;12:48. [http://dx.doi.org/10.1186/1472-6831-12-48] 6. Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: A prospective blinded study. Anesth Analg 2003;96(2):595-599. [http://dx.doi.org/10.1213/00000539-200302000-00053] 7. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39 (11):1105-1111. [http://dx.doi.org/10.1111/j.1365-2044.1984.tb08932.x] 8. Rose DK, Cohen MM: The airway: Problems and predictions in 18,500 patients. Can J Anaesth 1994;41(5):372-383. [http://dx.doi.org/10.1007/BF03009858] 9. Burkle CM, Walsh MT, Harrison BA, et al. Airway management after failure to intubate by direct laryngoscopy: Outcomes in a large teaching hospital. Can J Anaesth 2005;52(6):634-640. [http:// dx.doi.org/10.1007/]
S Afr Med J 2016;106(2):129. DOI:10.7196/SAMJ.2016.v106i2.10275
1. Parish A, Blockman M. Who will guard the guards? Medical leadership and conflict of interest in South African healthcare. S Afr Med J 2014;104(11):757-758. [http://dx.doi.org/10.7196/SAMJ.8546] 2. Grimshaw JM1, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342(8883):1317-1322. [http://dx.doi.org/10.1016/01406736(93)92244-N]
Difficult tracheal tube insertion: A new phraseology
to ensure an unimpeded passage. Such a difficulty arises when the diameter of the trachea is smaller than that of the ETT, i.e. the internal diameter of the ETT far exceeds the tracheal diameter. There are many definitions of different scenarios of difficult intu bation, which can be summed up as follows: difficult tracheal intu bation is defined as tracheal intubation requiring multiple attempts,[2] and occurs in 1.5 - 8.5% of patients who undergo tracheal intu bation. [8,9] Difficult direct laryngoscopy refers to inability on the part of the laryngoscopist to visualise the larynx because of anatomical abnormality or distortion of the larynx or trachea. There is, however, no mention in the literature of airways that appear to be simple during laryngoscopy and CLG, but turn out to be exceedingly difficult when actual insertion is being attempted. We consider that for such cases a new phrase, difficult tracheal tube insertion (DTTI), should be employed. Fortunately cases of DTTI can be managed successfully if smaller-size tubes are used or a malleable guide is introduced into the ETT prior to its insertion through the glottic opening.
The UCT class of 2000 reunion
To the Editor: It was with mixed emotions that we prepared for our 15-year reunion at the University of Cape Town in November 2015. Certainly the nationwide student protests and shutdowns made administration and organisation quite challenging, but they also gave us a chance to reflect on our own medical education and training. As graduates of UCT in 2000, we started our professional careers as young interns in the middle of the HIV epidemic. As medical students we joked about including HIV or TB on every differential list, but as young doctors it was no longer a joke but a grim reality. With no antiretrovirals to offer our patients, a limited supply of fluconazole and Bactrim and HIV ELISA results that took 6 weeks to return from a tertiary centre, we found ourselves signing piles of death certificates every week and standing helplessly in front of our patients despite having been trained as curative clinicians. In the 15 years since our graduation, medical education has been challenged with providing training that is socially relevant to the community served by its graduates. More recent competencybased education models are promoting additional roles for graduate doctors not only as medical experts but also as health advocates, collaborators, communicators and leaders. The outcomes are clear, but the mechanisms to teach these attitudes and skills are still debated. As part of our reunion weekend, not only did we have time for social conversations and sharing family time in the beautiful gardens
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of Kirstenbosch, but we also facilitated an ‘academic meeting’ on the Saturday morning. The purpose of this meeting was to share our experiences over the past 15 years and reflect on the varied paths we had chosen after graduation: from the prescribed internship and community service year, to working overseas, to specialising and sub-specialising, and how that journey had been different for each person, with unique challenges that moulded our decision-making and career choices. Somehow amid the chaos of being young, naive interns in comm unities devastated by HIV, our classmates had emerged as leaders, communicators, collaborators and health advocates. We heard how not even an MB ChB and an MBA degree can provide immunity against feelings of loneliness and uncertainty in one’s skills to perform the required job, that scholarship is lifelong, and that leaders are people who rise to a challenge. We were challenged to observe the world through different-coloured lenses and see the unique contribution that each individual can make, and to define ourselves as people rather than as doctors. We heard how the nightmare of the London tube bombings in 2005 would call to action years of clinical training and create leaders within minutes. We heard from advocates who not only promoted the plight of their individual patients, but are working daily to make a change and improve healthcare for their entire community. We observed the love and empathy of a small team that grew into a big team through collaboration and leadership to provide excellent healthcare for a small rural community. Many of our class had specialised, some remained in general prac tice; some were working in tertiary academic or government practice
and others in private practice. Some were working overseas, but over half of the class had returned to or remained in South Africa. Many of the class have also excelled in spheres of life outside medicine, travelled the globe, and been blessed with the joys of having a family. In reflecting on this milestone achievement of 15 years since graduation, perhaps these anecdotes provide some insight as to how change can be effected. At the time of our graduation we were eager to make a difference to healthcare in South Africa, armed with limited knowledge, skills and fledgeling critical thinking ability. It seems that even without overt exposure to a competency-based, graduate attributesdriven curriculum, the class of 2000 have emerged as ‘change agents’ in healthcare and their communities. As the first doctors of the 21st century (dubbed the ‘Millennium Medics’ by Prof. Immelman) we were going to make history anyway! Paula Diab
Discipline of Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
[email protected]
Angela Dramowski
Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
Nienke van Schaik
Health Systems Trust, Cape Town, South Africa S Afr Med J 2016;106(2):129-130. DOI:10.7196/SAMJ.2016.v106i2.10449
Correction In the article ‘Using mobile technology to improve maternal, child and youth health and treatment of HIV patients’ by Peter et al., which appeared on pp. 3 - 4 of the January 2016 SAMJ, the USSD number was given as *150*550#, which is incorrect. The number is in fact *134*550#, and anyone dialling the *150* number to test the service will receive a message saying the service is not running. The online version of the article (http://dx.doi.org/10.7196/SAMJ.2016.v106i1.10209) was corrected on 7 January 2016.
This month in the SAMJ ... Jerome Loveland*†‡§ is Academic Head of Paediatric Surgery, University of the Witwatersrand, Clinical Head of Paediatric Surgery at Chris Hani Baragwanath Academic Hospital, and an Associate Professor in the School of Clinical Medicine, University of the Witwatersrand. He is also a senior member of the Transplant Unit at Wits Donald Gordon Medical Centre. His specific clinical interests in paediatric surgery include hepatobiliary disease, oncology and neonatal and laparoscopic surgery, as well as hepatic and renal transplantation. In addition to his clinical work, he has a keen interest in clinical research in both paediatric surgery and transplantation, and is committed to developing this field at Wits University. Outside of his career, Jerome is a committed family man, supported by his wife and children. His mental battles are fought while running … *Patel N, Naidoo P, Smith M, Loveland J, Govender T, Klopper J. South African surgical registrar perceptions of the research project component of training: Hope for the future? S Afr Med J 2016;106(2):169171. [http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10310] †
abian J, Maher H, Bentley A, et al. Favourable outcomes for the first 10 years of kidney and pancreas transplantation at Wits Donald Gordon Medical Centre, Johannesburg, South Africa. S Afr Med J F 2016;106(2):172-176. [http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10190]
‡ §
Carapinha C, Truter M, Bentley A, Welthagen A, Loveland J. Factors determining clinical outcomes in intussusception in the developing world: Experience from Johannesburg, South Africa. S Afr Med J 2016;106(2):177-180. [http://dx.doi.org/10.7196/SAMJ.2016.v106i2.9672]
Jugmohan B, Loveland J, Doedens L, Westgarth-Taylor CJ. Mortality in paediatric burns victims: A retrospective review from 2009 to 2012 in a single centre. S Afr Med J 2016;106(2):189-192. [http://dx.doi. org/10.7196/SAMJ.2016.v106i2.8942]
June Fabian* is a specialist physician and nephrologist, currently doing clinical research at Wits Donald Gordon Medical Centre. *Fabian J, Maher H, Bentley A, et al. Favourable outcomes for the first 10 years of kidney and pancreas transplantation at Wits Donald Gordon Medical Centre, Johannesburg, South Africa. S Afr Med J 2016;106(2):172-176. [http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10190]
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